Reducing ‘Never Events’, falls and Gram-negative bloodstream infections are among the priority areas in new proposals to position the NHS as the safest healthcare system in the world.
National Director of Patient Safety, Dr Aidan Fowler, announced the proposals as part of a public consultation with a view to developing an NHS-wide strategy to be delivered from April 2019 alongside the new NHS Long Term Plan.
The commitment includes a proposal for some of the most important types of avoidable harm to patients to be halved over the next five years in areas such as medication errors and Never Events, alongside developing a ‘just culture’ for the NHS where frontline staff are supported to speak up when errors occur.
It builds on the improvements the NHS has made to patient safety over the last 15 years - including the open reporting of errors and near-misses through the National Reporting and Learning System (NRLS). Over two million incidents are reported there every year - leading to national action to ensure patients receive safer care. To date, England is still the only country in the world that has such a comprehensive system.
The consultation proposes that the NHS should focus on key areas of concern - based on the amount of harm caused - where litigation costs are highest and where there is the greatest variation. Ambitions will be set for each of these to halve the amount of avoidable harm there. Views are being sought to help inform the final strategy.
“It is a testament to the professionalism of frontline staff that in the clear majority of cases, patients receive safe care. The NHS is leading the way for patient safety, but we must not be complacent. Our ambition as part of the Long Term Plan is for an increased focus on safety improvement as this is what patients deserve,” explains Dr Aidan Fowler.
“Key to this will be to develop a 'just culture' across the NHS, where staff are supported to be open and transparent about what is going on without fear of punishment for errors that are beyond their control. Continuous learning and improvement must be at the heart of protecting patients from avoidable harm.
We want to hear from as many people as possible during this consultation to help us create a strategy which will provide every patient with the safest possible care.”
Other priority areas for the harm reduction ambition could include reducing harm from sepsis and pressure ulcers, reducing medication errors, improving maternity and neonatal safety and improving the safety of patients with mental health issues.
Already, some of this work is underway, such as the World Health Organisation launching its challenge in February 2018 to reduce severe avoidable medication-related harm globally by 50% over five years. In November 2017 the government announced its plan to halve the number of still births, neonatal and maternal deaths, and severe birth-related brain injuries by 2030.
Elsewhere in the consultation, NHS Improvement is proposing:
* There should be a curriculum for patient safety across the NHS that can be used from boards to wards to standardise how incidents should be reported and acted on. This builds on similar curricula that are available in countries including Australia and Canada. Currently all NHS staff are given training in fire safety but not patient safety, even though all of them will have witnessed a patient safety incident during their careers.
* Every NHS Trust should appoint or identify patient safety specialists who can bring their expertise to safety improvement efforts and who can ensure that patient safety remains a priority for their organisations. We are seeking views on the seniority of these positions.
* The NRLS will be replaced by a new system called the Patient Safety Incident Management System to improve the interrogation of data, spot trends and support learning. This system will explore using artificial intelligence to dig deeper into data so patient safety risks and improvements can be identified more quickly.
“Patient safety is the golden thread running through everything the NHS does and as we set out our Long Term Plan now is the time to re-focus our efforts.
While we have made excellent progress, I want NHS staff to tell us how we can go even further and better support them to improve patient safety,” says Daroline Dinenage, Minister for Care.
“Our strategy will contain bold, staff-driven initiatives, which will help us to build the safest healthcare system in the world, underpinned by a no-blame culture that champions people to speak up when things go wrong and learn from their mistakes.”
The initiative has been welcomed by NHS Providers. Head of Policy, Amber Jabbal, says: “Trusts already prioritise patient safety, but we should acknowledge that more can be done by joining up efforts and sharing lessons learned across all NHS organisations to make sure that patients are protected at all stages of care.
"To do this we must involve staff and patients to provide greater insight into the causes of incidents, improve learning and build a more transparent and just culture in responding when harm occurs.
"We look forward to working with Dr Aidan Fowler and trusts to develop a patient safety strategy which is consistent across the NHS and deliverable by trusts and their local partners."
The consultation will be open until February 15, 2019. Click here to take part in the survey.
