National Patient Safety Agency: Seven steps to patient safety: full reference guide (2004)

Summary

This document contains an overview of the National Reporting and Learning Service (NRLS)’s detailed guide to good practice, which covers building a safer culture and managing, reporting and learning from patient safety incidents. It sets out the seven steps that NHS organisations should take to improve patient safety.

It builds on recommendations from two reports and findings from studies in the UK, USA, Australia, New Zealand and Denmark. These highlighted the number of patient safety incidents, whether they contributed to patient deaths, and whether they could have been prevented.

The steps provide a simple checklist to help NHS organisations plan their activity and measure performance in patient safety. Following them will help ensure that the care they provide is as safe as possible, and that when things go wrong the right action is taken. They will also help NHS organisations meet their current clinical governance, risk management and controls assurance targets.

Content

The steps are:

1. Build a safety culture.
2. Lead and support your staff.
3. Integrate your risk management activity.
4. Promote reporting.
5. Involve and communicate with patients and the public.
6. Learn and share safety lessons.
7. Implement solutions to prevent harm.