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