The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients

DriversAugust 9, 2019Comments Off on The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients

What does this mean for libraries? 

LKS provide access to resources to support safe and effective care, such as point of care tools, evidence searches and current awareness alerts. We support staff to innovate and make changes to their work, and this can help increase staff engagement which is shown to reduce the number of safety incidents.

LKS also provide a place for staff to undertake e-learning courses, and this can support the roll out of the proposed universal patient safety syllabus and training programme for the whole NHS (p. 37).

LKS can support the mobilisation of knowledge through a variety of means (see the Knowledge for Healthcare Knowledge Management Toolkit for examples) and this can help spread learning through the organisation.

The proposed role of Patient Safety Specialist that is to be created in each organisation is one that could be supported by LKS.

Source: NHS England and NHS Improvement

Link to main document

See also the briefing by the NHS Confederation

Date of publication: July 2019

Summary of driver:

This strategy aims to move the NHS towards safer systems that provide the right care every time and learning from what works, not just what doesn’t. Too often individuals have not felt safe to admit errors and learn from them or act to prevent recurrence so the strategy aims to enable a culture transition from blame to learning.

Patient Safety is to be seen as a‘golden thread’ running through healthcare, and more can be done to share safety insight and empower people – patients and staff – with the skills, confidence and mechanisms to improve safety.

To do this the NHS will build on two foundations: a patient safety culture and a patient safety system. Three strategic aims will support the development of both:

  • improving understanding of safety by drawing intelligence from multiple sources of patient safety information (Insight)
  • equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system (Involvement)
  • designing and supporting programmes that deliver effective and sustainable change in the most important areas (Improvement).

To improve insight, the NHS will:

  • adopt and promote key safety measurement principles and use culture metrics to better understand how safe care is
  • use new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system
  • introduce the Patient Safety Incident Response Framework to improve the response to and investigation of incidents
  •  implement a new medical examiner system to scrutinise deaths
  • improve the response to new and emerging risks, supported by the new National Patient Safety Alerts Committee
  • share insight from litigation to prevent harm.

To improve involvement, the NHS will:

  • establish principles and expectations for the involvement of patients, families, carers and other lay people in providing safer care
  • create the first system-wide and consistent patient safety syllabus, training and education framework for the NHS
  • establish patient safety specialists to lead safety improvement across the system
  • ensure people are equipped to learn from what goes well as well as to respond appropriately to things going wrong
  • ensure the whole healthcare system is involved in the safety agenda.

To support improvement, the NHS will:

  • deliver the National Patient Safety Improvement Programme, building on the existing focus on preventing avoidable deterioration and adopting and spreading safety interventions
  • deliver the Maternity and Neonatal Safety Improvement Programme to support reduction in stillbirth, neonatal and maternal death and neonatal asphyxial brain injury by 50% by 2025
  • develop the Medicines Safety Improvement Programme to increase the safety of those areas of medication use currently considered highest risk
  • deliver a Mental Health Safety Improvement Programme to tackle priority areas, including restrictive practice and sexual safety
  • work with partners across the NHS to support safety improvement in priority areas such as the safety of older people, the safety of those with learning disabilities and the continuing threat of antimicrobial resistance
  • work to ensure research and innovation support safety improvement

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