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PATIENT SAFETY
Patient Safety Learning: A call for action
Patient Safety Learning used its second annual conference to launch ‘The Hub’ and to issue a call for action on patient safety; with inspiring and practical presentations on strategies to tackle some of the most pressing issues.
The Patient Safety Learning annual conference took place on 2 October 2019 at The King’s Fund and the theme was set at the outset by Jonathan Hazan, chair of the board of trustees. “Patient safety must become a core purpose of healthcare, not just one of its priorities, because priorities can be shuffled around,” he said, while welcoming delegates. “That is one of the themes of our Blueprint for Action and of this conference.” Helen Hughes, chief executive of Patient
Safety Learning, picked up the point. Almost 20 years have passed since the US Institute of Medicine published its ground-breaking report, To Err is Human,1
and the UK
Department of Health followed up with An Organisation with a Memory.2 Yet there are 11,000 people – or twice the capacity of the Albert Hall – who die avoidably in patient safety incidents every year. “We could have another 20 years of doing what we are doing [and it would not make the impact that is needed],” she said. “What we require is a move to action. “We want to focus on good practice and experience. We want to design for safety and not just to prevent harm. What we have described in our Blueprint for Action3
is
what good should look like. “That means: safety is a core purpose;
there are explicit standards for patient safety; all staff are qualified and experienced in safety; patients are seen as part of the team; there is a culture that prizes safety and learning; and that lessons can be applied quickly and easily.” In support of this, Hughes went on to formally launch ‘The Hub’;4
safety learning platform that has been designed with clinicians, patient safety experts and patients to act as a repository of good practice and to support a community through which people can share ideas. “The Hub is for everybody,” Hughes
stressed. “Today is the launch, and now we want to hit the button and get people using it and sharing it.” (#share4safety).
Change comes from the top
The rest of the event, which was attended by more than 150 people, focused on some of the persistent challenges in developing a culture of patient safety; and, importantly, ways to address them.
As Dr Elaine Maxwell, clinical advisor, National Institute for Health Research, pointed out, echoing the opening comments: “There is a tendency to focus on what goes wrong, rather than on creating a system for safety.”
an online patient
A key change, she argued, is that the complex system of the NHS “needs to operate in an open way” and “leaders need to support that.” Professor Ted Baker, the chief inspector of hospitals at the Care Quality Commission, agreed. In comments picked up by the press present at the event,5
he said that, while the
CQC had seen improvements in many of the areas on which it assesses NHS Trusts, safety “has not moved on.” “There is a culture of compliance: ‘we do it because the CQC tells us to’ not ‘we do it because we have a safety culture’,” he said; adding this meant he still receives 500-600 ‘never events’ reports every year, most of them “very repetitive” in dealing with the same litany of errors. However, in less reported comments, he argued that what needs to change is clear. Patients need to be involved and to be able to challenge the system. Staff need information and “to know what to do with it – which is why we need something like The Hub,” adding that “it could make a significant difference.” Sir Stephen Moss, who was turnaround chair of the Mid Staffordshire NHS Foundation Trust, warned that there needs to be a change in culture, led from the top. Tom Kark QC, who was senior counsel to the Mid Staffs Inquiry, and who has just completed a review of the Fit and Proper Test for board members, outlined some practical steps that it has suggested to stop the “revolving door” through which failed directors and senior managers can sometimes pass. These include the creation of a health directors standards council to investigate misconduct, and an end to ‘vanilla’ references. However, Linda Kenwood, principal lecturer in nursing at the University of Cumbria, argued that the key is for leaders to guard against their necessary “confidence” slipping into “supremacy”, and to have the “humility” to include the patient perspective.
Open culture, listening to patients
In another session on the ‘practical steps’ that can be taken to improve patient safety, Douglas Findlay, a learning and development
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