By John Tingle
The UK Government and the Department of Health are taking patient safety very seriously and, since the publication of ‘An organisation with a memory’ in 2000, the UK has like the USA been a world leader in the field of patient safety policies, practices and developments.
In the UK we have a very sophisticated patient NHS (National Health Service) patient safety infrastructure and system along with a NHS Adverse incident reporting system, the NRLS (National Reporting and Learning System). Despite having such a ‘Rolls Royce’, well-established patient safety infrastructure and system, terrible patient safety incidents such as that which happened in Mid Staffordshire a few years ago seem to plague the NHS. Patients died because of poor care and, according to the report, “[t]he Inquiry identifies a story of terrible and unnecessary suffering of hundreds of people who were failed by a system which ignored the warning signs of poor care and put corporate self-interest and cost control ahead of patients and their safety.”Our patient system missed the terrible care failings identified in this inquiry report. We are working hard on improving the system and my posts will provide regular updates on what is happening in the UK, Europe and beyond in patient safety.
Patient Safety: A World Problem
It is clear from reading the patient safety literature and from the work of organisations such as the World Health Organisation (WHO) that patient safety is a world problem and that valuable insights and lessons can be learned from how other countries are approaching the problems of developing an ingrained patient safety culture in their health systems. Minnesota appears to be doing really well in developing tools and strategies in the patient safety arena and we in the UK certainly can usefully benefit from the experiences of that State as can other countries. The 12th Annual Public Report, February 2016 has recently been published by the Minnesota Department of Health (MDH).
The report is well written, informative, contains excellent case studies and very useful data. The work being done in the State does seem to be making a positive and real difference in enhancing the quality of patient care and making patients safer. What is particularly useful in the report is the care areas, procedures discussion and the commentary on why adverse health events (AHE) occurred. There is a discussion of Root Cause Analysis (RCA) and again valuable information is given. For example in the report it is stated that the majority of adverse events were tied to root causes in one of three areas: rules/policies/procedures, communication and physical environment/equipment. Common communication problems are revealed in the discussion on RCA findings. Hospitals and other healthcare facilities reported that half the time information was either not sent to the right person, was not part of a structured communication process, or the process used was not used appropriately.
Well done, Minnesota; we can learn a lot from your experiences in the UK and your findings will be shared.
