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How NHS patient safety can be improved by creating a learning culture


Cognisco's Mary Clarke suggests how learning could improve the nation's healthcare system.

Improving patient safety and cracking down on preventable deaths in the NHS has been a key focus for Health Secretary, Jeremy Hunt. He has been running a ‘Sign up to Safety campaign which aims to save up to 6,000 lives over the next three years. In fact, the Department of Health launched a website called 'How Safe is my Hospital.' It allows people to compare hospitals in England based on a number of safety indicators, including ward staffing levels, incident reporting levels, pressure ulcers, falls and how the hospital is complying with patient safety alerts.

The campaign was planned following a review by the Department of Health, which found that 29 out of 141 NHS trusts could be under-reporting incidents to the National Reporting and Learning System. Hunt has said: "It is my clear ambition that the NHS should become the safest healthcare system anywhere in the world. I want the tragic events of Mid Staffs to become a turning point in the creation of a more open, compassionate and transparent culture within the NHS." This is obviously a step in the right direction for improving patient care after years of neglect, negligence and too many unnecessary deaths in some parts of the NHS. However, whilst reporting on safety levels in hospitals is a good way for hospital trust to become more accountable, it's more important to encourage a culture of learning across the whole of the NHS.

"The key to truly improving patient care and safety across the NHS is to understand and address the human factors that impact patient care most."

Interestingly, 75% of the UK NHS is currently using a reporting system called Datix that has been a pioneer in the field of patient safety since 1986; however, mistakes are still happening. Whilst most of the NHS is using this system to conduct their incident reporting, different trusts have different criteria for reporting incidents, varying views on what should be reported and as such, there is a real lack of consistency. The key to truly improving patient care and safety across the NHS is to understand and address the human factors that impact patient care most. To do this, organisations need more insight just about the competence of their medical teams but also how every individual behaves at work and the likely decisions they will make doing their jobs.

According to Martin Bromiley, the founder and director of the Clinical Human Factors Group [1], the NHS is starting to see the value of addressing 'human factors' to improve safety but progress is not happening quickly enough. Martin set up the Clinical Human Factors Group following the death of his wife, when the inquest revealed a series of factors termed as 'human factors' or failings in 'non-technical skills' were responsible, despite the medical team having many years of experience between them.

Although healthcare professionals generally don't set out to harm patients, they are all human beings. People can become complacent in their jobs or not feel confident in certain aspects of their role or take short cuts because of various pressures - all of these factors can translate into risky behaviour. Whereas in other industries this may not cause any harm, in healthcare this kind of behaviour is high risk.

Only last month three babies died from blood poisoning after being given a contaminated batch of liquid food which was two days out of date. This could have been a simple human error; however, because it was a hospital dealing with vulnerable patients it shouldn't have happened. All NHS professionals need to be regularly assessed to identify risky behaviours that may have become normalised, and tailored training implemented should it be needed. This needs to be done regularly across the whole of the NHS to create a culture of learning which helps counteract the risks associated human behaviour. Only by tracking human behaviour can the NHS improve its patient safety record.

[1] A coalition of healthcare professionals, managers and service-users who have partnered with experts in Human Factors from healthcare and other high-risk industries to campaign for change in the NHS

Mary Clarke is CEO at Cognisco


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