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Lost in the Jungle of Patient Safety Reports, Publications and Initiatives?

By John Tingle

In terms of the progress of developing a patient safety culture in the National Health Service (NHS) in England, the Daily Telegraph reports comments made by Professor Ted Baker, the Chief Inspector of Hospitals at the Care Quality Commission (CQC) at a recent conference in London. He held the view that “little progress” has been made improving patient safety in the NHS in 20 years, and that never events such as wrong site surgery were still happening because the overall culture is one of defensiveness. The Telegraph reported, “He told The Patient Safety Learning conference that hospital managers routinely hide evidence from the CQC, because they regard the organisation as out to blame them.”

The Telegraph also mentions an NHS estimate in July that 11,000 patients a year may be dying as a result of blunders, partly as a result of a “blame game” culture between staff.

The CQC is the NHS Independent regulator of health and social care in England.

These are strong words about the failure to make sufficient progress in properly developing an NHS culture of patient safety. They can be further justified when you look at NHS publications of around 20 years ago and reflect on how far or little we have moved on since then.

An organization with a memory

In the year 2000, the seminal NHS patient safety publication, “An organization with a memory,”, was published which clearly spelled out the patient safety problems that the NHS needed to resolve:

Experience suggests that the NHS as a service is not expert at preventing serious incidents or occurrences in which patients are harmed or experience very poor outcomes of care. Nor does it always learn efficiently or effectively from such failures when they do occur.

The problems identified in the report are all too familiar today with the same problems seeming to largely persist. This would appear to corroborate Professors Bakers 20-year statement made at the conference that “little progress has been made improving patient safety in the NHS over the past twenty years…”

The NHS has been no slouch

Over the past 20 years the NHS has been no slouch when it comes to patient safety initiatives. Many excellent reports and initiatives have been regularly produced and continue to be produced highlighting the nature of the problems and remedies.

It may be time now however to reflect on all this activity and to see whether it is positively contributing to the development of a NHS patient safety culture. There is a danger of patient safety policy overkill with all the literature and initiatives being produced both globally and nationally. We don’t want to overwhelm health carers with too much information.

Health Education England (HEE)

A good indicator of current NHS patient safety initiatives can be seen on the HEE website. There is a lot going on. HEE have also produced an excellent piece of patient safety training and education with their tool kit which maintains an important potential to contribute towards the development of a positive and effective NHS patient safety culture.

The patient safety tool kit is call “In Safe Hands.” Sections of the guide include discussions of human factors. Up to 80% of health care errors are caused by human factors associated with poor team communication and understanding. Embedding simulation training is also discussed as a powerful method of improving patient safety. HEE state safety-focused learning and training opportunities available within the NHS, delivering the education. The importance of speaking up is discussed. Learning why raising concerns is critical to maximizing patient and workforce safety across the NHS. The resource also includes videos on Human Factors and lots of other patient safety related material.


It seems difficult to assess the progress that the NHS has made in developing a patient safety culture. Incremental and measured progress has been made, not great leaps and bounds. It is a worry that there are views that not much progress has been made but this is the stark reality of an existing situation. The point of the exact extent of progress can be seen as a moot and arguable point. Patient safety has become a global business and a myriad number of publications, papers, reports, initiatives, campaigns are now being produced. Busy health carers everywhere can feel swamped and engulfed by the tide of patient safety information flowing out. At some point patient safety policy makers need to take stock of what information is out there and to start thinking more about the development of global patient safety information hubs which can pass information down the system in manageable chunks. The worry is that in England we have had 20 years or more of trying hard with patient safety and as Professor Ted Baker said in his conference comment, we have made little progress. There are reasons for this and patient safety information overkill may be one contributing cause.


John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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