Executive summary

This report makes the case for changing the way patient safety is approached in the NHS. It argues that change is needed in: how safety is understood, because current approaches to measurement don’t provide the full picture; how safety is improved, because existing approaches alone will not address the most intractable problems; how risk is perceived, because comfort-seeking behaviours will not create a genuine culture of learning.

The patient safety movement is now at a critical moment; to sustain momentum, there has to be recognition that things can – and should – be better.

There have been some remarkable successes in recent years to improve patient safety and tackle harm, and front-line teams supported by the Health Foundation have been an important part of these efforts (see pages 6-7 for examples of some of our current work). This report brings together what we have learned from this work, and also highlights some salutary lessons about the state of patient safety in the NHS and the complex task of continually trying to improve it.

We have learned that many systems are not designed with safety in mind, meaning that it is only the skill and resilience of health care professionals that prevents many more episodes of harm. We have learned that many care processes are unreliable, which can mean that the right equipment isn’t available in theatre, or the wrong drug is given to a patient. We have learned that many institutions don’t have a complete picture of safety, because they focus largely on past events rather than current or future risks. We have learned that there are some common factors that have repeatedly contributed to large-scale failings, but that these factors have consistently not been addressed.

Despite the many successful quality improvement projects the Health Foundation has supported, there have been many more that haven’t delivered the expected benefits. We are only now coming to fully understand the reasons for this. For instance, front-line teams consistently come up against ‘big and hairy’ issues such as inadequate information technology, inconsistent staffing and challenging established cultures. Yet these issues are far beyond the scope of individual teams, and the scope of quality improvement methods alone, to address. If the most intractable safety problems require nationally coordinated solutions, then existing approaches will not yield the future gains that patients and the public expect.

So what might safer care look like in the future?

In our view, a safer care system is conceived from the perspective of the patient, following his or her journey through different care settings, irrespective of organisational boundaries. It is networked, so that successes and failures identified in one part of the system can be readily accessed, understood and built on in another. And it is judged not by the prevalence of adverse events, but by the ability to proactively identify hazards and risks before they harm patients.

How can we get there?

  • The journey must begin with practical improvements, based on what is known to work. This report presents a checklist for safety improvement, based on our experience of supporting NHS teams to improve safety. The checklist should be used by front-line teams and organisations when addressing their most pressing safety problems. (See page 28.)
  • Improvements to safety on the ground can only be successful with the support of senior leaders in provider organisations. This report sets out the three vital steps that senior leaders should take to create an environment where safety improvement can flourish. (See page 29.)
  • The practice and policy of safety improvement are inextricably linked, reflecting recognition that the design of the wider system can support, and hinder, the efforts of front-line staff and senior leaders. This report sets out our vision for an effective system for safety improvement. (See page 34.)

Underpinning everything is the need to approach the work with trust, sincerity and openness. Local improvements in safety won’t be successful if they are not applied faithfully, just as national improvements in safety won’t be achieved if they become subverted into measures of accountability. These are the core lessons we have learned over the past decade; this report draws on them to make the case for why and how future improvements in safety can be realised.

Health Foundation patient safety projects in 2015

This map shows the patient safety projects that the Health Foundation has supported in 2015.

For more details about the ful range of the Foundation's past and present work on patient safety, please visit: www.health.org.uk/theme/patient-safety

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