Supported by the National Patient Safety Agency


  • Christine Beasley, chief nursing officer
  • Dr Gill Hastings, assistant director,The Health Foundation
  • Dr Helen Glenister, deputy chief executive, National Patient Safety Agency

Winner Lancashire Care Trust

The judges considered this project to be an outstanding and exciting example of a transformational approach to embedding an organisational culture of patient safety. It received universal praise for the high quality of its energy and engagement across a large, complex trust. The patient safety management system is comprehensive and produces quantifiable benefits

The winning project set out to strengthen three areas of weakness in to the investigation and learning from patient safety incidents (PSIs): routine application of a solution-focused investigation technique, system communication of learning and evaluation of solution implementation. The approach was designed to reduce the number of serious PSIs, with special regard to suicides and attempted suicides.

Members of the clinical governance network team attended root cause analysis (RCA) training and bespoke group facilitation workshops prior to the rollout of a massive RCA training initiative across the trust. Subsequent SHA monitoring of trust incident reporting has shown marked improvements in quality and timeliness. Each trust area holds innovative multidisciplinary RCA events - some attended by service users and carers - led by experienced root cause analysts to review incidents. Service delivery issues and contributory factors are also reviewed and reported to the trust board.

Blue Lights is an intranet-based electronic bulletin system that flags up all root cause solutions which are applicable across the trust. It can also be used to provide links to policies and online knowledge audits. 'Daring to Share' events highlight key themes from trust and national incidents and reports and are aimed at bringing staff and service users together with partner organisations to share key learning.

Root causes are, where possible, converted into root risks for local and trust-wide use. The system has led to genuine organisational change and has contributed to a decrease in suspected suicides and attempted suicides, with suicide mortality down by more than 20 per cent in the past two years.

Root causes, root risks and rapid fixes, contact

Highly commended NHS Tayside

Walkrounds were introduced in Tayside in February 2005 as part of the safer patients initiative and are designed as a formal participative model through which to discuss and improve patient safety

Reliance on adverse event reporting does not detect all patient harm and even if it could there are many features of the healthcare environment preventing staff recording every deviance from normal practice. Learning from serious incidents and near misses requires innovation.

Patient safety walkrounds promote a culture of patient safety and improve event reporting, increase awareness among the care team and make safety a leadership priority. They are also a useful means of collecting information from staff about barriers to safety and providing feedback to leadership about process implementation.

At least one member of the executive attends, accompanied by a scribe, a patient representative and local staff who have collaborated on pre-visit planning that ensures the process has no impact on service demands. Questions are discussed, actions agreed and a report circulated within 48 hours.

Progress is tracked and longer-term actions are reviewed quarterly. Safety briefings are now part of daily practice and infection control disseminates examples of good practice through the organisation.

More than 500 staff from all disciplines and each of the executive directors has taken part in a programme that has instigated more than 500 simple interventions. The system visibly demonstrates the commitment to patient safety and is a fundamental element of Tayside's goal to build a culture for change in relation to patient safety.

Patient safety leadership walkround, contact

Finalist Leicestershire, Northants and Rutland Healthcare Workforce Deanery

The clinical performance support unit delivers a standardised approach to the investigation and remediation of performance concerns relating to medical practitioners in primary care

All elements of any presenting case are examined using techniques including behavioural, competency and conduct analysis. Where the referring organisation accepts remedial recommendations made by the unit, doctors are found placements where they make a staged return to normal working.

Only those complex cases that cannot be resolved locally are now passed on to national bodies. Health secretary Patricia Hewitt said it was a model worth of replicating.

Clinical performance support unit, contact

Finalist Salford Royal Hospital Trust

A potentially lifesaving project in which oxygen saturation levels are indicated and carefully monitored

An adverse incident report described a chronic obstructive pulmonary disease patient being given high-flow oxygen during a five-hour period and the patient died as a result. An investigation found that oxygen was rarely prescribed, and when it was the percentage given was frequently wrong and knowledge of oxygen therapy and the COPD patient was poor. The investigating team developed an oxygen target saturation system.

Doctors now indicate required saturation levels and carers adjust the oxygen until it is reached. The process has won an NPSA bursary award and there have been no recurrences.

Oxygen, a lifesaver for some, a risk for others, contact

Finalist Princess Alexandra Hospital Trust

This system to classify the severity of incidents was introduced at the beginning of 2005 and has highlighted areas that compromise patient safety

This error-proofing approach required an understanding of error-proofing principles, removal of variation through standardisation, adherence to best practice and the promotion of a patient safety culture.

A number of initiatives have followed the move to error proofing: the medical assessment tool standardises treatment for accident and emergency patients; a patient-at-risk identification scheme called the Amber tool; care bundles; and SBAR (situation, background, assessment and recommendation).

Incidents are now down by 10 a month.

Incident reporting system, contact