PATI ENT SAFE T Y
acknowledgement of things that go wrong; one can surmise that this is for fear of litigation. We live in a continuing culture of blame in healthcare, yet the ideal culture for patient safety is one of openness and transparency. The report suggests that the culture of denial and rebuff needs to change so that when things do go wrong, there is overall accountability. There needs to be changes from the bottom up, with leadership and support from the top.
There is enormous complexity in the organisations involved in patient safety, as demonstrated by Oikonomou5
when,
with colleagues, they mapped all the organisations who have part of the regulatory or monitoring role for patient safety in England. They found that there are more than 126 organisations which are engaged in safety related regulatory activities in the NHS. In addition to these are the Health Service Commissioners, such as the 211 Clinical Commissioning Groups and the 10 Integrated Care Systems. Provider organisations are often faced with a wide range of disparate agencies and organisations – all of whom play some role in the creation, monitoring and enforcement of safety standards. These include governmental agencies; those responsible for regulating professionals; manufacturers and suppliers of drugs and medical devices; charities; patient advocacy groups; accreditors; professional associations; IT groups and various others.6
It is little wonder that patients who have a problem find it hard to be heard and wander around in a maze of ineffective inaction.
The system needs to be fundamentally reformed with fewer reporting mechanisms to different regulators and one which can prove itself to be accessible to those who need it to be present, effective and efficient. All the above actors require data to be sent to them in different formats, which is burdensome to the providers of healthcare. Surely a simpler system can be devised while still keeping patients safe?
The organisations to provide this reformed system may, or may not, already exist and will shortly be joined, it is assumed, by a new role of the Patient Safety Commissioner who will have a national role. It would be challenging to devise a new system but, given the Cumberlege findings, it is long overdue. It is absolutely clear that the voice of the patient needs to be louder and to be heard. CSJ
References 1 Woodhead K. First do No Harm: a hard-hitting review. Clinical Services Journal 19; 8: 22-24 2 Cumberlege report 2020 First do no harm.
OCTOBER 2020 Accessed at
https://www.immdsreview.org.uk/
3 Ibid 4 The Health Service Journal podcast, Why the Cumberlege review is being buried. Accessed at
https://www.youtube.com/watch?v=yR_1JaK7vns
5 Oikonomou E, Carthey J, Macrae C, et al, Patient safety regulation in the NHS: mapping the regulatory
landscape of healthcare. BMJ Open 2019; 9: e028663. Accessed at
https://bmjopen.bmj.com/ content/9/7/
e028663.info
6 Dixon Woods M, Pronovost P. Patient safety and the problem of many hands. BMJ Qual Saf 2016; 25: 485-8. Accessed at
https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC4959572/
The Cumberlege report possibly underestimates the complexity of perioperative data collecting with many hospitals still not reporting data digitally and, if they are, there are many different platforms in use which generally stand alone and do not share information across other digital systems, even within the hospital.
TUESDAY 27TH OCTOBER 2020
EAST MIDLANDS CONFERENCE CENTRE, UNIVERSITY PARK, NOTTINGHAM
Completing the Picture is a FREE annual educational event. Join peers for a CPD accredited day of education, insight and discussion around current practices and the development of the medical technology of the future.
WHAT TO EXPECT AT COMPLETING THE PICTURE 2020:
• An impartial and comprehensive educational programme delivered by a range of specialist speakers
• Multiple sessions, allowing delegates to tailor their own learning experience
• Opportunity to network with peers
• Exhibition stands and optional seminars
• Certificate of attendance for delegate CPD records
Who can attend? This free to attend event is open to EBME’s, Procurement, I.T Specialists & Healthcare Professionals
WWW.COMPLETINGTHEPICTURE.COM
REGISTRATION NOW OPEN
WWW.CLINICALSERVICESJOURNAL.COM l 17
“A must for all engineers in-tune with the future”
FREE TO ATTEND
“An extremely informative and interesting day”
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 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92
