A new patient safety training package could be rolled out to all nurses in a bid to reduce cases of avoidable harm and generate a culture change within the NHS.
The proposal is going to public consultation along with a raft of other measures as part of the development of an NHS patient safety strategy to be delivered from April 2019.
“Our strategy will contain bold, staff-driven initiatives, which will help us to build the safest healthcare system in the world”
The work is being led by NHS Improvement and is being lined up with the new long-term plan for the health service, which is due for publication this month.
All current and future NHS staff will be required to complete learning from a shared curriculum with tweaks according to their role in the hope this will standardise how incidents are reported and acted upon.
The plans state: “As people learn about the key concepts that underpin patient safety, they will be able to recognise behaviours and approaches that do not help and instead adopt those that do support patient safety.”
There are also ambitions to create a new network of senior patient safety specialists who can “become the backbone of patient safety in the NHS”.
These roles will be opened up to existing frontline staff including nurses, doctors, pharmacists, managers and allied health professionals, who will be upskilled in this area.
NHS Improvement wants to create a “just culture” where frontline staff are supported to speak up when errors occur and move away from a “blame culture” in which they feel too afraid to raise concerns.
The proposal (see PDF attached below) also includes a goal to half incidences of “avoidable harm” to patients over the next five years in key areas such as sepsis, pressure ulcers, e-coli, falls and maternity - in some cases building on efforts already underway.
Areas that will be prioritised will be those that cause the most severe harm to the patient, cost the NHS the most in legal fees and where there are the biggest variations in care and outcomes.
The NHS will also introduce a new patient safety incident management system that will use the latest technology such as artificial intelligence to interrogate data, spot trends and support learning.
“It is a testament to the professionalism of frontline staff that in the clear majority of cases, patients receive safe care”
Dr Aidan Fowler
The work has in part been driven by concerns raised through high-profile care scandals such at Gosport War Memorial, Mid Staffordshire and Morecambe Bay.
Dr Aidan Fowler, national director of patient safety at NHS Improvement and a former consultant surgeon, said: “It is a testament to the professionalism of frontline staff that in the clear majority of cases, patients receive safe care.
“The NHS is leading the way for patient safety, but we must not be complacent. Our ambition as part of the long-term plan is for an increased focus on safety improvement as this is what patients deserve.
“Key to this will be to develop a ‘just culture’ across the NHS, where staff are supported to be open and transparent about what is going on without fear of punishment for errors that are beyond their control.”
Dr Fowler said continuous learning and improvements must be at the heart of protecting patients from avoidable harm.
Care minister Caroline Dinenage said: “Our strategy will contain bold, staff-driven initiatives, which will help us to build the safest healthcare system in the world, underpinned by a no-blame culture that champions people to speak up when things go wrong and learn from their mistakes.”
Wendy Preston, head of nursing practice at the Royal College of Nursing, said the college supported a “human factors” approach to patient safety, which acknowledges influencers on a worker’s performance such as staffing, equipment, workspace and the culture of the organisation.
She added: “While there’s been some progress since the Francis Inquiry to develop guidance for human factors in healthcare and the nursing regulator has updated its code to reference human factors, more could be done to promote a shared understanding of the relationship between how healthcare systems are designed and how increasing the role of individual healthcare workers in their design could reduce harm greatly.”
Ms Preston said NHS Improvement’s plans were an “important step forward”.
The Francis Inquiry examined the causes of the failings in care at Mid Staffordshire NHS Foundation Trust between 2005 and 2009.
The consultation on the new strategy is open to both members of the public and NHS staff.