In other industries mistakes are considered unacceptable, yet in the NHS minor errors cause thousands of extra days in hospital

Every year major improvements are made to the quality of care provided by the NHS. Waiting times are greatly reduced, best clinical practice is encouraged and clinical effectiveness and efficiency in the use of resources continues. The NHS is in a continual process of change and improvement that is globally driven by science, medical advance and technology; nationally by the priorities set and resources made available; and at local level by boards, managerial and clinical leaders and staff innovations.

It is now time for boards and managerial and clinical leaders to ensure the safest possible care is systematically delivered to all patients all the time. A renewed focus on patient safety is vital for a number of reasons. The data continues to show that sometimes the actions taken to help people result in unintended harm.

As recently as November, research published in the UK confirmed that around one in 10 patients admitted to hospital will experience some form of harm. In the period from July to September 2007, the National Patient Safety Agency received 212,463 patient safety incident reports from NHS staff in England and Wales.

Not all the incidents are serious or preventable, but the data also includes more so-called 'minor' errors that could result in a few extra days in hospital. Overall this equates to thousands of extra days spent in UK hospitals each year - and the cost to patients and their families in human terms and the cost to the NHS in financial terms is substantial.

Yet too often the view pervades that "mistakes happen" and nothing can be done. In other industries this approach is unacceptable and it is essential that all of us ensure that top priority is given to improving safety as we all strive to deliver the highest possible standards of care.

Giving more attention to the safety and quality of care is what members of the public rightly expect. When things go wrong, it is a significant cause of distress to patients, their families and NHS staff and is increasingly a key issue for public confidence in the service. Nowhere is this more evident than in relation to concern about high rates of healthcare-acquired infections.

Safety awareness

The competence, professionalism and safety awareness of frontline clinicians is obviously a vital foundation for delivering safe, high-quality care. However, many safety shortcomings are often the result of how the NHS works as a system, in specific clinical areas, in trusts and across the boundaries of acute, primary and social care. This requires action by a range of people. No one professional group can solve the problem on its own.

With this in mind, the December publication of Safety First: one year on was an important milestone that marked a year since the publication of the Safety First review. Chief medical officer Sir Liam Donaldson commissioned the report to examine national arrangements for patient safety in England and ways in which these could be strengthened.

When the review was undertaken, the following points became evident:

  • the need for boards and senior managers to be more visible in understanding, managing and assuring the safety of care delivered to patients within their organisation;

  • the persistence of safety problems that should have been resolved and the failure to reliably learn, despite a national reporting system;

  • the need for the courage to have difficult conversations, while known deficiencies are vigorously and appropriately addressed in each local health system;

  • the lack of meaningful engagement of frontline clinicians in many efforts to improve patient safety, notwithstanding the importance placed by many on delivering the safest possible care.

Much progress has been made in the last year and patient safety is higher on the national agenda than ever. Safety First: one year on charts concerted efforts by a host of NHS organisations and others in tackling this issue. The operating framework states that patient safety is a national priority for 2008-09.

Safety is increasingly featuring as a core component in our approach to standard setting, inspection, performance measurement and commissioning. Significant moves by agencies such as the National Patient Safety Agency to work much more closely with all parts of the NHS will ensure that feedback from the National Reporting and Learning System is as useful as possible. The establishment of patient safety action teams within strategic health authorities will enable even more concerted and integrated action within local health economies.

The progress so far is welcomed, but the pace of change needs to be accelerated. Strong and visible national leadership is key to realising the patient safety drive, but there is also a need to do much more locally. Over the past 10 years, the government has introduced a programme to continuously improve the overall standards of clinical care, which has included focus on clinical governance, clearer national standards and a local duty of quality and robust inspection. A number of tools are in our hands, but how do we take this investment on the one hand, along with increased capacity and wider reforms on the other, and accelerate the transformation of the NHS?

Improving patient safety is a major priority in NHS South West. The SHA is working with the Health Foundation to drive forward excellence in patient safety. An ambitious plan will include cultural change, capacity building, innovation, learning and the introduction of best practice - all of which will bring benefits to our population. Designed with input from the Institute for Healthcare Improvement, starting in the acute sector and building on the IHI/Health Foundation safer patients initiative, the programme will also explore better ways of making patient safety improvements within primary care, mental health and ambulance services.

Crucial to this are actions to improve communication, reporting, learning and promoting cultural change. The South West Patient Safety Alliance will lead and co-ordinate this work, bringing together clinicians, managers, users and carers to provide a collaborative approach to improving patient safety and become a focus for sharing best practice between organisations.

Boards, senior managers and clinicians have a vital leadership role to play if improvements in patient safety are to be achieved.

Action plan

Here are six practical steps that boards, senior managers and clinical leaders can take:

  1. Ask yourself what you know about the safety of care in your own organisation. Make sure you see it for yourself and, wherever possible, measure what is being achieved. Gain a clear and personal understanding of the risks to patient safety and take systematic action to address them as a top priority.

  2. See safety as part of good resource management. Unsafe care wastes scarce resources. Use the discipline of developing the business case for safety to argue the case for organisational investment in improving safety systems. The "language of money" can often be a powerful impetus to action.

  3. Build safety alliances with clinicians. The leadership and involvement of senior clinicians is key. See a shared commitment to delivering the safest possible care as a bridge between managers and clinicians rather than a point of conflict.

  4. Build safety alliances with all staff. Obtain views of staff at all levels of the organisation, from the most senior to the most junior, as they operate the system and express views on how it can be improved. Use and energise this knowledge base so it becomes the driver of change.

  5. Talk to patients and families, especially those involved in incidents. Patients and families often have unique insights on the care they receive and where it might have gone wrong. Understanding these perspectives is a vital part of understanding system weaknesses and improving patient experience.

  6. Support clinicians in being open with patients and families. Too often our instinctive reaction when things go wrong is to close ranks and become defensive, especially when dealing with patients and relatives. Work with frontline clinicians to develop more open communication with patients, especially when things have gone wrong.

Building on the firm base of financial and organisational stability achieved during the last financial year and with an eye to the Darzi review, it is vital to seize the chance to address the glaring omission in the NHS record of achievement - that of making patient safety central to everything we do.

Improving patient safety requires major change in attitudes, behaviour and approach. It requires greater engagement with clinical and non-clinical staff, users, carers and the public; everyday innovation; and exploitation of science, technology and best practice to deliver the fastest and safest care. Patient safety is everyone's business, so let's make it a mainstream activity for boards and managerial and clinical leaders so high standards of care can be further developed and improved throughout the NHS.