More food for thought

Patient Safety is a complex science.  It is still a relatively young field, with just fifteen years since an Organisation with a Memory in human terms it is still a teenager!

The National Patient Safety Foundation (NPSF) in the US have now released their report; Free from Harm: Accelerating Patient Safety Improvement Fifteen years after To Err is Human – you can access this via  The group responsible for this report were headed up by Don Berwick and Kaveh Shojania on behalf of the NPSF.  The report identifies 8 recommendations:

  1. Ensure that leaders establish and sustain a safety culture
  2. Create centralised and coordinated oversight of patient safety
  3. Create a common set of safety metrics that reflect meaningful outcomes
  4. Increase funding for research in patient safety and implementation science
  5. Address safety across the entire care continuum
  6. Support the health care workforce
  7. Partner with patients and families for the safest care
  8. Ensure that technology is safe and optimised to improve patient safety

The content resonates with our work in Sign up to Safety and our views on what is needed over the next fifteen years.

Quality versus patient safety

The current approach is to focus on quality and effectiveness rather than the safety of patient care.  This approach is diverting attention from the unique and specific aspects of patient safety that require addressing, it is also diverting research and resources away from safety improvement.  The report stresses the importance of recognition that a safety science exists.

Focus on one harm at a time or total systems approach?

Over the last fifteen years patient safety has focused on reducing or eliminating specific harms such as falls or pressure ulcers or infections.  I can take some of the responsibility for this as our strategy at the National Patient Safety Agency (NPSA) certainly added to this approach.  However, activity related to patient safety requires a shift from this reactive approach (one which focuses on one harm at a time) and move to supporting a total systems approach. It requires focusing on design the systems, the environment, the equipment together with procurement for safety rather than simply trying to change minds and behaviour.

National coordination

Interestingly they recommend a new body for the US to act as a focal point for safety and to develop a national strategy (where have I heard that before).  Our view at Sign up to Safety is that leadership can be provided in a number of different ways; the campaign being one of them.

The difficult art of implementation

Implementation science formed the basis of my doctorate – a science I did not know existed until I started studying the gap between theory and practice.  Safety science investigates safety and the contributory factors and underlying causes of error and harm.  Implementation science supports patient safety science by focusing on the delivery of policy, recommendations, research, and theory so that it is adopted, spread and embedded into everyday practice.

Caring for those that care

The report stresses the importance of supporting the ‘dedicated’ workforce. We could not agree more.  Lets move away from the polarised view that clinicians don’t care when things go wrong and do their best to hide or cover up.  Lets ensure we bring joy and meaning to those that work in healthcare.  Lets also provide practical help for those really struggling to get through each day.

Enjoy reading the full report and let me know what you think.

Reference:  National Patient Safety Foundation (NPSF); Free from Harm: Accelerating Patient Safety Improvement Fifteen years after To Err is Human –  accessed via