Patient Safety Learning: A Blueprint for Action (2019)

Summary

Despite 20 years of effort, every year avoidable unsafe care still leads tens of thousands of patients to suffer death or serious, life-changing harm. A Blueprint for Action, a report from Patient Safety Learning, furthers the analysis of the systemic causes of this harm and describes actions to make patient care safer.

Last September, health and patient safety professionals and patients overwhelmingly welcomed the analysis of avoidable unsafe care offered in Patient Safety Learning’s Green Paper, A Patient-Safe Future. Matt Hancock, Secretary of State for Health and Social Care described it as “…the blueprint for action that we need.”

Following widespread consultation on the Green Paper, A Blueprint for Action extends this analysis to identify actions to address the systemic causes of unsafe care.

Content

A Blueprint for Action identifies two core issues that underpin the persistence of avoidable harm. The first is that by treating patient safety as a ‘priority,’ healthcare organisations make the safety of patients open to compromise. A Blueprint for Action makes the case that patient safety it is more than a ‘priority’ – it is part of the core purpose of healthcare.

The second core issue identified in A Blueprint for Action is that unlike, for example, fire safety, no person or body sets patient safety standards for healthcare organisations. As a result, the health and social care systems have no way to ensure that patients everywhere receive the same high standards of safe care.

A Blueprint for Action identifies six foundations of safe care. These include shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture.

A Blueprint for Action proposes a range of actions to address these foundations. These include the development of the hub for clinicians, researchers and patients to share learning and solutions for patient safety with communities of peers; establishing a forum of leaders to set standards and good practice for leadership of patient safety; developing a competency framework for patient safety; creating harmed patient care pathways to better support patients and staff following incidents of patient safety; convening a symposium of experts to develop better ways to measure and manage patient safety; and advocacy for adoption of what Professor Sydney Dekker has termed a Just Culture.

Download A Blueprint for Action in full.

Alternatively, you can download the Executive Summary.

In addition, we have created a visual summary of A Blueprint for Action, primarily for print purposes but also available to download.

We would love to hear your thoughts on our Blueprint for Action and work with you to explore pushing these actions forward. If you would like to be part of this work, please contact info@patientsafetylearning.org

We’ve already received strong support from patient, clinical and patient safety thought leaders and campaigners, including the following statements.

Dr Ted Baker, Chief Inspector of Hospitals, Care Quality Commission, said, “In our recent report “Opening the Door to Change” I called for a new era of leadership, focused on safety culture, engaging staff and involving patients. I strongly welcome “A Blueprint for Action” as it lays out how everyone involved in healthcare, including patients, can work together to bring about the change in culture that is needed to make our healthcare as safe as it can be.”

Dr Annie Hunningher, Barts Health, said, “This paper sets out the vision that we can change the way we structure, describe the processes and measure outcomes for true safety. It is leading the charge to understand and support a culture, a system, the multidisciplinary education and ‘metrics that matter’ to deliver safer care. Safety has been the Cinderella of healthcare management, not a priority and under-resourced. We now have an opportunity to collaborate and commit to genuine safety improvement. By setting standards, professionalising safety with ward to board safety understanding, and involving our patients we can collaboratively find the path to transform the future. Thank you Patient Safety Learning!”

Rachel Power, Chief Executive of the Patients Association, said, “Patient Safety Learning’s blueprint offers a convincing analysis and a coherent set of solutions – we support their approach, and their aim to bring patient safety into the mainstream. We agree that the solution must involve recognising patients as active partners in their care, ensuring that they are able to raise concerns when things are going wrong, and engaging them fully in all aspects of patient safety. It must be an over-riding priority for the NHS that patients are safe when they are in its care.”

Tom Kark QC, author of the 2019 Kark Review of the Fit and Proper Person Test, said, “The Patient Safety Learning Blueprint for Action is an important paper and could make a significant change to patient safety if… its proposals are put into effect.”

Professor Albert Wu of Johns Hopkins Bloomberg Center for Public Health, said, “Knowledge and know-how are crucial to improving the safety of health care. This first entails awareness, and then actual learning, on the part of clinicians, leaders and managers, and patient and families. Patient Safety Learning is dedicated to engaging the hearts and minds of all of these essential players. I foresee that they will play an important role in helping us learn together. Their publication, A Blueprint for Action, lays out a way forward.”

For the Academic Health Sciences Network (AHSN), Dr Cheryl Crocker, Network Patient Safety Lead and Natasha Swinscoe, Network Lead MD Patient Safety, said, “We welcome the Blueprint for Action report and fully support the call to co-ordinate improvement programmes better across systems. This encapsulates the focus of our patient safety work through The AHSN Network. We are delighted to be supporting Patient Safety Learning and are well-placed to make an active contribution in both health and care to all six recommended actions.”

Peter Walsh, Chief Executive, Action against Medical Accidents (AvMA), said, “This report is a welcome and sensible reminder of the sort of approach that I believe most people agree is needed to breathe new life into work on patient safety. We must not allow patient safety to be put in the ‘too difficult box’. It is far from fixed and it is vital that we have an approach which is fair and sensitive to the needs and contributions of both patients and staff.”

Andrew Corbett-Nolan, Chief Executive (Partner), Good Governance Institute, said: "This Blueprint for Action provides a crucial contribution to improving patient safety in health and social care. The report is a practical resource to support and sustain safe care. It is a must read for Board members of health and care organisations."

Peter Homa, Chair, NHS Leadership Academy, said, “A Blueprint for Action” is a magisterial summary of how we can, together, create a safer, more humane environment for patients, their loved ones and staff. International evidence is drawn upon to describe the preconditions for success including the requirement to learn from errors. We should ensure that the positive impact of learning from an error is far greater than the negative impact of the original error. This report and its authors, Patient Safety Learning, are powerful positive forces that will help us create a healthcare that is “patient safe”