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  • Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS (7 April 2022)

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    In this report, Patient Safety Learning highlights a patient safety implementation gap in the UK that results in the continuation of avoidable harm. It focuses on six specific policy areas where the implementation gap acts as barrier to patient safety improvement and calls for system-wide action in healthcare to transform our approach to learning and safety improvement. It also details six specific recommendations relating to policy areas identified in the report.

    This article contains a summary of the report, which can be read in full here.


    The World Health Organization states that unsafe care is one of the top ten leading causes of death and disability worldwide, with the NHS estimating that there are around 11,000 avoidable deaths annually due to safety concerns. However, despite a range of international and national initiatives aimed at reducing avoidable harm, it remains a persistent, wide-scale problem.

    A key reason for this is the implementation gap, the difference between what we know improves patient safety and what is done in practice. In this report Patient Safety Learning highlights six specific policy areas where this gap acts as a barrier to patient safety improvement:

    1. Public inquiries and reviews
    2. Healthcare Safety Investigation Branch reports
    3. Prevention of Future Deaths reports
    4. When patients and families take legal action
    5. Patient complaints
    6. Incident reports

    Having considered these six areas where the policy implementation gap undermines our ability to translate patient safety insights and learning into practical improvements, the report highlights four common underlying themes:

    • 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
    • Unclear patient safety leadership

    It calls on the Government, parliamentarians and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare, and invites them to engage in a system-wide debate about how healthcare can reshape its approach to learning and safety improvement.


    The report details six recommendations relating to the areas of the implementation gap that it highlights:

    1. Patient safety inquiries and reviews need system-wide commitment and resources, with effective and transparent performance monitoring to ensure that the accepted recommendations translate into action and improvement.
    2. HSIB reports and their recommendations need system-wide commitment and resources, with effective and transparent performance monitoring to ensure that their recommendations translate into action and improvement.
    3. The Coroner’s Prevention of Future Deaths system needs to be improved so that recommendations for patient safety improvements and organisational responses to the reports can be easily accessed. Processes need to be in place to provide assurance that learning from causal factors of avoidable deaths is captured consistently and the insight from these cases is disseminated and acted upon across all healthcare organisations.
    4. NHS England and NHS Improvement and NHS Resolution need to work together to improve the process for identifying the causal factors of unsafe care identified through litigation, ensuring this can be disseminated widely and acted on to improve patient safety.
    5. The introduction of the new NHS Complaints Standards needs to be closely monitored, with clear guidance for organisations on how to implement this and clarity on who is responsible for this within the organisation. This should be accompanied by public transparent reporting by organisations on the rollout of the new standard, allowing for consistent monitoring and comparison.
    6. NHS England and NHS Improvement and the MHRA must ensure that the development of the new PSIRF and changes to the Yellow Card scheme have a core focus on learning for action and improvement to tackle the implementation issues highlighted in this report.


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    a damning indictment on the non existent and at best very fragmented tokenistic patient safety system. my only comment is more attention must be paid to patients views throughout the processes, which currently are even worse than the system itself. 1. Even reporting of harm is not catered for, but pushed to a complaints model or a now very restricted incident investigation system PSIRF where i cannot see a strong patient voice. This needs remedy as i argued earlier this year and this is on the backburner and probably will be downgraded further from what i have heard read here when i was slightly more optimistic 

    2. but more substantially the patient voice needs to be empowered as is increasingly recognised in some services, like mental health and the same needs to be done for the whole safety and harm investigation and learning process. i refer to a leading expert in this area https://www.centreformentalhealth.org.uk/publications/humanising-health-care 

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