Meeting & Events
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Overview
13th March 2007– Safety First: An Overview of Patient Safety in 2007
In December 2006 the Department of Health published Safety First, a report commissioned by Sir Liam Donaldson, Chief Medical Officer, to reconsider the organisational arrangements currently in place to ensure that patient safety is at the heart of the healthcare agenda.
The review was explicitly aimed to address issues raised by the National Audit Office in its report, A Safer Place for Patients, as well as to look at the NHS approach to patient safety more widely. The report makes a number of key recommendations to build on the progress already achieved in embedding patient safety in the NHS. These include establishing a national patient safety forum to oversee the design and implementation of a national patient safety initiative; simplifying the reporting of adverse effects to make it easier for clinical staff to report on a confidential basis without the fear of retribution; and establishing Patient Safety Action Teams to support frontline staff in delivering the national patient safety agenda.
This meeting of the All-Party Parliamentary Group on Patient Safety aimed to discuss the implications concerning the publication of the Department of Health’s Safety First and to consider more broadly the key issues surrounding patient safety in 2007.
Speakers were:
Dr Howard Stoate MP, Chair of the group, opened the meeting by giving a brief introduction to the Safety First report and invited the speakers to comment on the report’s recommendations.
Lord Patel spoke about the value of the culture of patient safety emanating from the National Reporting System and the need for an accompanying system of learning. He called for those that deliver care, whether it be primary, secondary or tertiary, to take ownership and the importance of fostering a blame-free culture. He highlighted the role of the NPSA in establishing effective local learning - providing local solutions to local incidents.
Sir Liam Donaldson, as Chair of the World Health Organisation’s World Alliance on Patient Safety, reported on a range of initiatives that are being undertaken worldwide. This included the fact that the WHO has recently passed a resolution identifying patient safety as a key priority, launching a global Patient Safety Challenge, which will run over the next two years and has the support of over 50 countries.
A research programme to build an international taxonomy of patient safety issues in different parts of the world, including a study into unsafe practices in developing countries was also announced by Sir Liam. Currently there are methodological issues to be overcome and funding is still being sought, but the WHO remains committed to this programme.
Sir Liam also spoke of the need for evidence-based solutions through technology and education, specialist partnerships as well as exemplar hospitals
He identified the UK as a leading light in the field of patient safety whilst acknowledging several smaller outstanding programmes worldwide that were actively addressing issues of patient safety.
From his position as Chief Medical Officer, Sir Liam called for an improved analysis of incidents within the NHS – the National Reporting System has accumulated a mass of valuable data but methodological questions such as who decides when and where to act are yet to de resolved.
He also stressed the importance of developing effective local solutions, citing a ‘stop’ protocol in place at one hospital where before operating on a patient, doctors gather to re-examine the case notes before proceeding. According to Sir Liam, this considerably lowers any risk of wrong-side surgery for example. He also highlighted the benefits of increased patient involvement and outlined his vision for the road ahead, stressing that the engagement of front line staff was essential.
This discussion was followed by a Q&A session between the panel and attendees.