Nominate safety champions, say NPSA
Pharmacy departments (in common with other directorates, divisions or departments at National Health Service organisations in both the primary and secondary care sectors) should each have a patient safety champion.
Organisations should also have an executive or non-executive board member
with responsibility for patient safety.
These suggestions are among those set out in the seven step guide to improving
patient safety launched by the National Patient Safety Agency (NPSA). The
guide focuses on the need to create an open safety culture, concentrating
on reducing risks by tackling the root cause of safety incidents, rather
than targeting individual members of staff who have made errors.Ways to
improve patient safety locally are set out in the guide (see panel). Also
included are action points for managers of organisations and for teams
of staff. In addition, the guide lists the help that is available, including
various videos and the leadership, support and advice of a network of 31
patient safety managers appointed to strategic health authorities and NHS
regions in England and Wales.
Seven steps to improving 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 risk 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 |
Resources in development are also described.
These include an electronic web-based interactive tool designed to help
managers get appropriate information
from staff who have been involved in an incident, and a package of guidance
and training to assist NHS staff in talking to patients and relatives
following serious safety incidents.
The guide is designed to be adapted locally to help organisations meet
current clinical governance management and controls assurance targets.
According to Sue Osborne, joint chief executive of the NPSA, “Our
new guide sets out tangible steps to build a culture of learning from patient
safety incidents. The guide is not prescriptive and organisations will
be able to prioritise the actions as they see fit, according to how developed
they currently are in managing patient safety incidents.”
The guide comes ahead of two key NPSA initiatives to be launched shortly
to drive the patient safety agenda forward: the National
Reporting and Learning System and specialist training for staff on root
cause analysis.
The NPSA have announced that their new chair is to be Lord Philip
Hunt of Kings Heath. Lord Hunt, who was recently health minister for
England and Wales, takes over on 1 January 2004 from Professor Rory
Shaw.
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