“We have tended to focus on problems in isolation, one harm at a time, and our efforts have been simplistic and myopic.
If we are to save more lives and significantly reduce patient harm, we need to adopt a holistic, systematic approach that extends across cultural, technological and procedural boundaries – one that is based on the evidence of what works”
[Darzi, A, (2015) Health Service Journal, The NHS safety record needs to be as good as the airline and motor industries, [11 February, 2015]
We couldn’t have put it better ourselves.
It’s easy to glance at Sign up to Safety and cry ‘just another campaign’ or ‘why do we need this?’ We know that you are already working on reducing harm, and collectively we have been for over fifteen years. Yet we also know that we have not made the kind of impact we had hoped; patients still fall, we continue to administer the wrong drugs and operate on the wrong leg, and a patient deteriorating can still be missed.
We believe that in part it is because we have focused for too long on single areas of harm in isolation. There is also a huge missed opportunity in that there has been a persistent failure to learn from mistakes and incidents and we know that while many of the interventions that can make care safer already exist, there is a known gap between this evidence and every day practice.
Let’s all think differently about safety.
The next phase of the campaign
To help those who have joined adopt a more systematic approach, over the course of the next year we will be exploring how we can help them focus on the cross cutting system and human factors. This means that they may end up stopping things that are simply not working. We will focus on creating a continuous learning culture which addresses our current failure to learn from incidents and investigations.
We believe that we have yet to understand fully why improvement work is not sustained in the long term and our aim is to get beneath the surface of why there is an implementation gap.
Our programme to bring the pledges to life
Whether you’ve just begun your Sign up to Safety journey, or you’re moving on at speed, the pledges unify us all and are relevant to each individual. From October through to June 2016 we will help you revisit and bring to life the five campaign pledges; put safety first, continually learn, be honest, collaborate and be supportive. All those who sign up are committing to not just believe in, but to embed and be an example of the values and beliefs that make us all proud to work in the NHS. The five safety pledges are more than words on paper. They mean something. By making a commitment to bringing them to life, and by helping others to understand their role in this, we’ll be working together to create the right conditions for safer care.
We’ll be helping you, our participants, keep your pledges front of mind, providing a platform to celebrate progress, discussing what those look like in practice, supporting you to articulate what they mean to all your staff, and sharing your experiences amongst our community. We need your participation and feedback as we move forward. By moving forward together, there is a better chance you will stop feeling like you’re banging the same drum without being heard. You will stop feeling like you are working in isolation. Together we can learn more about how to make care as safe as possible, for each and every patient.
October; Put safety first – Committing to reduce avoidable harm in the NHS by half through taking a systematic approach to safety and making public your locally developed goals, plans and progress. Instil a preoccupation with failure so that systems are designed to prevent error and avoidable harm
December; Continually learn – Reviewing your incident reporting and investigation processes to make sure that you are truly learning from them and using these lessons to make your organisation more resilient to risks. Listen, learn and act on the feedback from patients and staff and by constantly measuring and monitoring how safe your services are
February; Be honest – Being open and transparent with people about your progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong
April; Collaborate – Stepping up and actively collaborating with other organisations and teams; share your work, your ideas and your learning to create a truly national approach to safety. Work together with others, join forces and create partnerships that ensure a sustained approach to sharing and learning across the system
June; Be supportive – Be kind to your staff, help them bring joy and pride to their work. Be thoughtful when things go wrong; help staff cope and create a positive just culture that asks why things go wrong in order to put them right. Give staff the time, resources and support to work safely and to work on improvements. Thank your staff, reward and recognise their efforts and celebrate your progress towards safer care.
Although we’ll be focusing on each pledge one by one, this is your campaign so you may feel our timeline is not the right time for you to use and share the information we provide. That’s ok, and so all resources will be digital so that you can use them at the most effective time for your own local campaign.
Your next steps:
- Revisit your Safety improvement Plan: Your Safety Improvement Plans are important and represent a lot of work; however we believe that by complementing topic focused work-streams with a focus on some of the most important issues that cut across every intervention, regardless of setting, we will be helping you achieve your goals. So rather than focus on single areas of harm we believe that all of our efforts should shift to addressing the myriad of contributory factors that impact on safety every day; communication failures, the availability and the design of the right equipment, inexperience, stress, attitudes and relationships, and the way we observe patients and use information. All of these impact on safety and apply across the NHS from secondary to primary, acute to community, hospital to GP practice, board to ward.
- Take part in our programme to bring the pledges to life and share your work: What has your organisation or your area of work or your team done to put safety first? Do you have a story to tell? What actions are you undertaking to bring this pledge to life that you can share for others to use? Even if you don’t think you have done much or you have only just started we are interested in how you are thinking about this pledge. If you do have something to share or you know some people in your organisation that you would like to recognise their efforts, please get in touch with us via signuptosafety@nhsla.com
- Look out for our e-newsletter SignUPdate: Subscribe and pass it on, look out for notices on twitter @signuptosafety – these are where we will share our learning from the explorations we have mentioned here such as our work on getting beneath the surface of why there is an implementation gap; we will share our videos, your videos, webinars which focus on the pledges as well as the cross cutting themes and we will share a variety of blogs, podcasts, and polls so you and your staff can get directly involved in our shared cause.
Patient Safety Now 