On 1 April 2016, the coordination of patient safety within the NHS was transferred to the remit of NHS Improvement, which also took over the functions of Monitor and the Trust Development Authority. NHS improvement aims to give provider organisations the support they need to deliver high-quality care that is financially sustainable. Patient safety data from 1 April 2016 can be found on the NHS Improvement website, whilst older data can be found on the ‘legacy websites’ of the organisations that were subsumed by NHS Improvement. The patient safety functions covered by NHS Improvement include:
- National Patient Safety Alerting System which disseminates alerts to healthcare providers via the Central Alerting System (CAS). Alerts generated between 1 December 2013 and 31 March 2016 are available on the NHS England patient safety alert webpage. From 1 April 2016, alerts can be found on the NHS Improvement alert webpage.
- Data on patient safety alert compliance. All providers are required to sign off alerts via CAS and non-compliance is published on a monthly basis.
- Compilation of never events data from 1 April 2016
- Provision of the Serious Incident Framework and Never Events Framework for managing these occurrences
- The National Reporting and Learning System (NRLS).
Service providers should also be aware of an upcoming national function, the Healthcare Safety Investigation Branch (HSIB) that will conduct independent safety investigations throughout the healthcare service. An expert advisory group, chaired by Dr Michael Durkin, published its recommendations on the establishment of this branch on 12 May 2016, with emphasis on the need for independence through legislation, learning and engagement of patients, family and staff.
Alongside these arms-length bodies, there are other national organisations that contribute towards patient safety, such as the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD). NCEPOD is a charity and company limited by guarantee which is independent of government bodies and professional associations. NCEPOD’s work is commissioned by the Healthcare Quality and Improvement Partnership (HQIP) on behalf of national funding bodies and the independent sector. Through confidential surveys and research, NCEPOD looks into patient management for certain disease conditions and makes these results public to enable learning and improvement. NCEPOD results are disseminated through reports on their websites, presentations on publication days of reports as well as presentations in hospitals (by invitation).
In the UK, another national function that providers should be aware of is the Parliamentary and Health Service Ombudsman. This is an independent complaint handling service that is accountable to parliament. The ombudsman is the final stage for complaints about poor or unfair service that have not been resolved by the NHS in England. Complaints should be lodged with the ombudsman only if the organisation in question has not sufficiently dealt with the issue. Following investigation by the ombudsman, if a complaint is upheld, recommendations will be made to acknowledge the mistake, compensate the complainant (if required) and to ensure improvements are made so that the same mistake does not happen again.
International safety campaigns
In 2002, a World Health Assembly Resolution was issued to encourage all WHO Member States to prioritise the issue of patient safety. As a result, the WHO Patient Safety programme was launched in 2004 which emphasised the importance of patient safety as a global concern. This programme allows for international cooperation and delivers systemic and technical improvement around the world.
This focuses on the importance of infection prevention and control (IPC) to prevent harm caused by infection to patients and staff. This unit will use the foundations and achievements of the Clean Care is Safer Care programme (2005–2015), and work with the Patient Safety and Quality unit to concentrate on five main functions:
- Leadership, connecting and coordinating
- Campaigns and advocacy
- Technical guidance and implementation
- Measuring and learning
Some of the work being undertaken by this programme aims to improve hand hygiene globally, prevent surgical site infections and combat antimicrobial resistance
WHO has undertaken a number of global and regional initiatives to address surgical safety. The most important and widely implemented piece of work has been the WHO surgery checklist. Much of this work has stemmed from the WHO Second Global Patient Safety Challenge ‘Safe Surgery Saves Lives’. Read the WHO Guidelines on Safe Surgery hereMedication Safety
A new patient safety challenge due to be launched in 2016 is the global challenge on medication safety. This challenge aims to change unsafe medication practices and highlight the barriers to safe medication use. Importantly, this challenge will utilise the patient experience in the process of reducing medication related harm.