By John Tingle
There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed.
Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues
NHS Patient Safety News
Recently the media spotlight has been turned yet again on some poor NHS care practices in maternity care. On a positive note, the new national NHS patient safety syllabus, draft 1.0 has been published.
Maternity Care Patient Safety Failings
Lintern, S. in the Independent newspaper reports that they have learned of dozens of deaths at East Kent Hospitals with more than 130 babies suffering brain damage as a result of being starved of oxygen during their birth over a four -year period.
“Warning in 2016 that lives were at risk because consultants were not showing up for weekend and evening shifts”.
This maternity crisis follows the recent one being investigated in Shrewsbury and Telford where BBC news had the banner headline stating:
“Shrewsbury and Telford Hospital: Babies and mums died ‘amid toxic culture”.
Boseley, S. states in the Guardian newspaper:
“Some women claim that they are being denied epidurals because of what the Sunday Telegraph says is “a cult of natural childbirth” in six hospital trusts. Several claimed they were told they were either insufficiently dilated or too far dilated to have an epidural.”
Unlearnt lessons
It is clear following on from the very serious patient safety failings chronicled by Kirkup in 2015 in the Morecambe Bay maternity care inquiry report that patient safety lessons still need to be learned in the NHS in this care area.
A national NHS patient safety syllabus: draft published
A fundamental pre-requisite to developing an ingrained patient safety culture in the NHS is to provide education and training in the subject to all staff. A national patient safety syllabus was heralded in the new NHS Patient Safety Strategy. The first iteration of it has recently been published by AOMRC (Academy of Medical Royal Colleges). It is described as the first NHS-wide patient safety syllabus and that it is applicable to all staff. It provides a common language and patient safety framework. Incident reporting and investigation is included along with other content such as creating a safety culture, human factors, and proactive risk management:
“The syllabus is based on a systems approach to human factors. It is holistic in its use of human factors, both system-and person based” (P5).
Don’t forget and about health law and ethics
In implementing and teaching the new syllabus, the study of health care law and ethics should not be neglected as these subjects permeate through many patient safety issues. The new syllabus is to be welcomed; it has the potential to positively galvanize NHS staff action and learning in patient safety.
A key issue will be how well the various sections of the NHS respond to, resource, and teach the syllabus in a cash strapped NHS. There are also dangers with a systems approach to patient safety, which can possibly work to deflect or obscure the personal, professional accountability of NHS staff for error. We always do need to promote the fact that nurses and doctors also owe individual, professional, legal duties to patients which they cannot detract from.
