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Medical Examiners of Deaths Proposed Change: We propose to include a new requirement for acute providers (NHS Trusts and Foundation Trusts only) to establish a Medical Examiner’s Office, in accordance with guidance published by the National Medical Examiner. The Office will, initially, review those deaths occurring on the Trust’s premises and not referred to the coroner, ensuring that the certification of death is accurate and scrutinising the care received by the patient before death. Patient Safety Learning supports this proposal. We welcome the decision to make the establishment of a Medical Examiner’s Office a requirement for acute providers. This proposal was first recommended following the Shipman Inquiry (2002-2005) and recent media coverage has revealed that a significant number of NHS trusts have still yet have appoint a Medical Examiner. Medical Examiners can play a key role in improving patient safety in cases where the patient’s death was the result of avoidable harm. They can provide vital insights into these cases and help to identify effective remedial actions to prevent their recurrence, as well as sharing this information for wider learning beyond their specific trusts. Patient Safety Incident Response Framework Proposed Change: The NHS Patient Safety Strategy indicates that the current NHS Serious Incident Framework and Never Events Policy Framework will be replaced, over the next two years, by a new single Patient Safety Incident Response Framework. To accommodate and signpost this planned change, we propose adding a specific reference to “successor frameworks” to the existing requirements relating to the current Frameworks. Patient Safety Learning supports the proposal to update requirements. We welcome the review of these frameworks and the development of a new Patient Safety Incident Response Framework (PSIRF). However, we have concerns about the delay in its release, which was initially expected towards the end of 2019 and now instead subject to a limited release this year with pilot organisations, rather than being shared more widely. We are also concerned about the lack of stakeholder engagement in this process, particularly for patients and families. Despite providing a valuable source of information when incidents occur, they are often not included in investigation processes. The failure to include and listen to patients and families in investigations can often result in more harm and increasing the likelihood of complaints and litigation. In updating these processes therefore it is vital their views are taken into account. National Patient Safety Alerts Proposed Change: The National Patient Safety Alerting Committee is establishing new, co-ordinated and accredited arrangements for the issuing of National Patient Safety Alerts to providers. We propose to include a new requirement for providers to ensure that they can receive each relevant National Patient Safety Alert, identify appropriate staff to coordinate and implement actions required within the timescale the Alert prescribes, and confirm and record when those actions have been completed. Patient Safety Learning supports this proposal. We welcome steps to ensure providers have appropriate arrangements in place to coordinate and implement actions required by national patient safety alerts and record when these have been completed. A recent report by Action Against Medical Accidents, An organisation losing its memory?, has indicated that a number of trusts have experienced significant delays in introducing safer practices highlighted by national patient safety alerts. They found in many cases that the trusts experiencing delays ‘indicated that they were in the process of improving internal systems for overseeing the implementation of patient safety alerts’. It is a positive step to see this is now being added to the NHS Standard Contract as a formal requirement for them to do so. However, we have concerns beyond the scope of these contractual obligations that this process does not appear to be monitored at a national level. While these measures place specific responsibilities on providers, we are not clear on what, if any, oversight arrangements will be put in place to accompany these. We think such national monitoring and public reporting is essential and would look for this to be implemented as a priority. Patient Safety Specialists Proposed Change: The NHS Patient Safety Strategy envisages the establishment of a network of patient safety specialists, one in each provider, to lead safety improvement across the system. We therefore propose to include a requirement on each provider to designate an existing staff member as its Patient Safety Specialist. Patient Safety Learning supports this proposal. We support this proposal in principle but have reservations about how this will be implemented in practice. The requirement to appoint a Patient Safety Specialist, as set out in the NHS Patient Safety Strategy, currently lacks detail about the nature of this role. What do we mean by a ‘Safety Specialist’? What knowledge and training should they have? Will the appropriate governance arrangements be in place to make sure their voice is heard by the organisation’s leadership? We think these arrangements should be specified, resourced, monitored and transparently reported. We will be responding to the separate consultation on this which opened on the 30 January 2020 in more detail. Common sources of harm to patients in hospital/Safety Thermometer Proposed Change: Feedback suggests that the existing Contract requirements on use of the Safety Thermometer are creating too great a bureaucratic burden, and not facilitating learning. We therefore propose to remove the specific requirements relating to use of the Safety Thermometer and, instead, introduce a higher-level obligation on acute providers to ensure and monitor standards of care in the four clinical areas which the Safety Thermometer addresses – venous thromboembolism, catheter-acquired urinary tract infections, falls and pressure ulcers. At Patient Safety Learning we believe that the health and social care system should develop models for measuring, reporting and assessing patient safety performance. This data should be gathered centrally and then used for learning and to implement actions that improve care. With regards to the removal of Safety Thermometer requirement, while we recognise that it has been noted that this has not been effective in facilitating learning, we would expect the newly proposed measures to follow these principles. We would also expect patient safety measurement to apply to all NHS organisations, rather than being an obligation limited to acute providers.

This White Paper: describes the framework's two foundational domains, culture and the learning system, outlining what is involved with each and how they interact provides definitions and implementation strategies for nine interrelated components (leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement and continuous learning) discusses engagement of patients and their families, the core of the framework, the engine that drives the focus of the work to create safe, reliable, and effective care. Healthcare organisations and systems may use the framework as a roadmap to guide them in applying the principles, and as a diagnostic tool to assess their work to date. Although initially focused on the acute care setting, the framework has evolved to be more broadly applicable in any setting, in acute care, ambulatory care, home care, long-term care and in the community.

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.

Key points of the paper: Suggests national safety standards for invasive procedures (NatSSIPs) should be read and acted on by all invasive procedure teams, including dentists. Highlights that involvement of all staff in development of a local safety standard for invasive procedures is important to ensure a policy that is successful in improving patient safety in your workplace. Suggests the whole dental team should take responsibility for continually improving patient safety.

The Framework identifies the competencies and areas necessary for organisational leadership and management of health services, acknowledging there should be a balance between three domains: Personal attributes. Core functions of leadership: competencies relating to a leader’s ability to set direction and know how to prepare an organisation for safe and effective service delivery. Ability to ‘Execute’/Mise-en-place: competencies relating to a leader’s ability to create enabling environments, systems, processes and mechanisms, and to empower people for delivering patient-centered, quality and safe services.

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”

This website links with some of the work that the BMA do: Trade union representation. Individual support and advice. Lobbying. Legal and financial services. Patient information - signposting on how the NHS works.

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This article includes: a comprehensive search of standards. aims to improve the quality of health apps, and is a critical ’stepping stone’ to producing actionable guidelines for developers and adopters.

There have been many advancements in medical education over the past 20 years, including how outcomes such as competencies are defined and used to guide teaching and learning. To support this positive change, the AAMC has launched the New and Emerging Areas in Medicine series. This first report in the series focuses on quality improvement and patient safety (QIPS) competencies across the continuum of medical education. It presents a roadmap for curricular and professional development, performance assessment, and improvement of healthcare services and outcomes. The competencies can help educators design and deliver curricula and help learners develop professionally. The competencies are for use in: engaging diverse health care professionals in collaborative patient-safety-improvement discussions, including cross-continuum and cross-discipline colleagues conducting gap analyses of local curricula and training programmes planning individual professional development developing curricular learning objectives developing assessment tools furthering research and scholarship in medical education and quality improvement guiding the strategic integration of QIPS into the curricula and the clinical learning environment.