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PATIENT SAFETY


they are not given the time to do appropriate levels of training on patient safety once they have started their clinical careers.10 Patient safety 2030 makes the point that training programmes need to be of high quality. There is increasing evidence that team based clinical simulation scenarios are an excellent means of learning. However, they recognise that training will be of limited value if participants are unable to translate the lessons into practice. They cite the existence of several barriers related to the lack of an improvement-focused culture. They suggest that entrenched hierarchies, the blame culture, and fear of speaking out are barriers to change. Individuals are powerless to speak up and have no voice – or are afraid to do so due to the punitive culture.


It is possible that the new data reporting system for patient safety in the NHS will enable data to be better understood and for learning to be taken from it. This will make clinicians more likely to report incidents, if they can see there is value in the data and feedback is evident. We are moving towards the era of big data in healthcare which will act to inform policy makers and strategies to review the causes of patient harm. For example, where patients may have many different medications for their co-existing diseases – this will help to ensure there are no safety risks with interactions between the drugs. Health systems can use administrative data to benchmark performance and identify potential best practices. Providers can also use big data to uncover inherent safety risks in a specific patient population and tailor interventions appropriately.


Conclusion


There are many important aspects that the service should be aware of in this Patient Safety 2030 report. It is a good read, evidence based and a result of additional input from many of the world’s most respected patient safety experts. In the last 15 years, there have been some exceptional developments in the management of patient safety within healthcare around the world. However, if we are to continue the progress already made and make the step change the report says is required to make the systems continue to improve, significant effort and time and investment will be required. Policy makers, leaders and clinicians now have a clear pathway identified.


References


1 NHS Improvement Patient safety strategy public consultation. Accessed at https://improvement. nhs.uk/news-alerts/avoidable-patient-harm-be- halved-key-areas-part-ambitious-strategy/


2 Yu A, Flott K, Chainani N, Fontana G, Darzi A 2016, Patient Safety 2030 National Institute for Health Research at Imperial Patient safety Translational Research Centre accessed at https://www.imperial.ac.uk/media/imperial- college/institute-of-global-health-innovation/


MAY 2019


We are moving towards the era of big data in healthcare which will act to inform policy makers and strategies to review the causes of patient harm.


centre-for-health-policy/Patient-Safety-2030- Report-VFinal.pdf


3 Care Quality Commission. Opening the door to Change 2018. Accessed at https://www.cqc.org.uk/publications/themed- work/opening-door-change


4 Ibid 5 Dubeck D. Healthcare Worker Fatigue: Current Strategies for Prevention [Internet]. Pennsylvania Patient Safety Advisory; 2014. Available from: http://patientsafety.pa.gov/ADVISORIES/document s/201406_53.pdf


6 Fraccaro P, Arguello Casteleiro M, Ainsworth J, Buchan I. Adoption of clinical decision support in


multimorbidity: A Systematic Review. JMIR Med Inform. 2015 Jan 7; 3 (1). Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4318680/


7 Pronovost PJ, Ravitz AD, Stoll RA, Kennedy SB. Transforming Patient Safety: A Sector Wide Systems Approach [Internet]. Doha, Qatar: World Innovation Summit for Health; 2015. Available from: https://www.wish.org.qa/wp- content/uploads/2018/01/WISH_PatientSafety_ Forum_08.01.15_WEB-1.pdf


8 Ibid 9 Ibid 10 Ibid


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