Patient safety
It is difficult to imagine that the evidence of an unsafe culture in other safety critical industries, where the consequences of incidents may also be serious injury or loss of life, would be deemed acceptable.
Surely it must be unacceptable in healthcare. Helen Hughes, Patient Safey Learning.
– including the fact that the fear of speaking up appears repeatedly in major patient safety scandals. Most recently, the maternity inquiries at Shrewsbury and Telford and East Kent have raised such concerns, echoing past reports such as the Mid Staffordshire Review.4,5,6
Safety Learning points out that cultures of blame have continued to emerge as an underlying cause of avoidable harm for over two decades as highlighted in many different inquiries and reviews.7 Further evidence of staff not feeling safe to speak up, and suffering severe repercussions when they do, are reflected by the shocking experiences and testimonies of whistleblowers in healthcare. Prominent recent cases, such the experience of Peter Duffy, have highlighted serious concerns about the culture in parts of the NHS.7,8,9 Patient Safety Learning states that, all too
often, staff raising patient safety concerns to their organisation are met with a hostile and aggressive response, rather than one that is open and welcomes challenge and scrutiny. Staff often experience legal threats, vexatious referrals to regulatory bodies, pay cuts, demotions, disciplinary action and contractual changes. They continue to face experiences like this when they go on to raise concerns to organisations such as the Care Quality Commission (CQC) or other external agencies, with organisational responses often marked by a
focus on reputation management over tackling safety concerns. Such responses to raising concerns have
Patient
recently been highlighted in the prosecution of Lucy Letby, who was found guilty of murdering seven babies on a neonatal unit at the Countess of Chester Hospital.10
The consultant who first
raised concerns about Lucy Letby’s behaviour, and other clinicians involved in this case, have highlighted issues regarding the hospital’s response and a failure to act appropriately on the information provided.11
These issues
have been identified as an area for further investigation in the terms of reference of the public inquiry led by Lady Justice Thirlwall looking into the Letby case.12
New guidance A new Safety Culture Programme Group met in July 2021 to discuss recommendations to develop a safety culture in the NHS.13
This led
to the decision to create a new Safety Culture Implementation Group to meet every 2-3 months to oversee this work. Subsequently, NHS England has published the following good practice resources: l Safety culture: learning from best practice (November 2022) – this identifies six themes from discussions of good practice and case studies related to this.14
l Improving patient safety culture – a practical guide (July 2023) – a toolkit intended to give
teams an understanding of how to craft and nurture a positive safety culture and provide a theoretical underpinning to how to shift culture.15
Additionally, there is also A just culture guide available on the NHS England website, which “encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way”.16 Patient Safety Learning acknowledges that
NHS England have made some positive progress in introducing new guidance and information, but plans for implementation are ‘not clear’. The staff survey results indicate that blame cultures and a fear of speaking up continue to persist in a significant part of the NHS. Coupled with findings of patient safety inquiries and whistleblower testimonies, this demonstrates the need for a more transformative effort and commitment to creating a safety culture.
Sharing good practice and learning
Although the NHS guidance produced to date is useful, Patient Safety Learning believes that a greater pool of resources is required to meet the scale of this challenge. This includes not only good practice guidance, but also examples of practical application for organisations to implement a safer culture.
Examples of implementation in practice There are specific organisations, such as Mersey Care NHS Foundation Trust, who have, over many years, committed to making significant changes in culture.17
Patient Safety Learning believes it practice guide18
would be beneficial for the NHS to explore how it can help organisations, such as Mersey Care and others, share their practical experience of implementing culture change programmes with other organisations. The Safety culture: learning from best published by NHS England
includes links to some case studies setting out examples of good practice. Patient Safety Learning believes this might provide a useful starting point to further expand resources. While good practice guidance and theory is
20
www.clinicalservicesjournal.com I August 2024
Photographee.eu -
stock.adobe.com
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60
