Patient safety systems
Patient safety systems are a fundamental foundation of the NHS patient safety strategy. Each of the many organisations that make up the English healthcare system (both NHS and non-NHS) has its own remit and responsibility for improving patient safety.
Hospitals, general practices and other providers are responsible for the safety of their patients and sharing local information about risks and best practice. Patient safety is supported from neighbourhood and place to system, via integrated care systems (ICSs), to ensure the provision of safe care and help to tackle problems that cut across care settings.
ICS are supported by NHS regional teams and ultimately the NHS England national patient safety team and other national colleagues who co-produce patient safety policy, advice, guidance, strategies and programmes designed to improve our safety systems. The National Patient Safety committee, established in 2021, brings key national healthcare organisations together to address complex patient safety issues that require cross-organisation effort and input, to make care safer within the NHS.
The national patient safety team work closely with the NHS England quality strategy team to support quality planning, assurance, and improvement through NHS England’s quality governance processes. This includes ensuring publications for integrated care systems and planning documents fully embed patient safety. The patient safety team has helped to co-produce the Quality Functions document (available to NHS staff via the FutureNHS collaboration platform) that require key patient safety actions. These actions include the recruitment of ICS-nominated patient safety specialists, medication safety officers, medical device safety officers and patient safety partners.
Digital clinical safety
The Digital clinical safety strategy launched in 2021 incorporates the three aims of the NHS patient safety strategy: Insight, Involvement and Improvement. Initial work includes launching the Digital Clinical Safety Training programme and creating more clinical safety officers across the system.
Enhancing patient safety in primary care
With primary care (community pharmacy, dental services, general practice and optometry) encompassing over 90% of all NHS consultations, there remains a huge opportunity to understand more and to further improve patient safety in new and innovative ways in this area.
NHS England commissioned research into the incidence, nature and causes of avoidable significant harm in general practice, which was published by Avery et al., 2020. This review estimated there are between 19,800 and 32,200 incidents of avoidable significant harm in general practice in England per year. This work described and classified these patient safety incidents and generated suggestions to mitigate these risks. The key incident themes were identified as: diagnosis 61%, medication-related 26% and delayed referrals 11%.
We have been working across primary care to identify areas for improvement and co-design solutions to promote incident recording via the learn from patient safety events service (LFPSE) and exploring how to implement the Patient safety incident response framework to improve sharing and learning of safety themes.
Narrowing the patient safety inequalities gap
Healthcare inequalities “are not inevitable and can be significantly reduced.. avoidable health inequalities are unfair and putting them right is a matter of social justice” (The Marmot Review 2010). When healthcare inequalities cause harm or increase the risk of harm to patients in healthcare, they are defined as patient safety inequalities. Patient safety inequalities have been classified into themes by Wade et al., (2022) and include inequalities that affect patients and staff, both of which can impact on the delivery of safe patient care.
NHS England are starting to gather information on the diversity of the people affected by safety events as well as those who deliver patient care. We are also seeking to understand the biases that are inherent within our systems and integrating our approach with Core20PLUS5 to identify improvements to reduce patient safety health inequalities.