Global Summit

The first Global Summit for Patient Safety was held in London on 9 March and 10 March.  This was an invited group of individuals in relation to patient safety discussing policy and strategy for improving safety and reducing avoidable harm with reflections from experts and ministers from across the globe.  Next year it will be held in Berlin and Margaret Chan promised that it may also coincide with an International Patient Safety Day.

Day 1 highlights:

  • The scale of the problem and opportunities – Prof Lord Darzi
  • The importance of research and emerging complexities in patient safety and in particular the issue of Anti Microbial Resistance (AMR)-  Prof Dame Sally Davies
  • The holistic approach to patient safety – Gary Kaplan
  • The patient safety toolbox for 2030 – Tejal Ghandi
  • Behavioural insights – Michael Hallsworth

Some of the key messages:

  • Victor Dzau – from the (former) IOM in the US – ‘streamline data collection systems’
  • Gary Kaplan – ‘value staff and create an atmosphere of respect as a key component of safety’ and ‘helplessness, hopelessness and resignation are key enemies of patient safety’
  • Prof Appleby – ‘patients don’t talk about patient safety, they talk abut feeling safe’ and ‘not keen on identifying things as avoidable or unavoidable’
  • Jennifer Dixon – ‘The NHS requires a coherent strategy across the system and a reduction in the ‘thicket of measures’
  • Don Berwick – ‘we have wrongly focused on inspection and regulation as the answer’ and ‘focus in the main on improvement and much less on control’ and ‘too much focus on reporting systems’ and ‘inspections induce gaming’ and ‘you have to choose between fear and safety – they are incompatible’ and ‘the pursuit of a root cause is a mistake – error isn’t linear’
  • Ed Kelley – ‘success factor for ‘movement’ in Scotland is the focus on change not on targets’ and ‘safety needs to be locally personalised’
  • Michael Hallsworth – ‘behavioural insights has a lot to offer the world of patient safety’ and ‘focus on heuristics (enabling a person to discover or learn something for themselves)’ and ‘behavioural insights are not just a tool from a toolbox, they are the basis on which we can improve our healthcare’ and ‘behaviour more ritualistic and automatic than we realise; our minds takes shortcuts’

Day 2 highlights:

Some of the key messages:

  • The Secretary of State set out the latest announcements on patient safety including:

    Creating a learning NHS

    • A new Healthcare Safety Investigations Branch (HSIB) from 1 April 2016 – which will also include legal protection for staff to enable ‘a safe space’ for those involved in incidents to be able to speak up – it will focus initially on maternity  (because this is an important area but also to test the processes)

Blaming people misses the point – we need a culture where people feel safe to speak out and we study the context (environment and systems), learn about what can go wrong, what others are doing to put it right and share the lessons learnt

  • ‘Intelligent transparency’ with a ‘league table’ rating organisations on whether they had a good reporting culture or not
  • All hospital deaths to be examined by a ‘medical examiner’ from 2018
  • Need for a new mind set across the NHS of improvement, sharing, honesty, curiosity to learn
  • Need to review the GMC and NMC guidance to ensure staff are credited for admitting errors
  • NHS Improvement to support this new mind set and review policies and procedures that could help
  • Royal College of Physicians and NHS England to produce guidance on record reviews of mortality
  • James Titcombe: Don said we have to choose between safety and blame – I chose safety

Don Berwick:

Somewhere out there is a doctor making a mistake now – how will we support them to learn, and how will we ensure that they are supported

  • Adam Hill, CMO McLaren: Complex care for complex patients in a complex system can only be delivered safely with decision support – data is nothing without learning – collect noting that doesn’t add to the learning.  Understand what to measure and when to measure it – decision support systems should be based on past practice and not on guidelines.  Look at the work of Ken Catchpole, Allan Goldman and Martin Elliot at GOS, the work of Birmingham Children’s hospital to create wireless information systems in PICU
  • Sally Davies, CMO England:  AMR is the most significant emerging safety issue of our time
  • Matthew Syed: Author Black Box thinking
  • Martin Bromiley:  Ask open questions to understand and anticipate, listen without judgement and talk openly about your errors
  • Atul Gawande:  Safety is dependent upon individuals working effectively and optimally within teams – which requires thought, the right processes and coordination and an innate understanding of a shared purpose

Margaret Chan – Director General WHO:

Need political commitment, political leadership, policies that encourage reporting, a paradigm shift in culture, the right performance management and a patient safety movement across the globe



HEE Commission

Health Education England Patient Safety Commission Report

On Tuesday 8 March – during Patient Safety Week – Health Education England launched a report;  Improving Safety through education and training.

This was picking up from the Berwick report and its recommendation that

‘the NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning’

The recommendations:

  • Create a culture of shared learning
    • ensure learning from patient safety data and good practice
    • develop and use a common language to describe all elements of quality, improvement science and human factors
    • ensure robust evaluation of education and training for patient safety
  • Patients at the centre of education and training
    • engage patients, family members, carers and the public in the design and delivery of education and training in patient safety
    • support the duty of candour with training package
  • Focus on safety from start to finish
    • support learners and staff to raise and respond to concerns about patient safety
    • create a coherent approach to mandatory training for patient safety
    • patient safety for NHS leaders
  • Education and training for patient safety
    • education and training must support an integrated approach to care
    • ensure increased opportunities for inter-professional learning
    • principles of human factors and professionalism must be embedded across education and training
    • ensure staff have the skills to identify and manage potential risks

While all equally important, inter-professional learning has huge potential for developing the foundations for mutually respectful, kind, understanding teams – vital for a safety culture where staff can feel able to speak out and listen to each other.


Patient Safety Reporting (3)

Patient Safety Reporting – the future

The Patient Safety Team at NHS England – shortly to move to NHS Improvement – have been working on the ‘new’ NRLS – the Patient Safety Incident Management System (a new acronym of PSIMS).

The new Patient Safety Incident Management System will:

  • Re-engineer the current data taxonomy
  • Review the way we capture data and the electronic forms and web interfaces
  • Look at mobile devices and apps for data capture
  • Review the way the national system is explored and analysed with specific attention to national feedback and clinical review, standardising online analysis tools and developing data sharing agreements with the other systems
  • Review the way the incidents are investigated and managed
  • Share learning with summative reports and statistics
  • continue with the patient safety alerting system
  • Develop an online collaborative sharing platform
  • Provide the usual helpdesk and system support

Discussions at the meeting this week included:

  • Build on the principle of locally led, data driven safety improvement
  • Lever new technologies for better and more user-friendly platforms for capture, feedback and analytics
  • Consider different strategies for collection (building on the call for potentially reducing the number of things that are collected or different mechanisms for different incidents)
  • Review the catch all mentality – and review what is needed at a local level versus the national level – they have different purposes
  • Perhaps consider a two tier system of catch all locally and triage certain incidents nationally

Recommendations from the Imperial report for NHS Improvement to consider are (in summary):

  • Achieve clarity of purpose for distinct local and national systems
  • Specify a limited number of incidents collected nationally and collect structured and free text data
  • Make the collected national data available to compare performance and set ambitions
  • Maintain existing local risk management systems and empower local improvements through the Patient Safety Collaboratives
  • Conduct routine analysis and apply ‘cutting edge data mining technologies’ so it can be used by the Royal Colleges
  • Apply the principles of user-focused design
  • Undertake an extensive communication and education campaign to raise awareness of the importance, role and impact of incident reporting
  • Articulate the benefits and track progress
  • Track nationally collected patient safety incidents in certain priority areas such as primary care, mental health and community care
  • Look to international best practice on patient safety information systems and share lessons globally

Lets hope NHS Improvement also take into account the lessons from Carl’s article (yes another plug!).




Patient Safety Reporting (2)

The National Reporting and Learning System

The National Reporting and Learning System, or the NRLS as most refer to it as, was designed from around 2001 when the National Patient Safety Agency was launched.  Numerous options were considered for the collection of adverse events.  During this time the term adverse events was replaced with ‘patient safety incidents’ and the guidance ‘Seven Steps to Patient Safety’ described the levels of a patient safety incident from no harm through to death.

The aim was to connect the national system to all local risk management systems to try to minimise the burden on frontline staff from having to report twice (to the hospital system and to the national system). We employed 33 patient safety managers who (amongst all their other duties) travelled the length and breadth of the country helping individual risk managers map their datasets to the national dataset.  The NHS doesn’t have a great track record with IT systems but this one has to be seen as one of the successes.  It captures from across England and Wales anything that is reported into the local risk management system day in day out.

The system now collects over a million incidents a year.  This needs some context.  The vast majority are no harm (the equivalent of high risk industries ‘near miss’) and low harm events; these are indicators of the level of risk in the system.  Also this is within the environment of activity which includes:

  • Over 1 million patients seen every 36 hours
  • Around 10m operations every year and 22 million attendances to A/E per year

There were some really interesting reflections on the successes and failures of the NRLS.

One of the most astonishing was that clostridium difficile was spelt 371 different ways in NRLS reports.

This makes it very hard when you want to (as the analysts say) interrogate the data – putting in 371 key words for a search on incidents related to clostridium difficile is somewhat tricky. This is also only one example – when free text is used in a reporting system there will always be multiple ways in which a single issue can be described.

The usual things were found:

  • Variation in reporting strategies
  • Variations in coding the level of severity – which is often subjective
  • Poor data quality
  • Limited incidents on anything out of hospitals
  • Poor feedback systems

All leading to a difficulty in knowing quite what the NRLS is telling us

The complexities of incident reporting systems are beautifully captured by Carl Macrae’s ‘The problem with… incident reporting’ in the BMJ Quality and Safety journal that really all you need to do is go and read this.

We have posted the link to this on the Sign up to Safety website.

Patient Safety Reporting (1)

The second day of Patient Safety Week was a coming together of experts related to patient safety reporting.  We were informed about the research and development work related to the current National Reporting and Learning System and about potential different mechanisms for tackling large national data systems.

The work was undertaken by Imperial Patient Safety Translational Research Centre – funded by NHS England and as part of the NHS National Institute for Health Research.

The report starts with a summary of patient safety information systems in the NHS today:

  • The National Reporting and Learning System (NRLS)
  • Strategic Executive Information System (STEIS)
  • Medicines and Healthcare products Regulatory Agency Yellow Card and medical device reporting (MHRA)
  • Care Quality Commission notification database (CQC)
  • Public Health England notifications
  • NHS Safety Thermometer
  • Serious Adverse Blood Reactions and Events (SABRE)
  • Serious Hazards of Transfusion Scheme (SHOT)
  • Complaints

I can add to this with claims at a national level and other data collection systems related to specialty specific issues including those expected by auditors, researchers, Royal Colleges and so on – AND we have a tendency to forget the multiple hospital level and regional level reporting that is also required.

We were told by Jim Mackey, new CEO of NHS Improvement, that this current ‘patchwork’ of information systems will be reviewed with the aim of reducing duplication of reporting where possible. I can remember trying to do that when we set up the NRLS in 2004 and finding it much more complex that was at first envisaged.

But in the words of Don Berwick – we have to reduce the amount we measure and therefore the amount we report so that it is purposeful and meaningful and is focused on learning and not performance management.

So with the variety of new technologies and intelligence around large data systems that we didn’t have in 2004 I am hoping and hopeful that this endeavour is a success.



Spotlight on Maternity

Patient Safety Week started off with a launch of a ‘Spotlight on Maternity’

If an organisation commits to place a spotlight on maternity then the Government is asking that they consider these focus areas when setting out their plans. Locally-led and self-directed improvement is vital and therefore any plans and actions should also be considered in the context of local services

The spotlight on maternity is a way of drawing attention to the nature and scale of avoidable harm and to suggest ways in which this could be tackled, building on the work already achieved to date.

The five high level themes are:

  1. Building strong leadership in maternity services and developing a bespoke Safety Improvement Plan for maternity
  2. Building capability and skills for all maternity staff  and improving communication within and across teams
  3. Sharing progress and lessons learnt across the system
  4. Improving data capture and knowledge in maternity services
  5. Focusing on early detection of the risks associated with perinatal mental illness

These will not be new to most of you but this is partly the point – that the foundations or building blocks for patient safety are always going to be leadership, skills development, sharing learning, and improving data capture and knowledge and early detection of risks.

The next step is for anyone working in maternity settings and services to ask these five questions as the basis for your bespoke safety improvement plan:

  • How safe are we?
  • How do we know?
  • Where are the areas we should be focusing on for the next three to five years in order to reduce avoidable harm?
  • How can we address the system and human factors that impact on safety time and time again; communication, handover, observations, patient information, patient engagement, design of pathways, services and procurement?
  • What is our long term model for improving safety so that our efforts are sustained?
  • How can we create the right safety culture for our organisation that picks up the lessons from the ‘just culture’ community and supports staff when things go wrong?

Helpful Resources

The guide is found at:  :

Over the coming months we will be sharing information and knowledge about patient safety via this blog and the Sign up to Safety campaign ‘outlets’ such as our newsletter and webinars.

For help in creating your plan see the Sign up to Safety website:

For further information on measurement of Safety Improvement Plans see the Sign up to Safety webinar library:

For inspiration on how other organisations have showcased improvement work please see the ‘From the frontline’ section on the Sign up to Safety website:


Being constructively awkward

Guest Blogger David Naylor

A few years ago I interviewed six people who had a reputation for being ‘constructively awkward’. They worked in a variety of community and NHS settings and told stories that seemed to inform the attention now being paid to speaking up and the duty of candour. They told stories, for example, about confronting people in a train carriage about mobile phone use; of crewing a yacht and noticing a buoy in the channel, being laughed at by the crew for saying the obvious and then being thanked by the captain for their attention; and insisting that a consultant find another way of explaining a child’s treatment in words that the parents could understand.

These are small stories that impacted on a few people but they are important moments. Moments when the internal conversation (‘I need to say something here’), underpinned by sufficient self-authorisation led to speaking out loud. A moment of refusal; that one was not prepared to let things go un-noticed; an act of confronting to point out what may be being ignored.

What I learnt from my research and my own experience is that I notice much more than I speak to. Obvious you might say, but consider the observation of Robert Francis on the frequency of the word ‘hindsight’ (123 times) and ‘benefit of hindsight’ (378 times) in his report [1]. We see more and know more than we speak to; and sometimes this has consequences for others.

However, simply demanding people ‘speak up’ more and be more open, transparent and candid is insufficient advice to help you and me overcome the mechanisms that can silence us.

This is not an NHS problem. Our history is replete with moments when a blind eye has been turned. As I am writing, Dame Janet Smith’s report[2] into Jimmy Savile is being discussed. A further example of how the context in which one finds oneself can strongly influence the decision to speak or not, even though one knows deep down that something is not right, not okay.

The trouble with speaking up is that it is disruptive. Not agreeing is to suddenly feel the anxiety associated that the risk of expulsion from the group holds for us. Our evolutionary advantage as a species is in part based on our ability to work cooperatively. However, in the hierarchically governed world that most of us work in, cooperation is expected and demanded. As a consequence, we have lost the knack of disagreeing and the skilful, respectful curiosity about one another’s thinking and frames of reference.

How many meetings have you been in where the real task seems to be getting others to bend to your will? While this may be ok in situations where immediate action is required, and these actions are clear, agreed and rehearsed; it can be unsafe when the situation is hard to read and complex. Here, the insistence on agreement will suppress curiosity and a full investigation of what is really going on. Culturally, we may have taken a backward step back to a time of ‘the old ingrained dislike of being interrupted, which seemed like a mutilation’ (Zeldin, 1998, p.33[3]).

The term ‘constructively awkward’ holds in mind the dilemma we face when we notice something and feel we should speak up. We need to point to what may be being ignored and do so in ways that keep relationships going. Based on what people told me the following may help if you’re interested in thinking about your own constructive awkwardness.

  • Pay attention to your internal dialogue, because it can help build one’s sense of authority to speak up. Coming across a situation that one finds troubling can evoke an internal conversation, because there is something going on that threatens one’s sense of oneself as an ethical person. What does a person like me do in situations like this? So, first of all you have to allow this conversation to develop so that it creates a pause in the forward trajectory of your thinking. To do this you need time and to be curious about and tolerant of your own thinking and feeling.
  • Expect to be disrupted by your emotional reactions; one’s values are after all being challenged. I interviewed a priest who described giving his congregation ‘both barrels’ in the Sunday sermon after an unpleasant episode of discrimination. While some people seem to assume that the expression of emotions is unwelcome and should be kept private, this is risky. Emotions are data. Their suppression removes from the scene clues about how things are actually working in practice. There is a tendency to ask patients and relatives to speak to emotions, but this maybe is a way of avoiding the deployment of our own feelings to deepen our understanding of what is going on.
  • We need to hone the skill of ‘backtracking’. Given that we can ‘lose it’, apologising with good grace and returning to the point one was trying to make is worth practicing. This means giving oneself the benefit of the doubt.
  • We need to create a context for others to speak up. I am a senior consultant at The Kings Fund. When I speak I expect people to, at the very least, allow me the time to speak. My role, my title, my name badge and the building I work in underpin my sense of authority. If that is the case then it must also be reasonable to assume, if you do not have these accoutrements speaking up is a tougher ask. If you are a junior doctor, a patient or a third sector leader you have to rely much more on what can be a fragile internal self-authorisation process. So, how you model the culture of conversation (think back to Zeldin) in your team or department can help determine if people speak up. One thing to pay attention to is: where is the dissent and who has not spoken? If everybody agrees with you then you’re not far from trouble.
  • Accept that you will worry about looking and sounding stupid. As one interviewee described it ‘the plonker factor’. This seems like an inevitable self-inflicted micro aggression on one’s temerity to go against what maybe yeas of socialising not to question, be rude or be emotional. Be wary of the voice that says that people as senior as me should know this already or do not behave like this.

Finally, it’s not all about anxiety. Acknowledge that there is some pleasure to be found in putting people right; influencing what is going on; and generally questioning what is going on.

[1] Great Britain. Department of Health (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London, The Stationary Office. (HC947).

[2] BBC Trust. The Dame Janet Smith Review Report (2016). London.

[3] Zeldin, T. (1998) An intimate history of humanity. London, Vantage.