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Today, Professor Don Berwick publishes his report on the safety of patients in England.
I had the pleasure of supporting his advisory group as they carried out their huge amount of academic research and engagement with professionals and the public, so I know how much hard work each of these people has put in, despite taking part on a voluntary basis with no remuneration.
Not too long ago patient safety was seen as an “add-on”, with separate agencies in charge and no absolute direction for NHS services to take their advice and work on board.
Now, patient safety is truly “mainstreamed”. It is no longer the preserve of a select few academics and experts – it is at the heart of every job in the NHS, on the ward, in the GP’s surgery, in every community service and all the way through the system to the NHS England Board. The absolute importance of patient safety is also now recognised at every government level from our local authorities to Whitehall.
But there is still much more to be done!
As Professor Berwick has so clearly articulated, openness and honesty about the mistakes we make and the near-misses we have is absolutely vital if we are going to make the NHS as safe as it possibly can be. We have an ambition to make the NHS the safest healthcare system in the world, and we know the unique structure of how we deliver services to our patients in every sector and every setting means this ambition is certainly achievable.
Now is the time to build upon this foundation and make further advances in the world of safety improvement so the legacy of Francis, Keogh and Berwick is that of a confident and learning health system that listens to the needs of its patients and staff in order to deliver the safest and best healthcare.
We have a good platform to build on:
- With our National Reporting and Learning System, we have already built up the world’s most comprehensive database of patient safety incident information. We collect over 100,000 reports a month from across the whole system and we are now looking forward to collecting even more directly from general practice and just as importantly, from our patients and their carers. This is not just for the sake of it. Incident reporting is a means to an end – the goal of continually improving the safety of the NHS.
- Every hospital in England is using the WHO Surgical Safety Checklist, and we are supporting local organisations throughout the country to develop and spread their own ways of assuring patients are safe. We can continue to make great advances by identifying the problems that lead to harm and the innovations and ideas that can reduce that harm and make sure they are implemented across the system.
- Initiatives like University Hospitals Birmingham’s electronic prescribing system are preventing thousands of potential prescribing errors every year. Hundreds of individual projects to prevent falls and pressure ulcers among older and more vulnerable patients are making a huge difference to real people’s lives and experiences in hospital. We must continue to allow this kind of local innovation and encourage others to do likewise.
An important message in Prof Berwick’s report is that patient safety improvement is a never-ending task. The job of keeping patients safe is never done, and the constant advances in medical and surgical procedures mean we need to remain vigilant. As NHS England’s Director of Patient Safety, I know the desire to improve is incredibly strong throughout all parts of the NHS. I am determined to harness that enthusiasm as we move forward together to an ever-safer health and care system for all our patients.
There is no panacea for error. It would be dangerous to pretend there could be a magic solution. But if we get the actions above right, it’s my genuine hope that within the next five years we will not be just talking about increasing reporting and raising awareness. We will be able to measure the NHS getting safer. And we will feel the difference every day at work, where we will be working within a culture that really does value safety.