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  • A Blueprint for Action: a summary of the six foundations of safer care for patients

    Patient Safety Learning
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    Patient safety is typically seen as a strategic priority. This sounds important, but it means that, in practice, health and social care decision-makers will weigh (and inevitably trade-off) the importance of patient safety against other priorities, like finances, resources or efficiency. We believe that patient safety is not just another priority: it is part of the purpose of health care. Patient safety should not be negotiable.

    Our report, A Blueprint for Action, sets out the action needed to progress towards the patient-safe future. Underpinned by systemic analysis and evidence, it proposes practical actions to address the six foundations of safer care for patients.

    These foundations are shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and Just Culture.


    Shared learning for patient safety

    Organisations should set and deliver goals for learning from patient safety, report on progress and share their insights widely.

    • We have created the hub, an online platform and community for people to share learning about patient safety problems, experiences and solutions. 
    • We research and report on the effectiveness of investigations into unsafe care.

    Leadership for patient safety

    We call for overarching leadership for patient safety across the health and social care system. 

    • We propose a Leadership Forum for Patient Safety that will lead the design and co-ordination of safe care and emphasise a systems approach and human factors. 
    • We recommend that all health and social care organisations publish annually their goals and outcomes for safer care. 
    • We recommend that integrated care systems set standards for patient safety in service commissioning, care delivery and care pathway design. 
    • We will work with the health and social care system to support strengthening leadership for patient safety.

    Professionalising patient safety

    Standards and accreditation for patient safety need to be developed and implemented. These need to be used by regulators to inform their assessment of safe care. 

    • We will work with the health and social care system to support the development of these standards. 
    • A competency framework for patient safety is needed to ensure that all staff are ‘suitably qualified and experienced’. We propose to work with Health Education England and others to develop this. 
    • Health and social care organisations need specialist patient safety and human factors experts with leadership support, resources and governance. hese roles must be clearly defined, with reporting lines to the board (both Executive and Non-Executive). These specialists will help lead re-design for safety, as well as learning from unsafe care, patient engagement, complaints, near misses, clinical reviews and audits. 
    • Guidance, resources and toolkits need to be developed and implemented with the support of specialist expertise in patient safety and human factors. We will promote and share these through the hub.

    Patient engagement for patient safety

    We will work with the health and social care system to encourage and support the actions necessary to ensure patients are valued and engaged in patient safety.

    • We will initiate development of ‘harmed patient care pathways’ for patients, families and staff following a serious incident. 
    • We will help develop and support effective patient advocacy and governance for patient safety.

    Data and insight for patient safety

    Models for measuring, reporting and assessing patient safety performance are needed that include quantitative as well as qualitative data. 

    • We will convene a panel of experts to identify the critical data and insight needed to measure and monitor patient safety. 
    • We will work to ensure that patient safety is designed into digital health initiatives as a core principle, rather than an add-on. 

    Just Culture

    All health and social care organisations should develop programmes and publish goals to eliminate blame and fear, introduce or deepen a Just Culture and measure and report their progress. 

    We will celebrate great work and innovation for patient safety through our Patient Safety Learning Awards and the hub.


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