The first “World Patient Safety Day” took place on September 17, 2019. It is an annual event and one of the World Health Organization’s (WHO) officially mandated global public health days. The aim is to create awareness of patient safety and to urge people to show their commitment to making health care safer. The publicity generated by the event has worked to focus global attention on patient safety issues and is a call for action in the area.
The Care Quality Commission (CQC) occupies a pivotal role in the National Health Service (NHS) and social care sector in securing health quality and patient safety. Its inspection activities through its reports and publications form the backbone of quality and safety in these sectors. As the independent regulator of health and social care in England it faces a mammoth task. The CQC has recently published its annual report and accounts, which provide useful insights into its work. The report provides a window on how England regulates health, social care quality, and patient safety. There is detailed reflection in the report about how the organisation can better perform its functions and the challenges and opportunities currently facing it.
NHS Resolution has several functions in the NHS (National Health Service) in England which include managing legal claims brought against NHS hospitals and other health organisations, as well as important patient safety responsibilities. They have recently published guidance on supporting a just and learning culture for staff, patients, and caregivers following incidents in the NHS.
The guidance is wide ranging and includes examples of just and learning culture development practices. Example one is a just and learning charter that NHS hospitals and other health organisations can adapt or adopt. The NHS charter provides in the first paragraph a sample introductory pledge:
On July 2, 2019 a new National Health Service (NHS) patient safety strategy was launched in England. The strategy promises many things and lays out the future trajectory of NHS patient safety policy making.
Aidan Fowler, the NHS National Director of Patient Safety highlights the scale of the NHS patient safety problem in the foreword to the strategy:
Too often in healthcare we have sought to blame individuals, and individuals have not felt safe to admit errors and learn from them or act to prevent recurrence…The opportunity is huge. Hogan et al’s research from 2015 suggests we may fail to save around 11,000 lives a year due to safety concerns, with older patients the most affected. The extra treatment needed following incidents may cost at least £1 billion (p3).
One of the great difficulties in patient safety and health quality is keeping up to date with all the material that is produced. A myriad number of patient safety and health resources exist globally. By sharing good quality resources, we can help advance the global patient safety agenda.
NHS Resolution (the operating name of the National Health Service Litigation Authority) has excellent patient safety and clinical negligence resources, learning materials and should be viewed as a priority global information source.
Matt Hancock, the Secretary of State for Health and Social Care on February 6 gave a wide-ranging speech on the future direction of patient safety in the NHS. The speech is important as it gives key insights into government priorities for patient safety policy development in the NHS.He stated that we all trust nurses and doctors more than any other profession. He spoke about the importance of a “just culture” in the NHS and openness, honesty, and trustworthiness. Read More
The NHS (National Health Service) in England is developing a new patient safety strategy which will be published in the Spring of 2019. A consultation paper is out and responses are invited until next month. The strategy will sit alongside the NHS Long Term Plan and hopefully will ingrain safety within it. Read More
NHS Improvement has just published a report on Surgical ‘Never Events’.The report presents an analysis of the local investigation reports into 38 surgical, ‘Never Events’ from across England that occurred between April 2016 and March 2017 (the last full year with data available).
In the UK, emergency and urgent care patients visit the A & E (Accident and Emergency) units of local hospitals (known as ERs in the U.S.) A & E service provision is the public face of the NHS. It is seen by many as the bellwether of the national health care system and the basis on which its performance is judged.
The Health and Social Care Regulator of England, the Care Quality Commission (CQC), which maintains important patient safety and health quality reviews, has recently published a report on A & E urgent care that found that the 2017-2018 winter season saw an unprecedented demand for emergency services, continuing a year-over-year increase. The number of emergency admissions has grown by 42 percent over the last 12 years, adding pressure to the NHS.
Failings in National Health Service (NHS) care for patients with mental health problems is a worryingly persistent story in the English media. Many reports show harrowing and dramatic failings in NHS care provision for the mentally ill some of which result in avoidable deaths.The Health Service Ombudsman (HSO) represents the final stage in the NHS complaints procedure and is an independent office reporting directly to Parliament.The HSO carry’s out investigations into complaints and makes the final decisions on those that have not been resolved by the NHS in England.In a recently published report the HSO reveals reveals unjust, shocking and tragic failings in NHS care provision for patients with mental health problems.Some mental health care complaints figures are given in the report.In 2016-2017 there were 14,106 complaints made to NHS mental health trusts (hospitals) with ,65% being upheld or partly upheld by the local organisation.Case work data between 2014-15 and 2017-18 was analysed and five key themes showing persistent failings that the HSO see in complaints being made emerged from this exercise:
Diagnosis and failure to treat.
Risk assessment and safety
Dignity and human rights.
Inappropriate discharge and provision of aftercare.
The HSO also points out in the report that the other common factor in the cases examined is too frequent substandard complaint handling by the NHS organisation. This adds insult to injury, compounding the impact of failings. Read More