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.
The proposals have been set out by our National Director of Patient Safety, Dr Aidan Fowler, as part of a public consultation in order to inform the development of an NHS-wide strategy to be delivered from April 2019, alongside the new NHS Long Term Plan.
It builds on the improvements the NHS has made to patient safety over the last fifteen 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. We are seeking views 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.
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.’
Dr Aidan Fowler, National Director of Patient Safety, NHS Improvement — and a former consultant surgeon
Priority areas for the harm reduction ambition could include reducing Never Events; harm from sepsis; pressure ulcers; Gram-negative bloodstream infection such as e-coli; falls; 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. Also, 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, we propose that:
- 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.
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.
Caroline Dinenage, Minister for Care