Patient safety – one year on

A National Patient Safety Agency (NPSA) report published a year after the Department of Health (DoH) published its own initial look at patient safety says “many major milestones” have been reached but stresses there remains much to do.

Safety First – One Year On details multi-agency progress against the recommendations of the DoH’s “Safety First” publication. It says NHS organisations are generally “pulling together” to push for patient safety, with the past year’s most notable achievements including establishment of a National Patient Safety Forum, joint work with Strategic Health Authorities to create Patient Safety Action Teams; agreement and signature of a Patient Safety Charter by over 20 organisations, and NPSA lead taking in developing a national patient safety campaign.

Detailed consultation has also taken place with over 800 stakeholders on what the national reporting and learning system (NLRS) can do to support the NHS and improve its collection and dissemination of data; the NPSA says that, in future, it will “lead on designing and establishing a system for reducing the burden on reporting on the NHS via a new Patient Safety Direct system”.

In response to an earlier NSPA proposal, Patient Safety Action teams (PSATs) were established in the 10 Strategic Health Authorities on 1 October 2007 and the NPSA is working with the PSATs and SHAs to determine action priorities. “Safety First” suggested all reports on patient safety incidents should be considered within 24 hours, with the NPSA notified within 36 hours in instances of serious harm or death. In response resources to aid local incident investigation are in development and being consulted on. The DoH is also working on guidance for the chair and board of each NHS organisation to develop and implement patient safety policies, and, responding to the earlier paper’s call for the Healthcare Commission to monitor progress on patient safety against national and local targets, the Commission is now using indicators on safety in its annual “health checks”.

To encourage “greater openness with, and support for, patients “when things go wrong” the Department will in future “work to identify barriers to openness in the NHS”.

Safety First – One Year On also argues that, while interim national contracts for acute services already allow local commissioners to negotiate quality and safety requirements, legislation should be enacted to enable NHS and independent sector providers to be registered against such requirements, with those failing “facing action”.

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