Publications/Guidance

Saving babies' lives: a care bundle for reducing stillbirth. This guidance is part of a drive to halve the rate of stillbirths from 4.7 per thousand to 2.3 per thousand by 2030, potentially avoiding the tragedy of stillbirth for more than 1500 families every year. While the majority of women receive high quality care, there is around a 25 per cent variation in stillbirth rates across England. The guidance addresses this variation by bringing together four key elements of care based on best available evidence and practice in order to help reduce stillbirth rates. 

The UK: your partner for patient safety This publication outlines some of the patient safety initiatives the UK is currently pursuing, and the organisations which are leading the way in standards of safety. The different sections also provide information on the partners who can best help you achieve your goal of safer, better healthcare. 

From a blame culture to a learning culture. Health Secretary addresses the Global Patient Safety Summit on improving safety standards in healthcare.

NRLS Research and Development Final Report. This report from Imperial College London focuses on the current system used by NHS staff to report patient safety incidents, called the National Reporting and Learning System (NRLS). The report authors explain this system requires refinement and renovation, so as to take advantage of new technologies and recent behavioural insights. For example app-based technologies offer a simplified platform that engages staff in the incident reporting process. This will not only improve the ease of reporting, but also the accuracy of data reported. In particular, the report reiterates problems around under-reporting of safety incidents, and reveals structural concerns within the NRLS, that have inhibited its usefulness as a tool to drive safety improvement. 

Patient Safety 2030 published by Imperial College London suggests a ‘toolbox’ for patient safety. This would include: using digital technology to improve safety; providing robust training and education, and strengthening leadership at the political, organisational, clinical and community levels. Other points in the ‘toolbox’ include effective and high-quality education and training; strengthening measurement methods, including incident reporting, and exploring new digital solutions. However, the authors warn that interventions implemented to reduce avoidable patient harm must be engineered with the whole system in mind, and empower patients and staff to become more involved in preventing harm and improving care. 

News

Healthcare Safety Investigation Branch (HSIB) Expert Advisory Group. On 16 July 2015 the Governments published its response to three inquiries into patient safety: the Morecambe Bay Investigation, Robert Francis’ report into whistleblowing (Freedom to Speak Up) and the Public Administration Select Committee report on clinical incidents. In particular, the Government response, Learning not blaming, set out plans for an Independent Patient Safety Investigation Service to be established and in place from 1 April 2016. Launching this report, on 16 July 2015, the Secretary of State also gave a speech setting out his ambition for the NHS to become the world’s largest learning organisation. Following feedback from the group and others, the function’s name was changed to the Healthcare Safety Investigation Branch (HSIB). 

The Care Quality Commission is to review data security in the NHS, as national data guardian Dame Fiona Caldicott starts to develop new security standards and rules on how patient information is shared after it was revealed that the NHS is particularly vulnerable to cyber attacks due to the vast difference in its cybersecurity across each of its 40,000 hospitals, GPs' surgeries and care homes. 

Minister hints at flexibility over £250k clinical negligence costs limit. The Government has suggested that it may be prepared to be flexible about the upper limit for fixed costs in clinical negligence cases. Speaking during a Westminster Hall debate on 9 March 2016, Health Minister Ben Gummer stated that the proposed upper limit of £250,000 was not arbitrary, but chosen based on the original intentions of Lord Justice Jackson's review of civil litigation costs in 2010. 

New league launched to encourage openness in the NHS. Monitor and the NHS Trust Development Authority have launched "Learning from mistakes league" – a league table identifying levels of openness and transparency within NHS trusts and foundation trusts. The league table has been drawn together by giving providers scores based on the fairness and effectiveness of procedures for reporting errors, near misses and incidents; staff confidence and security in reporting unsafe clinical practice and the percentage of staff who feel able to contribute towards improvements at their trust. NHS Improvement will work with providers at the bottom of the league to assist them with improving their openness and transparency.