Seven-step guide to improving patient safety launched by NPSA
A seven-step guide to improving patient safety has been launched by the National Patient Safety Agency. The guide emphasises the need to create an open safety culture and comes ahead of the national reporting and learning system, to be launched by the NPSA shortly.
The new guide lists ways in which National Health Service organisations
and their staff, in both primary and secondary care, can improve safety
locally (see Panel). It includes action points for management and lists
help that is available, including videos and the support of the 31 patient
safety managers appointed to strategic health authorities and NHS regions
in England and Wales.
NPSA’s seven steps to patient safety
• Safety culture Create a culture that is open and fair
• Lead and support staff Establish a clear and strong focus on patient
safety across the organisation
• Risk management Develop systems and processes to manage risks and
identify and assess things that could go wrong
• Promote reporting Ensure staff can easily report incidents locally
and nationally
• Patients and public Develop ways to communicate openly with and
listen to patients and the public
• Learn and share Encourage staff to use root cause analysis to learn
how and why incidents happen
• Prevent harm Embed lessons learnt through changes to practice,
processes and systems |
The seven steps emphasise the creation of open and non-punitive safety
culture and the analysis of patient safety incidents and near misses
to establish root causes rather than errors by individuals.
Professor Charles Vincent, professor of clinical safety research at Imperial
College, London, said: “Designing simpler, standardised processes
of care which reduce reliance on memory, and remove obvious ‘error
traps’ such as look-alike drug labels, is fundamental for all health
care processes. However, safety is also achieved by the active efforts
of people, anticipating possible problems, flexibly adapting to crises
and working co-operatively to support each other. While some solutions
can be built into the system, we will always need to emphasise the safety
culture and the role that people play in creating safety.”
Article, p719 |
