Developing a patient safety strategy for the NHS What do you think?

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Contents Page

Introduction 3

Patient safety 4

Our aim 6

Our ideas 10

Thank you 20

For more information 21

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Introduction We are working on a new strategy which will improve how we keep people safe in the NHS.

This strategy will affect how all NHS staff work.

This document has ideas for the new strategy. We want to know what you think.

Please give us your views by answering the questions and sending us your answers.

You do not need to answer all the questions, only those you have views on.

We need your answers by Friday 15th February 2019.

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A strategy is a long term plan.

Patient safety

Sometimes things go wrong in healthcare.

Anyone can make mistakes.

It’s very rare for NHS staff to do things wrong on purpose.

We want to reduce the chances of people coming to any unexpected harm while they are getting a healthcare service.

The national patient safety team

The NHS has a team of people who make sure that health services keep people safe.

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They also:

• Look into situations when something goes wrong

• Learn from things that go wrong so we can make things safer

Our challenges

Sometimes the NHS is not as good as we would like at learning how to make things safer.

Sometimes the NHS is not as good as we would like at listening to patients and families when things go wrong.

Some healthcare staff don’t feel confident enough to report when something has gone wrong.

Some health services do not know how to help their staff find safer ways to do things.

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Our aim

We want the NHS to be the safest healthcare system in the world.

We want the NHS:

• To be the best in the world at learning how to make things safer

• To have workers who understand how to keep people safe

• To take action that will cut the number of things that go wrong in particular areas of healthcare by half

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Our 3 principles

A principle is the way we do things.

We have 3 main principles:

• Fairness. All our staff should feel confident that they won't be blamed for accidentally making mistakes

• Openness. We should all be ready to speak up and tell the truth about everything

• Getting better. We should all be learning how we can improve

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Question 1:

A. Do you agree with these aims and principles?

B. What do you think makes staff feel that they will be blamed when they accidentally make a mistake?

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C. How can we stop staff from being unfairly blamed?

D. How can we encourage staff to be ready to speak up and tell the truth about everything?

E. How should we help staff to learn about keeping people safe?

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Our ideas We have 3 main ideas:

1. Learning from incidents

About 2,000,000 incidents are reported every year in the NHS.

We can’t read every one of them.

Our ideas are:

• Developing a new computer system which helps us to understand the information from those incidents.

• Looking at how the National Patient Safety Alerts Committee (NaPSAC) gives advice and guidance.

NaPSAC gives useful and practical information about how to avoid making mistakes in healthcare.

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NaPSAC involves patients, service users, carers and families in its work.

• To use Medical Examiners as one of the ways in which we can spot problems and to help us work out how we can improve safety

• NHS England and NHS Improvement share information more

This will help to make sure that we have better ways of using information to understand how to keep people safe.

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Medical Examiners look at cases where someone has died. They check that the doctors have done everything right.

They suggest new ways of working so that more people stay alive.

Question 2:

A. Do you agree with these ideas? Please give the reasons for your answer.

B. Would you suggest anything different?

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2. The way we work

When we looked into some of the things that have gone wrong we found that:

• Some health services don’t know enough about how to keep people safe

• Different services deal with advice about safety in different ways

Our ideas are:

• To get all health services to deal with advice about safety in the same way

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• Better training for staff around patient safety

• Setting up senior patient safety specialists. We will have them in every organisation. They will help health services report and learn from incidents and improve safety in the best way

• Setting up a patient safety support team. This would be a team of people who can go into any health service which is having problems with patient safety

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Question 3:

A. Do you agree with these ideas? Please say why.

B. Would you suggest anything different?

C. What things should we teach staff about keeping patients safe?

D. How should training be given to staff?

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E. What skills and knowledge should patient safety specialists have?

F. How can patients and carers be more involved in helping to keep patients safe?

G. Should we create a new team who can help individual organisations to improve their safety?

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3. New ways of working We want to take action that will cut the number of things that go wrong in particular areas of healthcare by half.

Our ideas are:

• Improving the work of the Patient Safety Collaboratives (PSC) programme. The PSC helps healthcare organisations to improve safety

• Choosing which areas of healthcare to focus on

We are already thinking about how to help healthcare services:

• Stop patients from getting more ill than they already are

• Use good ideas that have already been developed

• Deal with medication more safely

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• Make sure mothers and babies are safer in hospital

• Stop patients catching a bug in hospital

• Stop patients falling over and hurting themselves

• Reduce the number of patients who get sores from lying in bed all the time

• Help patients get better food

• Help people with mental health problems

• Use completely new ideas to make it impossible for certain mistakes to happen

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Question 4:

A. Do you agree with these ideas? Please say why.

B. Would you suggest anything different?

C. What is the best way to improve the safety of particular parts of healthcare?

D. What is the best way to involve all staff in the changes?

E. How will we know when we have changed?

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Thank you Thank you for your views.

Your answers will help us when we write the National Patient Safety Strategy. This should be ready in spring 2019.

Please now send your answers back to us by email:

Clicking the button above will automatically create a new email with our address on it and your survey attached. You will then need to click ‘send’ to email your survey back to us.

We need your answers by Friday 15th February 2019.

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For more information If you need more information please contact us by:

Email: patientsafety.enquiries@nhs.net

Web: improvement.nhs.uk

Telephone: 0300 123 2257

Twitter: @NHSImprovement

Post: NHS Improvement Wellington House 133-155 Waterloo Road London SE1 8UG

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