Patient safety cannot be assured through a “one size fits all” approach but must be monitored through measures customised to local circumstances, a report by a leading member of the government’s post-Francis safety review group has concluded.
Charles Vincent, director of the Centre for Patient Safety and Service Quality and the Clinical Safety Research Unit at Imperial College London, is chairing a sub-committee of the National Patient Safety Advisory Group looking at measurement, tracking, transparency and learning.
In a separate piece of work he and his team were commissioned by the Health Foundation to look at measurement and monitoring of safety.
The report sets out a framework which it advocates all healthcare organisations can use as a basis for developing local measures and processes to assure themselves their services are safe.
Presenting the report at a session at the NHS Confederation conference this afternoon, Health Foundation assistant director Elaine Maxwell said it was not enough just to measure past incidence of harm as that does not “tell you how safe you are today”.
“What we have done in patient safety [in the past] is look at what engineers would call tightly coupled errors… but actually the biggest problems in patient safety are loosely coupled: the things that we do to make an older person lose confidence so that they can’t go home and end up in residential care,” she added.
The report, The Measurement and Monitoring of Patient Safety, sets out a five elements to assuring organisations are safe:
- measuring past harm;
- reliability of services, encompassing behaviour and systems;
- sensitivity to operations in the form of the ability to monitor services on an hourly and daily basis;
- the ability to anticipate and be prepared for problems;
- the ability to learn from safety information and integrate improvements into services.
Report co-author Susan Burnett said: “I believe that you need all five to be considered in an organisation for you to be to say you are monitoring and measuring patient safety.”
She said a lot of the good work they had found while producing the report had involved “empowering people at the front line to collect the information that they want”.
The advisory group, chaired by Don Berwick, was asked by prime minster David Cameron to look at making zero harm a reality in the NHS and is due to report in July.
Dr Maxwell said the Health Foundation planned to consult widely on the proposed framework and make recommendations to the four governments of the UK towards the end of the year.
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