“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, Involvement and Improvement.
A New Strategy for Patient Safety--Insight, Involvement, Improvement 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:
The NHS will:
• adopt and promote key safety measurement principles and use culture
metrics to better understand how safe care is
• use new digital technologies to support learning from what does and does
not go well, by replacing the National Reporting and Learning System with a
new safety learning system
• introduce the Patient Safety Incident Response Framework to improve the
response to and investigation of incidents
• implement a new medical examiner system to scrutinise deaths
• improve the response to new and emerging risks, supported by the new
National Patient Safety Alerts Committee
• share insight from litigation to prevent harm.
The NHS will:
• establish principles and expectations for the involvement of patients,
families, carers and other lay people in providing safer care
• create the first system-wide and consistent patient safety syllabus, training
and education framework for the NHS
• establish patient safety specialists to lead safety improvement across the
• ensure people are equipped to learn from what goes well as well as to
respond appropriately to things going wrong
• ensure the whole healthcare system is involved in the safety agenda.
The NHS will:
• deliver the National Patient Safety Improvement Programme, building on the
existing focus on preventing avoidable deterioration and adopting and
spreading safety interventions
• deliver the Maternity and Neonatal Safety Improvement Programme to
support reduction in stillbirth, neonatal and maternal death and neonatal
asphyxial brain injury by 50% by 2025
• develop the Medicines Safety Improvement Programme to increase the
safety of those areas of medication use currently considered highest risk
• deliver a Mental Health Safety Improvement Programme to tackle priority
areas, including restrictive practice and sexual safety
• work with partners across the NHS to support safety improvement in priority
areas such as the safety of older people, the safety of those with learning
disabilities and the continuing threat of antimicrobial resistance
• work to ensure research and innovation support safety improvement
This conference, A New Strategy for Patient Safety--Insight, Involvement, Improvement, will populate the strategy’s template with detailed information and practical guidance on the future plans for improved patient safety throughout the NHS.
The role of culture is widely referenced in driving improvements in patient safety. How can we influence safety culture positively and what must we do to support this?
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.
A “just culture” is a phrase that has become popular in the lexicon of the NHS in recent times. It is also often equated with a “learning culture”. But what do we mean by these terms, and can they be used interchangeably?
North Middlesex University Hospitals were one of four NHS trusts to take part in a Human Factors program delivered in collaboration between UCLPartners and Medled. This involved a week-long training course, followed by 10 months of support including workshops, site visits with coaching and access to a network of like-minded professionals.
During the program, the North Middlesex Human Factors Team implemented changes in a host of areas. Examples included streamlining forms to make them easier to complete; adopting a new type of needle to prevent medical errors; designing a patient safety walkabout programme and changing the sepsis pathway to help escalate treatment.
Vikki and her colleagues have also trained 350 staff in the trust to use the principles they were taught and launched a Learning from Excellence Program.
This talk will highlight the following;
- What do we really mean by Human Factors? And why does it matter in Patient Safety?
- The training and support approach taken in this program – moving beyond ‘raising awareness’ to embedding change
- The impact on staff and patients at North Middlesex University Hospitals
- How other organisations can implement a similar approach
A Blueprint for Action sets out the action needed to progress towards the patient-safe future. Underpinned by systemic analysis and evidence, it proposes practical actions to address the foundations of safer care for patients and to share details of the hub through a new learning platform for patient safety
Sixty-eight cases of healthcare professionals either “diverting” or working under the influence of controlled drugs were reported to CDAOs across England in 2018. The Insights Involvement and Improvement framework will be used to illustrate one of these cases. Future work aiming to improve safety culture across the wider system will also be presented.
After the Keith Evans report “Using the Gift of Complaints” commissioned by NHS Wales in 2014, things needed to change to improve patient safety in Wales. The journey of setting up a nationwide patient safety system has just begun. This case study looks at some of the challenges faced with implementing a national system and what others can learn from the process.
The presentation will give lessons learned and pointers towards collaboration and persistence to ensure safer care.
“if it’s not written down it didn’t happen”; probably one of the most uttered sentences in healthcare. And it is a falsehood.
A falsehood that that is arguably undermining the embryonic ‘Just Culture’.
Healthcare professionals cannot ‘write everything down’; there are not enough hours in the day. The contemporaneous record is always, therefore, incomplete.
When incidents are investigated staff are asked to produce witness statements. Most of those asked will simply copy out the contents of the incomplete healthcare record, believing that is all they ‘allowed to do’ because they have been indoctrinated in the apocryphal phrase.
In fact, what the witnesses should do in the statement is fill in the inevitable gaps that are in the records. If they do that, investigators will have the complete picture; they will understand not just what happened, but why. This is essential in a systems based investigation.
This session will provide an overview of the critical analytical skills that managers can use to ensure that staff produce excellent witness statements.
More of our everyday life is becoming digital and reliant on new technology such as artificial intelligence, and healthcare is no exception. Patients, healthcare professionals, and policymakers are becoming increasingly aware of the culture clash between the ‘move fast and break things’ world of tech, and the ‘safety first’ world of healthcare. How do we ensure that digital health products are safe, yet still dynamic and responsive to individual users’ needs?
The Patient Safety Academy has been formed from collaboration between two research groups in the University of Oxford, with expertise in patient safety, human factors/ergonomics and improvement science; the Quality, Reliability, Safety and Teamwork Unit (QRSTU) and Oxford Simulation Teaching and Research (OxSTaR).Project support involves provision of human factors patient safety training to all team members involved in a project. The PSA team provide support which enables the staff to choose the areas of concern they want to focus on, work together to generate potential solutions and then trial these solutions. The result is staff –led projects with improvements which fit their service and with successes and learning they can share with other teams.
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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