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5 steps to improve health worker safety and patient safety Establish synergies between health worker safety and patient safety policies and strategies: Develop linkages between occupational health and safety, patient safety, quality improvement, and infection prevention and control programmes. Incorporate requirements for health worker and patient safety in health care licensing and accreditation standards. Integrate staff safety and patient safety incident reporting and learning systems. Develop and implement national programmes for occupational health and safety of health workers: Develop and implement national programmes for occupational health for health workers in line with national occupational health and safety policies. Review and upgrade, where necessary, national regulations and laws for occupational health and safety to ensure that all health workers have regulatory protection of their health and safety at work. Appoint responsible officers with authority for occupational health and safety for health workers at both the national and facility levels. Develop standards, guidelines, and codes of practice on occupational health and safety. Strengthen intersectoral collaboration on health worker and patient safety, with appropriate worker and management representation, including gender, diversity and all occupational groups. Protect health workers from violence in the workplace Adopt and implement in accordance with national law, relevant policies and mechanisms to prevent and eliminate violence in the health sector. Promote a culture of zero tolerance to violence against health workers Review labour laws and other legislation, and where appropriate the introduction of specific legislation, to prevent violence against health workers. Ensure that policies and regulations are implemented effectively to prevent violence and protect health workers. Establish relevant implementation mechanisms, such ombudspersons and helplines to enable free and confidential reporting and support for any health worker facing violence. Improve mental health and psychological well-being: Establish policies to ensure appropriate and fair duration of deployments, working hours, rest break and minimizing the administrative burden on health workers. Define and maintain appropriate safe staffing levels within health care facilities. Provide indemnity and insurance coverage for work-related risk, especially those working in high-risk areas. Establish a ‘blame-free’ and just working culture through open communication and including legal and administrative protection from punitive action on reporting adverse safety events. Provide access to mental well-being and social support services for health workers, including advice on work-life balance and risk assessment and mitigation. Protect health workers from physical and biological hazards Ensure the implementation of minimum patient safety, infection prevention and control, and occupational safety standards in all health care facilities across the health system. Ensure availability of personal protective equipment (PPE) at all times, as relevant to the roles and tasks performed, in adequate quantity and appropriate fit and of acceptable quality. Ensure an adequate, locally held, buffer stock of PPE. Ensure adequate training on the appropriate use of PPE and safety precautions. Ensure adequate environmental services such as water, sanitation and hygiene, disinfection and adequate ventilation at all health care facilities. Ensure vaccination of all health workers at risk against all vaccine-preventable infections, including Hepatitis B and seasonal influenza, in accordance with the national immunization policy, and in the context of emergency response, priority access for health workers to newly licenced and available vaccines. Provide adequate resources to prevent health workers from injuries, and harmful exposure to chemicals and radiations; provide functioning and ergonomically designed equipment and work stations to minimize musculoskeletal injuries and falls.

The National Action Plan centres on four foundational and interdependent areas, prioritised as essential to create total systems safety, with 17 recommendations to advance patient safety. Culture, Leadership, and Governance 1. Ensure safety is a demonstrated core value. 2. Assess capabilities and commit resources to advance safety. 3. Widely share information about safety to promote transparency. 4. Implement competency-based governance and leadership. Patient and family engagement 5. Establish competencies for all healthcare professionals for the engagement of patients, families, and care partners. 6. Engage patients, families, and care partners in the co-production of care. 7. Include patients, families, and care partners in leadership, governance, and safety and improvement efforts. 8. Ensure equitable engagement for all patients, families, and care partners. 9. Promote a culture of trust and respect for patients, families, and care partners. Workforce safety 10. Implement a systems approach to workforce safety. 11. Assume accountability for physical and psychological safety and a healthy work environment that fosters the joy of the health care workforce. 12. Develop, resource, and execute on priority programmes that equitably foster workforce safety. Learning system 13. Facilitate both intra- and inter-organisational learning. 14. Accelerate the development of the best possible safety learning networks. 15. Initiate and develop systems to facilitate interprofessional education and training on safety. 16. Develop shared goals for safety across the continuum of care. 17. Expedite industry-wide coordination, collaboration, and cooperation on safety.

In this blog, Patient Safety Learning make the case that staff safety is intrinsically linked to patient safety. It sets out how the six foundations for safer care from the report, A Blueprint for Action, can be used to consider how making improvements to staff safety complements patient safety.[1] It looks in more detail at four key aspects of staff safety and how these areas are intertwined with improving patient safety: Physical safety – considering how the Covid-19 pandemic has highlighted the importance of this in ensuring patient and staff safety is not jeopardised. Safe staffing levels – outlining the importance of this to protect the welfare of staff and avoid creating conditions in which patient safety incidents are more likely to occur. Psychological safety – setting out the importance of having organisational cultures that enable staff to feel secure in speaking up about incidents of unsafe care, ensuring that opportunities for learning and innovation are not shut down by a blame culture. Support to staff after patient safety incidents – highlighting the key role that providing emotional support to health and social care staff who are involved in patient safety incidents can play in fostering an environment of openness and learning. It concludes by setting out the activities Patient Safety Learning will undertake over the course of September to raise awareness of, and promote action for, staff safety. References: 1. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.

Allow me to start this essay with a real personal story: more than a decade ago, while I was doing my Transplant & Hepato-Biliary Surgery fellowship in the USA, I had to have elective orthopaedic surgery. The good news was the hospital where I was about to have the surgery was the number one in the US News Ranking for Orthopedics that year. The bad news was that I was literally ‘terrified’ while I was in the pre-op holding area, just before I was wheeled into the operating room! How could that be? Me: the surgeon, terrified of having a straightforward orthopaedic procedure in the number one orthopaedic surgery hospital in the US? The answer was yes. It was precisely for this reason – that I am a surgeon who knew what could go wrong in a clinical unit like the OR and that I was terrified of becoming just another casualty of a medical error! Back in 2016, in their book 'Safer Healthcare', Charles Vincent and Rene Amalberti beautifully articulated the safety levels in hospitals where they classified five levels of care: Level 1: The care envisaged by standards. Level 2: Compliance with standards / ordinary care with imperfections. Level 3: Unreliable care / poor quality, but the patient escapes harm. Level 4: Poor care with probable minor harm but overall benefits. Level 5: Care where harm undermines any benefit obtained. As a practicing healthcare professional (a surgeon), I can, unfortunately, say that the majority of clinical units in hospitals are performing around Level 3 (unreliable care / poor quality, but the patient escapes harm) with fluctuations towards Level 4 (poor care with probable minor harm but overall benefits) for below-average performers or Level 2 (compliance with standards / ordinary care with imperfections) for a very few leading medical centres... sometimes! Patient safety was defined as the absence of harm. I believe it is time to define patient safety using a patient-centric approach where patient safety can be defined as the absence of harm for each patient, by the right person(s), at the right time(s) and the right place(s). Such definition would help us think about a systemic and individual framework to safety, where safety is customised to every patient, all the time, in the backdrop of a safe clinical unit. Last year marked the 20th anniversary of the landmark paper 'To Err is Human'. Although the past 20 years have seen much progress in the understanding of the healthcare safety which helped bridge the knowledge gap in this significant field, we still have a significant implementation and structural gap, which continues to contribute to the ongoing inherently weak safety conditions for patients. The main reason for writing this essay is to say that 20 years after To Err is Human, the majority of hospitals are treading around Level 3 (mediocre patient safety conditions to use layman’s terms!). Such a situation is entirely unacceptable for high-reliability industries like aviation, nuclear, and oil and gas. Fifty to sixty years ago, these industries were not as safe as they are today but reached their watershed moments (tipping point) and had to transform their safety practices. This essay is a call for action to highlight the following: Healthcare continues to be structurally weak when it comes to the safety conditions. This lack of resilience leads to ongoing medical errors and harm to patients. There is an urgent need for us to have a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. As healthcare systems are complex adaptive systems, the only way to do that is to build resilience in the system. Here are my practical solutions: Adopting co-production principles: co-design, co-delivery and co-assessment. Introducing complementary checklists for both patients and healthcare professionals throughout the patient journey. Safety reconciliation: transition of care or any patient transfer carries potential patient harm – e.g., fall, tubes or IV dislodgement, communication failure with new staff members, such as radiology department technicians, etc. Hence, it is vital that a safety reconciliation is performed by both the patient/families and healthcare professionals (co-production) using checklists. Leveraging implementation science: by introducing safety principles into the day to day clinical practices at the bedside (undergraduate, postgraduate, and board-certified practitioners). Human Factors Engineering (HFE): introducing HFE principles into bedside clinical practice – e.g., effective communication, situational awareness, flat hierarchy and team-based simulated learning – will introduce resilience into the system and help reduce potential harm to patients.