- New incident response framework will move away from traditional thresholds for investigations
- Patients to be involved in investigations and to join clinical governance committees
- New safety strategy could save 1,000 lives and £100m a year by 2023-24
The NHS will move away from traditional thresholds for serious incident investigations as part of its new national patient safety strategy.
Organisations will be encouraged to investigate incidents which offer the greatest potential for learning, rather than investigating every incident. This would free up resources to invest in delivering improvements which address findings from completed investigations, according to the NHS England and Improvement document published today.
While the requirements to investigate certain incidents, such as deaths resulting from poor care, will not change, the new patient safety incident response framework will set out “principles, systems, processes, skills and behaviours for incident management as part of a broader system approach…moving away from a focus on current thresholds for serious incidents”.
The 60-day incident deadline could also be relaxed, provided timelines are agreed with those affected by the incident. Investigators will also need to be trained in safety investigation. Regional teams could commission investigations of incidents across multiple care settings.
The NHS will set new expectations for the involvement of patients, staff and families in investigations along with at least two patients being appointed to all clinical governance committees by April 2021.
The new patient safety strategy, designed to sit alongside the NHS long-term plan published in January, also reveals plans to transform the National Patient Safety Alert committee, set up in 2018, into a more general safety committee for the NHS, similar to the transport safety board.
The committee will oversee the system response to Healthcare Safety Investigation Branch’s recommendations and hold organisations to account.
The safety strategy claims improving patient safety in the NHS could save almost 1,000 extra lives and £100m in costs a year from 2023-4 with clinical negligence claims cut by £750m by 2025.
A 2015 study suggested up to 11,000 avoidable deaths occur each year costing the NHS £1bn.
Under the plans, each NHS trust will have a dedicated safety specialist. Meanwhile, a new safety curriculum will be rolled out for staff across the health service with levels of training based on their role.
The specialists will be in place by April 2020 along with new networks at local, regional and national levels.
In the foreword to the strategy, Aidan Fowler, national patient safety director, said: “This is not a document written by us telling you what you should do. It is rather a document curated by us on behalf of the NHS and is a statement of our collective intent to improve safety by recognising that to make progress, we must significantly improve the way we learn, treat staff and involve patients.”
Key proposals in the strategy include:
- A new patient safety curriculum for the training of NHS staff;
- New patient safety specialists in organisations to lead safety improvement;
- New cultural metrics to measure how safe the NHS is;
- An overhaul of the national incident reporting system with a new digital incident reporting system open to staff and patients and available on mobile phones;
- A new patient safety incident response framework to improve how the NHS responds to incidents of harm;
- Embed learning from the new national medical examiner service;
- Reform the National Patient Safety Alert committee to better respond to emerging risks;
- Better shared learning from litigation data to prevent harm; and
- New national patient safety improvement programme delivered by patient safety collaboratives and academic health science networks.
Patient Safety Strategy