A culture of continual learning

I know things move on.

I know that we can’t live in the past.

However when our past holds valuable gems which can help us with our future then I am all for reminding people where we have been.

Patient Safety – a brief history of our time

December is our focused month on the pledge, continually learn – so to get us all ready for this I thought I would create a brief history of patient safety for those new to safety who may not know where we have been and as a way of helping learn about patient safety.

In the NHS in England the patient safety movement started in 1998 with A first Class Service – which described what we know today as clinical governance.  Then in 2000 Sir Liam Donaldson’s advisory group wrote a report ‘an organisation with a memory‘ which described the priority areas for safety, the types of techniques for improving safety and focused people on the findings from Charles Vincent’s work in reviewing case notes for adverse events.  The Vincent pilot study of two organisations led to the overused (and only really applicable to acute care) statistic everyone used on safety… 10% of healthcare results in harm caused by the care the patient receives and not their illness and half of that is avoidable.

Following this, Building a Safer NHS – led to the creation of the National Patient Safety Agency (NPSA) in 2001 (the same years as the first iPOD and 9/11) and the normalisation of the terms patient safety, root cause analysis, systems approach to safety, safety culture and just culture.  These built on lessons from other industries in particular aviation and the groundbreaking work of Professor James Reason – who designed the ‘swiss cheese model‘ and helped develop tools such as the incident decision tree – a vital tool to help create the just culture for safety.  We learnt over time about what it takes to create a safety culture, the role of leadership in safety and how important it is that teams understand their impact on safety, how to report incidents and how to learn from them and how to address the problems they detect.

The NPSA set up the National Reporting and Learning System (NRLS), published the Seven Steps to Patient Safety, ran campaigns to improve hand hygiene (cleanyourhands), reduce infections associated with central lines (matching michigan), rolled out safety tools such as the WHO surgical checklist, and worked with industry to help design infusion pumps, ambulances and medication packages.  Patient Safety Alerts were sent out.  Incident reports came flooding in – over a million a year.

The NPSA was joined by the NHS Institute for Innovation and Improvement (NHSIII), the various iterations of system regulators (now Care Quality Commission) and professional regulators, the Health Foundation, the Institute of Healthcare Improvement, academia and patient groups. The World Health Organisation developed a patient safety centre and created a number of global challenges as well as the patients for patient safety programme.

Over time we learnt about human factors, ergonomics and behavioural change and worked in partnership with others on campaigns such as Patient Safety First.  The NHS has explored the science of improvement, the use of PDSA cycles, LEAN methodology, resilience engineering and high reliability organisations.  Every year the collection of research and books on patient safety and all its component parts grows larger and larger.

At the same time there has been inquiry after inquiry, review after review with recommendation after recommendation.  Notables are; the Bristol Royal Infirmary Inquiry, the organ retention scandal, Winterbourne View, Mid Staffs and Morecambe Bay.  Also we have been shocked by individual cases such as that of nurse Beverley Allitt, GP Harold Shipman and others.

In 2004/5 there was a National Audit Office report on patient safety.  In 2006 the publication of Safety First another review of patient safety and in 2008 the NHS became 60.

In 2012, the Health and Social Care Act led to the abolition of the NPSA and the NHS III.  At the same time as the Olympic Games a small team of patient safety staff transferred from the NPSA to the NHS Commissioning Board (now NHS England) and are now moving from NHS England to NHS Improvement.  In 2013 we had the Keogh Mortality Review, the first NHS Change Day and the Berwick Report.

And finally in 2014 the launch of Sign up to Safety, fifteen patient safety collaboratives and the Q initiative.

I am certain that I have missed much but I did say brief!

All of the above and so much more can be still found in archived sites you will be amazed at how brilliant it all is – happy searching!



1 Comment

  1. Hi Suzette  A great summary – it is useful to look back and remind ourselves of the journey. Please feel free to delete my comment as on re – reading realise you have indeed included Bristol. ( note to self don’t post comments at 3 in the morning!!

    Regards  Wendy  1wenmac 

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