which to prioritise patient safety. But we must. Trends are likely to increase risks, not diminish them. The complexity of patients and their coexisting diseases will create severe challenges for clinicians both cognitive and physical, which may compromise performance and decision making, leading to errors, adverse events and eventually harm to patients.5 Patients admitted to hospital with several existing diseases often stay longer, and are subject to greater risk, due to the complexity of their care. Patients are at risk of interactions of drugs or other therapies, duplication of tests, potentially confusing self management and treatment guidelines and medication or treatment errors.6 New opportunities for error will occur in

future, Patient Safety 2030 reports as care becomes more complex, while it will be useful to move towards a more personalised model of care with helpful genomics too, the volume of data for each patient will increase exponentially and will increase immeasurably the complexities for clinical care and thus the consequent opportunities for harm to be caused.

A systems based approach

Patient safety 2030 recommends addressing challenges which will significantly impact on the pace of change by engaging with proactive initiatives for patient safety. They speak of a systems engineering approach which will operate across different care settings, regulators, policy makers and patients. The systems should involve action on culture, patient and staff- centred and be evidence based.7

They emphasise that

action should be taken at all levels; local, national and global.

The following elements should be identified within the systems engineering approach: l Consistent commitment by the leadership l Clear goals and definitions of success l Data to prove that change is needed and to measure progress and improvement

l Incentives for meaningful participation and success

l Shared accountability and openness, focusing on system problems rather than individual mistakes, and learning rather than blame

l Well-defined processes for change (often including patient safety alerting systems)

l Education about goals and approaches to change

l Multidisciplinary teams, including stakeholders in addition to the primary caregiver, with a focus on frontline staff and patients

l Focus on communication and collaboration l Sustainability plans.

The report also recommends that there should be a change in culture.8

Action is

already being taken, with the Care Quality Commission (CQC) reporting last December on how 18 NHS Trusts manage the issues around never events, and those which contribute to them taking place. There are some interesting and unsurprising findings9

in the CQC report,

‘Opening the door to change’ including the fact that staff are struggling to cope with the volume of safety guidance. They have little time to implement the guidance effectively, and the systems and processes around them are not always supportive. Where staff are trying to implement the guidance, they are often doing this on top of a demanding and busy role that makes it difficult to give the work the time it requires. Patient safety 2030 mentions the need for a supportive organisational culture being essential to the success of new patient safety initiatives. It determines that the culture – often seen as a nebulous and non-quantifiable concept – should be able to be defined and measured. It also identifies that a positive culture is balanced with accountability. This is known as a ‘just culture’ and is really important to all levels of staff – so that they feel they have a voice which will be listened to, and that there will be a sensible outcome. There are validated culture measuring tools


which they describe in some detail. A culture of learning is also described whereby the data on patient safety incidents can be interrogated so that more learning than is currently possible occurs, to enable the service to be more proactive. A new patient safety incident management system is in the process of being developed at present by NHS Improvement. They cite the NRLS database as the reason for this update to the data management system, as it is now 12 years old and needs to be upgraded to ensure a more agile and capable database for interrogation and collation of the information.

Frameworks for the patient safety toolbox

Some of the areas which can assist in the development of patient safety cultural awareness, and which will reduce the risk of potential harm, are: regulation and governance; leadership; education and training; data and information; digital health and behavioural insights and design. Regulation and governance help to establish minimum standards, while ensuring that patient safety is a priority in the institution. It holds providers accountable and enables enforcement actions if appropriate. However, if the balance is wrong, innovation is stopped and it can incur additional costs. Leadership in improvement efforts should come from all levels of an organisation – as well as from patients. Everyone working in the facility should be empowered to have a voice and to take a leading role in preventing harm. Data management systems need to be strengthened and their outputs used more effectively for learning. However, they also emphasise that data needs to be distilled into an understandable and useful format rather than being the source of an increased cognitive burden.

Education and training is reported to be largely superficial. In addition, the CQC found that staff are either not getting the training they need at undergraduate level or

MAY 2019

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