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PATIENT SAFETY
Continuing action for imperatives in care
Kate Woodhead RGN DMS examines NHS Improvement’s strategy for England. The challenges and new frameworks could save 1000 lives and £100 million annually from 2023/24.
Patient safety has been high on the political and health agenda since the original and sentinel report ‘To err is human’ published by the Institute of Medicine in the USA 20 years ago.1
The healthcare world was shocked by the fact that we cause harm to one in 10 of our patients. We have moved a long way since that time, and the science of patient safety has emerged as a serious and fascinating academic study of human behaviour in a high risk industry. In addition, the topic and consequent changes made to make our health systems safer has engaged all the developed healthcare nations, and the World Health Organization is leading patient safety challenges across the planet.
NHS Improvement recently published the strategy for the next few years for England. The three strategic aims are to continuously improve patient safety by building on two existing foundations, which are the patient safety culture and a patient safety system. It will be done by using three elements, that of insight, involvement and improvement.
A just culture
Within the vision for safe patient care in England,2
under each of the subtitles, is
a raft of objectives for the NHS to achieve. However, it is recognised that, in order to succeed, there has to be more action to persuade the workforce in the NHS that there is a ‘just culture’. The ‘no blame’ culture of the past largely ignored accountability and so was not seen to be fair. If no-one is to blame, there is no fault, and so everything will just stay the same. The ‘just culture’ was described by
James Reason as long ago as 1997 as an: “atmosphere of trust in which people are encouraged, even rewarded for providing essential safety-related information, but in which they are clear about where the line must be drawn between acceptable
The strategy recognises that healthcare is complex and many factors are likely to influence the outcome. A systems approach to errors considers all relevant factors, and means that the pursuit of safety focuses on strategies that maximise the frequency of things going right.
SEPTEMBER 2019
and unacceptable behaviour.”3 The strategy recognises that healthcare is complex and many factors are likely to influence the outcome. A systems approach to errors considers all relevant factors, and means that the pursuit of safety focuses on strategies that maximise the frequency of things going right. More-often-than-not the lived experience in many organisations is that the systems cause the issues, but that the individuals are blamed and dismissed, enabling it all to happen again. The faults in the system persist uncorrected.
Catchpole and Giddings et al describe this related to surgery as: “The prospective identification of such components in an otherwise successful system can lead to removal of these error-inducing conditions before they can contribute to patient injury. Such a systems-based approach is likely to provide greater and more sustained benefit than by paying yet more attention to obvious, but often irreversible, human errors.”4 The features of a patient safety culture which the patient safety strategy sets out, include, staff who feel psychologically safe - which means working in an environment which is inclusive and compassionate, and in which they will be treated fairly. It also implies that staff do not need to behave defensively to protect themselves and,
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