PATIENT SAFETY
instead, opens the space in which they can learn.
Diversity is also a feature of a just culture where trust and respect are shown to all equally, and where people may thrive as themselves. Leading collectively through the team enhances the voice of even the least powerful roles, and so enhances safety. Working in a way which undermines by discrimination or humiliation leads to fear, which decreases team psychological safety and workplace learning. Progress on delivering a safer culture will be enhanced by the introduction of a national patient safety syllabus and the designation of roles in NHS Trusts for patient safety specialists. Careful monitoring will also be undertaken.
Insight and understanding
It is essential that in order to understand the continuous process of getting patient safety safer, there is the need to measure it. The strategy acknowledges the need to undertake this and will do so according to the following principles: l Be clear about the purpose of each measure, ‘dashboard’ or ‘scorecard’
l Be clear when a change is an improvement l Don’t use too many measures – this can crowd out the important ones
l Measures of culture, infrastructure, process and outcomes are all useful
l Use the same measure for the same purpose across all organisations
l Make data collection easy, using existing data where possible
l The terms ‘avoidable’ and ‘unavoidable’ are unhelpful for patient safety
l Incident reporting is never a measure of actual harm
l The design of data presentation is critical to how it is interpreted
l Work in partnership with analysts, patients, improvers and clinicians.
There is also a plan to replace the current National Reporting and Learning System (NRLS) which has been in place since 2004 and is now rather outdated technology. A further objective of the new technology is to make data and learning more accessible
Action on patient safety and a greater understanding of the failures of the care which is currently provided is always welcome – however hard it is for clinicians to accept the mistakes which lead to harm and possible death.
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and transparent. It seeks to offer a self service portal to search, analyse and download data to support learning and improvement as well as safety science and international collaboration. In addition, there is to be a new Patient Safety Incident Response Framework which will replace the Serious Incident Framework. There is to be a new system to review and understand better, the care which patients receive at the end of life, especially if something has not been correct as far as the family is concerned and they are unhappy. The current support is provided by national quality board guidance which advises Trusts on how they should support, communicate and engage with families following a death of someone in their care. It does not mandate a ‘one size fits all’ approach in recognition that each family, and each Trust, is different. It is hoped that Trusts will use the good practice it sets out to complement and improve work they are already doing to support families.5
In order to be
comprehensive about the care to bereaved families, the strategy proposes to set up a system of medical examiners to provide independent scrutiny of deaths which occur within the health system. This will be set up in acute care and then be expanded to include all deaths in the community and in independent providers. This is expected to:
l Provide a better service for the bereaved, and an opportunity for them to raise concerns about care with a doctor not involved in that care
SEPTEMBER 2019
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