We are committed to providing regular updates on progress with the implementation of the Digital Clinical Safety Strategy to show how we capture insights about digital clinical safety, how we are training our workforce to support safety in this area and how we use technology to drive safer care.

October 2023 update

Since the publication of the Digital Clinical Safety Strategy in September 2021, we have been working towards two aims:

1. To improve the safety of digital technologies in health and care, now and in the future.
2. To identify, and promote the use of, digital technologies as solutions to patient safety challenges.

The health service continues to see the steady increase of digital health technologies, and with it a heightened interest in digital clinical safety. This has driven progress towards these aims as well as the strategy’s five strategic commitments. Ensuring patient safety is reflected in the digitisation agenda remains a key component of the National Patient Safety Strategy.

Commitment 1: Collect information about digital clinical safety, including as part of the Learn from Patient Safety Events (LFPSE) service and use it to improve system-wide learning.

To measure digital clinical safety, it is necessary to capture data about how digital systems impact patient safety, both positively and negatively. Furthermore, it is important to review this data and communicate key findings or alerts to the wider system. The following work supports Commitment 1:

• We have worked with the LFPSE team to ensure the system accurately and thoroughly captures digital clinical safety information. This includes adding three new digital clinical safety specific fields for certain types of incidents.
• There is now a national process in place to ensure routinely collected patient safety data is reviewed by digital clinical safety experts in the same way that all other safety incidents are reviewed, including a formal review of all incidents indicating severe harm or death.
• The digital safety teams within NHS England became accredited to issue National Patient Safety Alerts.

Commitment 2: Develop new digital clinical safety training materials and expand access to training across the health and care workforce.

We have conducted a system wide digital clinical safety learner needs assessment with 250 participants and 11 industry providers. Stakeholders indicated that while current DCS training is important in developing digital clinical safety competence, the consensus was that greater access to training was needed to increase the numbers of Clinical Safety Officers (CSO) (dedicated people who lead on digital clinical safety in an organisation) and increase competence in other digital safety roles across the system. These insights informed the development of a new three-tiered digital clinical safety training programme.

• We have developed and launched a new training package called the Essentials of Digital Clinical Safety, with over 1,100 members of NHS staff trained so far.
• We have also developed an intermediate training package specifically for senior leaders and patient safety specialists.
• An innovative ‘train the trainer’ pilot has been commissioned to train 24 digital clinical safety professionals as trainers, enabling regions to rapidly increase the number of CSOs and create an environment of peer-to-peer support and local mentorship for digital clinical safety.

Commitment 3: Create a centralised source of digital clinical safety information, including optimised standards, guidelines and best practice blueprints.

Digital clinical safety aims to support a culture of learning from incidents as well as learning from excellence, with different health and care organisations working together to capture and model best practice.

As part of our work with stakeholders, it became clear that those working in digital clinical safety desired support to access best practice information and build communities and networks. To support this, we have created a dedicated FutureNHS workspace to showcase blueprints that share best practice. The workspace also supports the NHS to build communities around digital clinical safety.

Blueprints

Blueprints provide best practice guides to NHS organisations to enable them to carry out digital transformation quickly and cost-effectively. They are a core part of What Good Looks Like (WGLL), highlighting good practice examples of delivering technology in a wide range of NHS organisations. They include important ingredients needed for sustainable health improvements such as organisational leadership and culture, clinical and staff engagement as well as the people and processes required. Specifically, a number of publications have supported organisations to have access to this type of best practice.

To date, in partnership with individual NHS organisations, we have published six blueprints to help organisations ensure clinical leadership and involvement at the earliest opportunity when a new digital system is implemented, so that risks are mitigated and plans are clinically focussed with a user centred design approach.

Commitment 4: Accelerate the adoption of digital technologies to record and track implanted medical devices.

The heart of digital clinical safety is translating safer care into improved outcomes for patients’ health, quality of life, experience and journey through the health service. To achieve this, there needs to be an ambitious national focus on surfacing and scaling opportunities for digital to improve safety. Scanning technology is a key driver in improving traceability of implanted medical devices. The Government’s Mandate to NHS England stipulates that by March 2024, all trusts should adopt barcode scanning of high-risk medical devices.

The following actions have been taken to support organisations to use scanning to drive safer care.

• We launched a Scan4Safety website including a suite of Scan4Safety guidance material that enables organisations to understand the key benefits and cost savings associated with a Scan4Safety Programme. It includes key messages from MHRA, NHS England and trusts already using Scan4Safety. It offers trusts a practical guide for how to get started.
• We have continued to provide advice, guidance and support to organisations that were prioritising local implementation of Scan4Safety. In addition, we have also engaged with board members across acute providers to better understand their awareness of and plans to introduce Scan4Safety.
• The Outcomes and Registries programme will be used to improve patient safety and outcomes in procedures that use high-risk medical devices.

Commitment 5: Generate evidence for how digital technologies can be best applied to patient safety challenges.

Using digital as a tool for patient safety improvement starts with testing and building evidence about when and how digital technologies can make care safer. A robust evidence base is required to demonstrate what works, what doesn’t work and where investments are best placed to scale up promising technologies.

Developing an evidence base for digital clinical safety relies upon collaborative working with major digital transformation programmes. It also requires close collaboration with industry, as well as academic institutions to understand which technologies are resulting in safer care. This requires prioritising digital clinical safety across the research agenda and using routinely collected data to derive insights about how digital technologies contribute to or could prevent ham.

To support this:

• We have worked with existing patient safety data to explore patient safety risks associated with certain digital technologies.
• We have built analytic partnerships with organisations like NHS Resolution to explore the potential for patient safety claims data to reveal new insights about digital clinical safety.
• We have leveraged integrated working across patient safety teams to ensure that digital clinical safety features on upcoming national frameworks for patient safety research priorities.
• We have developed a benefits case for major digital transformation programmes in frontline services to evaluate their impact on safety.