Patient safety has made great progress since the publication of To err is human 20 years ago but there is much more to do. The NHS does not yet know enough about how the interplay of normal human behaviour and systems determines patient safety. The mistaken belief persists that patient safety is about individual effort. People too often fear blame and close ranks, losing sight of the need to improve. More can be done to share safety insight and empower people–patients and staff –with the skills, confidence and mechanisms to improve safety. Getting this right could save almost 1,000 extra lives and £100 million in care costs each year from 2023/24. The potential exists to reduce claims provision by around £750 million per year by 2025.
Addressing these challenges will enable the NHS to achieve its safety vision; to continuously improve patient safety.To do this the NHS will build on two foundations: a patient safety culture and a patient safety system. Three strategic aims will support the development of both:
- improving understanding of safety by drawing intelligence from multiple sources of patient safety information (Insight)
- equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system (Involvement)
- designing and supporting programmes that deliver effective and sustainable change in the most important areas (Improvement).
The actions we –the NHS– will take under each of these aims are set out below.
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 system
- 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.
Download/Read the full publication – The_NHS_Patient_Safety_Strategy_.pdf – on improvement.nhs.uk.