PATIENT SAFETY
l Enhance patient safety by ensuring that all deaths are scrutinised by an independent medical examiner so that any issues with the quality of care can be identified and acted on
l Ensure the appropriate direction of deaths to the coroner
l Improve the quality of death certification. Involvement
This work identified in the strategy involves patients becoming partners in their care by creating the role of patient safety partners. The plan is that patient safety partners might be useful to hospitals by being empowered to become vigilant stakeholders as patient safety champions and being involved in staff training. They will need to have a clear role, with objectives and training needs – perhaps working with or to a non-executive director or director with responsibility for patient safety. This level of involvement could ensure the voice of patient safety at Board level. The strategy suggests they may have a role in contributing to service and pathway design, in safety governance and in strategy and policy. They would be remunerated for their work. Further guidance on this role is to be forthcoming in the next few months. The national patient safety team wishes to make it possible for every member of the NHS to access consistent, high quality patient safety resources according to their role, in order to broaden and deepen training. To that end, the strategy suggests that there should be a concerted effort to provide appropriate training in line with: l Developing a robust, achievable and aspirational plan for patient safety training for the NHS
l Make safety training within professional educational programmes explicit and mapped to the competencies in a national syllabus
l Ensuring every member of the NHS has access to patient safety training; from ward to board and from commissioner to provider.
A further new role is proposed – one of the patient safety specialist. This role would have
oversight of and provide support to all patient safety activities across their organisations. They would also ensure that systems thinking, human factors and ‘just culture’ principles are embedded across the board.
Improvement
Quality improvement knowledge provides the understanding to know that continuous improvement and sustainability have a close relationship. There are a great many tools available for students of patient safety science to understand variation, study systems, build learning and capability, and determine evidence-based interventions and implementation approaches to achieve the desired outcomes. The Patient Safety Collaboratives are currently hosted by the Academic Health Science Networks and are charged with delivering on four national priorities. They are, preventing deterioration and sepsis, medicines safety, maternal and neonatal safety and adoption and spread of tested interventions.
Identification of NEWS2 across acute and ambulance Trusts, and adoption of the scheme across more Trusts to achieve successful recognition of a patient who is deteriorating, will help to manage these patients better. More work needs to be undertaken on it and there is also further work on a paediatric version to help improve the recognition and response to deterioration in acutely ill children. The adoption and spread of other clinical care bundles and safety checklists will be overseen by the revised national patient safety improvement programme.7 The Maternity and Neonatal safety improvement seeks to ensure that the care given to new mothers and babies is safe and of high quality. The ambition is to continue to improve and to reduce the number of still births, neonatal deaths and asphyxial brain injury by 50% by 2025. Not only will this programme be better informed by using a single portal for the gathering of information but the many and varied organisations which get involved at present will have the benefit of greater insight. The programme will also have access to a new care bundle8 concerning risk assessment, prevention and
surveillance of pregnancies at risk of foetal growth restriction, raising awareness of reduced foetal movement and some aspects of reducing preterm birth.
The Medicines Safety Improvement
Programme which chimes with WHO’s third patient safety challenge aims to reduce medication harm in the NHS, focusing on high risk drugs, situations and vulnerable patients. There are an estimated 237 million medication errors in England every year, of which 66 million are clinically significant. The strategy aims to assist in reducing the number of medication incidents by delivering system enables including better shared decision making, training and the implementation of electronic prescribing systems, which already began in 2018/19. General practice prescribing will be assisted by the use of a pharmacist led IT system for reducing clinically important errors in prescribing. The target for the latter is to reach 40% of GP practices by 2020. The Mental Health Safety Improvement
Programme seeks to provide bespoke support on individual mental health Trusts specifically to their individual safety priorities. Each Trust should have a safety improvement plan by April 2020 and they will be supported in their development by experts from regional and local safety teams. Further collaborative developments will be undertaken after the first phase is complete.
A few other projects which are designed to have an impact are the continued emphasis on patient safety issues which specifically affect the elderly such as falls, pressure damage, infections and problems related to nutrition and hydration. They are complex and need considerable input at many levels. Currently, NHS Improvement and NHS England have a facilitator role in the Falls collaborative programme. In 2019/20 a new CQUIN incentive scheme has been designed to implement to reduce falls in hospital. Wider work related to patients on the frailty index will have more proactive management, as signalled by the NHS Long Term Plan. In addition, crisis response and same-day emergency care services plan to reduce avoidable admissions and the
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