“Patient Safety is the avoidance of unintended or unexpected harm to people during the provision of healthcare”.
Although the NHS strives to provide patients with the safest possible care, there are times, unfortunately, when things go wrong. Around two million patient safety related incidents are reported every year, with most occurring within the acute, mental health and community care sectors.
The NHS Long Term Plan highlighted several safety issues that need to be addressed; the fear of blame and retribution which curtails reporting and learning, lack of staff understanding of patient safety matters and workforce issues. With the aim to make the NHS the safest healthcare system in the world, a new strategy for patient safety sets out plans to focus on continuous learning and measurable improvement.
Based on three principles which are; A Just Culture, Openness and Transparency and Continuous Improvement, the strategy recognises three areas of work priority: Insight, Infrastructure and Initiatives.
A New Strategy for Patient Safety-Insight, Infrastructure, Initiatives is a conference designed to bring together all stakeholders who have a responsibility to deliver safe patient care. The conference will provide delegates with improved insight of:
- The aims of the strategy and the principles on which it has been created
- The areas of work identified as priority and the elements within them that will bring about quality improvement
- The strategy implementation, including the latest developments and initiatives to deliver the desired results
Through the agenda, delivered by key expert speakers, delegates will gain an essential update on the future direction of patient safety within the NHS and hear how it intends to become the safest place in the world to receive treatment.
“Every patient – whether in hospital, at home, in a GP surgery – expects compassionate, effective and safe care. To achieve that, we need to improve learning, we need to better shout about the work that the best trusts are doing, and the NHS must be as open and transparent as we can.” Matt Hancock, Secretary of State for Health and Social Care
The State of Care report by the CQC states that safety is the most significant cause for concern within the NHS. To support safety improvement, the new strategy proposes national action to ensure patients receive safer care. It aims to concentrate on the key areas of concern which are based upon the amount of harm caused, where mitigation is highest, and where the greatest levels of variation occur. Across these three areas the ambition is to reduce avoidable harm by 50% including the occurrence of ‘never event’s and medication errors.
There are three guiding principles:
A Just Culture- Blaming people for non-malicious errors is not conducive to improved safety. The focus should be on changing systems and procedures to allow people to conduct their job more safely.
Open and Transparency-Encouraging staff to be open and honest when mistakes happen allows for shared discussion, learning and revisions to be made.
Continuous Improvement-A continuous focus to make quality improvements to the system by assessing what needs to be improved, how changes will make things better and how the impact can be measured. Empowering staff and patients to recognise and respond is crucial.
The three areas of work identified as priorities are:
As part of the insight theme, the aim is for an improved ability to draw insight from multiple sources of information by acquiring, reviewing, understanding, analysing and exchanging patient safety data. The National Reporting and Learning System (NRLS) will be replaced by a new system, the Patient Safety Incident Management System. Within this system, the use of new technologies, such as Artificial Intelligence and Machine Learning and new techniques, such as Safety-II, can be utilised to best effect.
It is important that all staff have the skills and tools to influence patient safety. A universal safety curriculum is to be developed for all staff and a network of safety specialists plus a dedicated patient safety support team are to be created to support the capability and capacity of staff to improve levels of safety.
The ambition to deliver a 50% reduction in measurable harm is to be achieved through effective improvement initiatives such as the Patient Safety Collaboratives (PSC) programme, the falls collaborative programme, the Stop the Pressure programme (STPP), plus specialised work in mental health and maternal and neonatal health.
This conference, A New Strategy for Patient Safety-Insight, Infrastructure, Initiatives, will populate the strategy’s template with detailed information and practical guidance on the future plans for improved patient safety throughout the NHS.
The new strategy for patient safety is designed to develop the NHS into the safest healthcare system in the world. It will focus on three principles that should underpin implementation of
the strategy: a just culture, openness and transparency and continuous improvement. The strategy aims to: draw insight from multiple sources of patient safety information; give staff at all levels the skills and support they need to help improve patient safety and decrease harm in key areas by 50% by 2023/24.
A national report by the CQC found that too many people are being injured or suffering unnecessary harm because NHS staff are not supported by sufficient training, and because the complexity of the current patient safety system makes it difficult for staff to ensure that safety is an integral part of everything they do. In another report, all hospitals told the CQC that patient safety was their top priority, but too often they did not have an effective safety culture or reliable systems to ensure this.
One of the guiding principles of the Patient Safety Strategy is Openness and Transparency.
Adopting a ‘Just Culture’ enables staff to speak up when things have gone wrong, rather than fear blame and punishment. Supporting staff to be open and honest allows for learning from the mistakes and changes to be made to improve future safety, thus promoting another of the strategies principles of Continuous Improvement.
To better equip staff to deal with patient safety there are proposals for a patient safety curriculum for all current and future NHS staff, the development of a network of senior patient safety specialists and the establishment of a dedicated patient safety support team that can be assigned to organisations that are particularly challenged in relation to safety.
Artificial intelligence (AI) and Machine Learning (ML) are being touted as the next-generation of technology to transform healthcare. Whilst there is evidence to support patient safety there are concerns with regards to responsible implementation.
In England, Gram-negative bloodstream infections (GNBSIs) are increasing despite the decreases seen in Meticillin-Resistant Staphylococcus aureus(MRSA) bloodstream infection and Clostridium difficile infections (CDI). The Government have therefore set an ambition to reduce healthcare associated GNBSI by 50% by 2020/21.
The ambition for the NHS is to be one of the safest places in the world to give birth and aims to halve the rates of stillbirth, maternal and neonatal deaths and birth-related brain injuries in babies by 2030.
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