“Implementation gap” renders reviews of patient safety incidents ineffective, finds charity

Patients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found.

Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families.

It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership.

Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations.

“This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.”

The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement.

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Source: BMJ, 8 April 2022