A Blueprint For Action 240619

patient safety learning The Patient-Safe Future: A Blueprint for Action 1
Contents
Executive Summary ........................................................ 5
1 Introduction.............................................................. 13
2 What we learned from A Patient-Safe Future........... 17
3 Patient Safety is a strategic purpose........................ 23
4 Shared learning ....................................................... 29
5 Leadership for patient safety.................................... 41
6 Professionalising patient safety ............................... 49
7 Patient engagement for patient safety ..................... 57
8 Data and insight for patient safety ........................... 67
9 Patient safety culture ............................................... 75
10 About Patient Safety Learning ................................. 81
References.................................................................... 85

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4 The Patient-Safe Future: A Blueprint for Action patient safety learning

Executive Summary
Place the quality of patient care,

especially patient safety,
above all other aims.
Don Berwick, 20131

Executive summary
Patient Safety Learning seeks to transform thinking

and action for patient safety
Patient Safety Learning is a charity and independent voice for improving
patient safety. We harness the knowledge, enthusiasm and commitment
of health and social care organisations, professionals and patients for
system-wide change.
We use what we learn to envision safer care. We recommend how to get
there. Then we act to help make it happen.
A Blueprint for Action describes the path to a

patient-safe future
Our previous Green Paper, A Patient Safe Future3, identified systemic
5,526
causes of patient safety failure. Patients reported to have
suffered serious, life-changing
A Blueprint for Action builds on this analysis to describe the actions
harm in the year to Sep 2018
needed to make the patient-safe future a reality.
due to unsafe care2
Patient safety is a major and persistent problem

Every year, avoidable harm leads to the deaths of thousands of
patients, each an unnecessary tragedy. Unsafe care also causes the
long-term suffering of tens of thousands and costs the health service
billions of pounds.
Many people have been doing good work over the last 20 years, but
patient safety remains a persistent problem. We propose that health and
£2.2bn
social care need to think and act differently to make the transformational direct cost to the NHS of clinical
change needed to realise a patient-safe future. negligence in 2017/184
Patient safety is part of the purpose of health and

social care
Patient safety is typically seen as a strategic priority. This
sounds important, but it means that, in practice, health and social
care decision-makers will weigh (and inevitably trade-off) the
importance of patient safety against other priorities, like finances,
resources or efficiency.
We believe that patient safety is not just another priority: it is part of the
purpose of health care. Patient safety should not be negotiable.
Systemic causes of unsafe care

We believe that patient safety fails for one or more of the following
systemic causes:
• Patient safety is not regarded as a core purpose by leaders

Executive summary
• Organisations do not take ‘all reasonable and practical steps’ to

improve safety.
• We don't have standards for patient safety in the way that we do for
other safety issues, and those that we do have are insufficient and
inconsistent.
• We focus too much on responding to, and mitigating the risk of,
harm. We don’t pay enough attention and take action to design
healthcare to be safe for patients and for the staff who work
within it.
• We don’t learn well enough, share or act on that learning for

patient safety.
• Staff working in healthcare are not ‘suitably qualified and

15% experienced’ for patient safety and are not properly supported by
leaders and specialists in safety design and human factors.
of hospital expenditure and • Patients are not sufficiently engaged in their safety during care and
activity costs are estimated to after harm; patients need to be part of the team.
be due to patient safety failure5
• We don’t have good ways of measuring and performance managing
whether we are providing safe care.
• A culture of blame and fear undermines our ambitions to design and

deliver safer care.
Foundations of patient safety

Patient safety is a system-wide challenge. We list below six evidence-
based foundations for action to address the causes of unsafe care:
1 Shared learning for patient safety
2 Leadership for patient safety
3 Professionalising patient safety
4 Patient engagement for patient safety
5 Data and insight for patient safety
6 Just Culture
These foundations form the basis of our Blueprint for Action.

Executive summary
Summary of actions
The actions we are proposing build on these foundations and are
described in more detail in the full report. A summary of these actions is
set out below.
Action: shared learning for patient safety

Organisations should set and deliver goals for learning from
patient safety, report on progress and share their insights widely.
We are creating the hub, an online platform and community for
people to share learning about patient safety problems,
experiences and solutions.
We research and report on the effectiveness of investigations into
unsafe care.
Action: professionalise patient safety

Standards and accreditation for patient safety need to be
developed and implemented. These need to be used by regulators
to inform their assessment of safe care. We will work with the
health and social care system to support the development of these
standards.
A competency framework for patient safety is needed to ensure
that all staff are ‘suitably qualified and experienced’. We propose
to work with Health Education England and others to develop this.
Health and social care organisations need specialist patient safety
7-8
and human factors experts with leadership support, resources and The number of serious harm
governance. These roles must be clearly defined, with reporting incidents each year in which the
lines to the Board (both Executive and Non-Executive). These RCGP estimates a typical GP
specialists will help lead re-design for safety, as well as learning will be involved6
from unsafe care, patient engagement, complaints, near misses,
clinical reviews and audits.
Guidance, resources and toolkits need to be developed and
implemented with the support of specialist expertise in patient
safety and human factors. We will promote and share these
through the hub.
Action: leadership for patient safety

We call for overarching leadership for patient safety across the
health and social care system. We propose a Leadership Forum
for Patient Safety will lead the design and co-ordination of safe
care and emphasise a systems approach and human factors. This
forum should:

Executive summary
• Develop practical models of leadership and governance for

patient safety, including how patient safety risk assessments
can inform decision-making and the business case for
patient safety.
• Map current roles and strategic goals for patient safety.
• Co-ordinate patient safety networks and improvement
programmes so that they are systemic in their
implementation.
• Share learning.
• Support the development of standards, resources, tools,
‘how to’ guides, maturity models and self-assessment
frameworks.
We recommend that all health and social care organisations
publish annually their goals and outcomes for safer care.
We recommend that integrated care systems set standards for
patient safety in service commissioning, care delivery and care
pathway design.
We will work with the health and social care system to support
strengthening leadership for patient safety.
Action: patient engagement for patient safety

We will work with the health and social care system to encourage
and support the actions necessary to achieve the following:
Hospitals which involved • Patients need to be valued and engaged in patient safety at
patients reported
the point of care; if harm occurs; in investigating unsafe
38% •
care; in the design of service improvements; and holding
organisations to account for safer care.
Organisations need to fund, recruit, train and provide
fewer harmful medical errors
ongoing support for patients engaged in patient safety
46% •
advocacy.
Organisations need to ensure that staff and leaders have the
fewer adverse events7
necessary knowledge, skills, attitudes and behaviours to
meaningfully engage and involve patients in patient safety.
We will initiate development of ‘harmed patient care pathways’ for
patients, families and staff following a serious incident.
We will help develop and support effective patient advocacy and
governance for patient safety.

Executive summary
Action: data and insight for patient safety

Models for measuring, reporting and assessing patient safety
performance are needed that include quantitative as well as
qualitative data. We will convene a panel of experts to identify the
critical data and insight needed to measure and monitor patient
safety.
We will work to ensure that patient safety is designed into digital
health initiatives as a core principle, rather than an add-on.
Action: culture for patient safety

All health and social care organisations should develop
programmes and publish goals to eliminate blame and fear,
introduce or deepen a Just Culture and measure and report their
progress.
We will celebrate great work and innovation for patient safety
through our Patient Safety Learning Awards and the hub.
We can all play a part

Health and social care are complex systems and many organisations and
people play a role in patient safety.
We need to better understand how we can all work together to address
the systemic issues that cause unsafe care and harm.
It is clear that those below all have key roles in safe care:
• Health and social care leaders and managers
• Patient Safety / Risk Managers
• Frontline clinical and care staff
• System regulators, such as CQC and MHRA
• Professional regulators, such as the GMC, NMC, HCPC and many

others
• Department of Health and Social Care
• Policymakers
• The Healthcare Safety Investigation Branch (HSIB)
• Networks representing provider organisations
• Think Tanks, such as the Kings Fund, Health Foundation
• Patients and the public
• Commissioners and funders

Executive summary
• National Patient Safety leaders, such as NHS Improvement
• Academic Health Science Networks
• Patient Safety Collaboratives
• Researchers and academics
• Human Factors experts and safety system designers
• Media
• Politicians
• Royal Colleges
• Arms-length Bodies
• NICE
• Freedom to Speak Up Guardians
• Charities
• Professional societies and associations
• Trade Unions
• Educators
• MPs and Parliament

and many others.
Only by working together can we create a patient-safe future.

Executive summary

1 Introduction
“To err is human, to cover up is unforgiveable and to fail

to learn is inexcusable.”
Sir Liam Donaldson8

1 Introduction
A Blueprint for Action

Avoidable unsafe care kills and harms thousands of people each year2.
To stand by while such suffering continues is intolerable.
A Patient-Safe Future showed that systemic action across inter-related
activities is needed if we are to make patients safer. Following its
publication, we consulted a range of people and organisations to get
feedback on the analysis, vision and proposals it described. 1 in 25
This report, A Blueprint for Action, reflects the feedback we received and patient safety incidents
describes the actions needed to make patients safer. These include result in severe harm9
actions we call for others to take and actions that we at Patient Safety
Learning will initiate.
We propose actions aimed at major causes of unsafe care. If we
eliminate or reduce the causes of a problem, we eliminate or reduce the
problem itself.
Benefits of addressing causes of unsafe care

• If we share learning about patient safety, we will equip many more
people with tools, insight and thinking that they can use to make
patients safer.
• If we create a model of leadership for patient safety that is shared
system-wide, we can ensure that organisations are led consistently
to deliver and improve safer care for patients.
• If we professionalise patient safety, we ensure that everyone is
informed and skilled in patient safety, including human factors and
systems thinking. We can set and reasonably expect consistent
standards of safer patient care.
• If we engage patients in patient safety, we can make health and
social care safer as patients can offer continuity of insight through
the stages of their care.
• If we have better data and insight for patient safety, we can
understand our performance, make better decisions and take more
effective action to improve patient safety.
• If we have a culture for patient safety, we greatly increase
the openness and transparency needed to operate our
organisations safely.
Underpinning all of these is the recognition that patient safety is part of

the purpose of our care organisations. Only by making patient safety part
of every decision – organisational, financial and, of course, clinical – will
we achieve a patient-safe future.

1 Introduction
The need for action

Efforts over the years attest that patient safety issues are not amenable to
easy resolution. In part, this is a result of what has been termed the
‘implementation gap,’11 evidenced by the many cases that lead to well-
researched and evidence-based recommendations, but from which little
or no practical change obtains.
The case for action is compelling. It is made by each of the thousands of
40% people dying or harmed each year, by the frustrations of staff working in
unsafe systems and by the billions of pounds spent as a consequence of
unsafe care.
of NHS acute hospitals’
core services, Over the past 20 years, we have come to understand what the problems
are. Various studies, including A Patient-Safe Future, have helped explain
37% why patient safety problems exist and persist.

If we are to make the sustained, systemic changes needed to achieve a
of NHS mental health trusts’ patient-safe future, we need to understand how to make them happen.
core services, and This is the purpose of A Blueprint for Action.
22% We propose that with systems thinking, human factors and a focus on
practical action, it is possible to make patient care safer. We want this
report to help everyone who designs, delivers and receives health and
of adult social care providers social care to make the future safer for patients.
were rated as ‘requires
improvement’ on safety at the In this report, we describe actions that we think will make a real difference
end of July 201810” to patient safety. We have taken care to specify actions. We believe these
actions are relevant, pragmatic and practical and that they will strengthen
and speed up our journey to a patient-safe future.

1 Introduction

2 What we learned from A Patient-Safe Future
“For me, safety cannot and should not be a distinct silo,

but run through everything we do;
for only then will it be sustained.”
Dr Matthew Inada-Kim12

“…patient safety is not just about statistics. Adverse events damage the
lives of real people – patients and families – who are affected, harmed or
die as a result of that unsafe care. Unsafe care also places a large and
needless financial burden both on patients and on the health-care
systems that treat them”
World Health Organisation (2013)13
Patient safety is a systems issue

A Patient-Safe Future showed that patient safety is a systems issue and
that avoidable unsafe care has complex causes.
It identified the systemic causes of patient safety failure. It described a

patient-safe future by showing what would be different if these causes
were addressed. It also recommended actions to progress towards such
a future.
A 90-day consultation started upon publication. Organisations and
individuals were engaged directly and online to get their feedback.
A positive reception
Every response welcomed A Patient-Safe Future as a valuable
contribution to thinking about patient safety.
Respondents said that they appreciated:
• The system-wide view.
• The use of evidence to drive conclusions.
• The concrete way in which the patient-safe future was described.
• The practical nature of the recommendations for action.
• Our proposal to develop and launch a learning platform for
patient safety.
There was broad concurrence that action was needed against the five
priority areas the Green Paper identified:
• Shared learning
• Professionalising patient safety
• Patient safety data
• Leadership
• Culture

Suggestions for more attention

Respondents suggested areas that they thought had been omitted or
which they thought deserved greater emphasis. These included:
• More was needed about how patients can and should be involved
for patient safety.
• Greater emphasis on systems thinking and human factors in
addressing unsafe care
• The effect of pressure on resources on safe working
• Whistleblowing
• That ‘care’ encompasses health and social care
How A Blueprint for Action reflects what we learned

We reflect the feedback we received in a number of ways:
Patient engagement
We have added a new stream of work: Patient engagement for
patient safety.
Systems thinking and human factors

The role of system-wide thinking is now more explicit, as is
human factors.
Recognising the role of constrained resources and increasing

demand in unsafe care
The report recognises the demands on safety of what Liberati et al14
15% called ‘adverse structural conditions’ (such as increased demand and

constrained resources). It calls for decision-making about resources
and the management of demand that treat patient safety as an explicit
of “…hospital expenditure
priority, minimising compromise in the pursuit of apparent efficiency or
and activity..” costs are due to
cost constraint.
patient safety failure5
Patient safety failure is itself a substantial cost. It harms patients, diverts
clinical resources, increases stress for staff and generates costs that run
to billions.
These additional costs can include:
• Additional care and support for patients and families.
• Time and cost associated with complaints and investigations that
follow serious safety incidents.
• Time, legal costs and negligence payments to patients or families
who litigate.

• Investigations that waste the time of clinicians, managers and
•
patients because they do not lead to meaningful action.
Duplication of the efforts of others who have already researched
£2.2bn
and resolved the same safety problems and solutions. Costs in Direct cost to the NHS of
replacing the services of staff suspended during investigation or clinical negligence in 2017/184
following whistleblowing.
• Costs in replacing and training new staff where staff involved in
incidents of unsafe care feel so traumatised or unsupported that
they cannot return to work
Healthcare is not good at assessing and monitoring the full costs of “The annual cost of…adverse
unsafe care, despite the enormous direct costs it represents. events in England is equivalent
Unsafe care also represents a significant opportunity cost: resources to
consumed by patient safety failure are resources taken away from caring
for others.
When demand on health and social care organisations and staff are
2,000
growing, such direct and indirect costs are especially important. If GPs
resources are constrained, diverting resources from patients must affect or
the quality and safety of care.
We believe that a powerful business case for patient safety exists: that
properly addressing the systemic causes of unsafe care will save costs
3,500
and free up resources to serve patients better. We think this case needs hospital nurses”5
to be made.
Value and protection of whistleblowers in patient safety

Whistleblowers have made a valuable contribution to bring patient safety
issues and scandals to light. Many whistleblowers suffer unjust
punishment in their professional and personal lives as a result of their
decisions to do the right thing by speaking up for patient safety.
Two of our themes (‘professionalising patient safety’ and ‘data and insight
for patient safety’) include actions to support whistleblowing and greater
openness in raising concerns. We recognise, however, that more needs
to be done and expect to see more actions to emerge as we engage on
‘leadership for patient safety’ and ‘patient safety culture’.
We need to harness the insight of health and social care staff to improve
safety and prevent harm. We should not turn our staff into whistleblowers.
We need them to be able to share concerns and know that these will be
welcomed, listened to and acted upon.
Patient safety in health and social care

Much work on patient safety focuses on healthcare and predominantly on
acute care. More investment in research, policy thinking and design is

needed, however, for the safety of users of primary care, community care,
mental health and social care.
We believe that the actions we propose to improve patient safety in health
will, in large part, be relevant and valuable in social care. Safety in care
needs not just to attend to absolute risks such as safeguarding and
infection control but also the complex decisions that enable people to live
with dignity and independence. Such thinking becomes especially
important given the increasing aspirations to, and focus on, provision of
integrated care.


3 Patient Safety is a strategic purpose
“While we have, understandably, focused on specific,

targeted initiatives, we have not made wholesale and
sustainable progress. We have a long way to go in
ensuring that safety is at the core of why every health
care organization exists, and what every health care
leader believes is their purpose. I describe this as
moving safety from a priority to a purpose. A priority is
something that we can rate . . . higher or lower. A
purpose is timeless and non-negotiable.”
Patricia McGaffigan, Institute for Health Improvement, 2018 15

3 Patient safety is a strategic purpose
‘Patient Safety is a priority’ – is this the problem?

Patient safety persists as a problem because, at its heart, it is a systemic
issue. We have identified six systemic reasons for patient safety failure,
and we examine each of them in this report so that effective action can be
taken.
But before we do, we think it worthwhile to consider another, more
fundamental, factor to explain why current efforts to address patient
safety are so hard to deliver and haven’t achieved the required results.
Health and social care organisations have many strategic priorities:
financial priorities, policy priorities, regulatory priorities, patient safety
priorities. These are weighed against each other and organisations and
individuals decide which ones take precedence. The importance assigned
to one in relation to another is a matter of choice.
If patient safety is considered a strategic priority, it, too, becomes a matter
of choice. Health and social care organisations choose how much
attention, time and resources they devote to patient safety, trading it off
against their other priorities.
We know from variations in safety performance assessed by CQC10 that
some organisations pay more attention to patient safety than others. This
makes patients who receive treatment in one organisation safer than
patients who receive the same treatment in another.
We think it wrong that safety is negotiable. We believe that organisations
need to demonstrate that they are taking ‘all reasonable and practical
steps’16 to deliver safe care.
Patient safety is part of the purpose of health and

social care
The NHS constitution17 makes several references to patient safety.
For example, section 3a, Patients and the public: your rights and pledges
to you, states:
“You (the patient) have the right to be treated with a professional standard
of care, by appropriately qualified and experienced staff, in a properly
approved or registered organisation that meets required levels of safety
and quality.”
It is striking, however, that this seems to fall short of stating that
patients have a right to safe care, with patient safety as part of the
purpose of care.

The shortfall is subtle, but it makes all the difference in the world. It leads
to situations like these:
• How some organisations place responsibility for safety on the

shoulders of clinicians and care staff, yet at the same time, they
don’t ensure that staff work in safe systems, they increase the
volume and complexity of the clinicians’ and care workers’ jobs and
“Patients essentially want three then add insult to injury by blaming them when they make mistakes.
things from their hospitals:
don’t hurt me, • How health and social care organisations measure the harm they
heal me, do (for example, through the numbers of serious incidents of harm),
and be nice to me. instead of how safe they are.
And they want them • How we don’t mine the rich knowledge that comes from
in that order.” reporting ‘near misses’ and other insights into opportunities for
Dr.Bala Chandrasekhar, 201918 improvement to help us design safer care and to respond better
when harm happens.
• How organisations say that patient safety is intrinsic to what they
do, then make decisions that affect care (concerning, for example,
resources, staffing, facilities or patient service) without explicitly
assessing the impact on safety. If organisations don’t make these
assessments, then they could be making ill-informed and risky
decisions without even being aware of it.
Commissioning, contracts and patient safety

Currently Clinical Commissioning Groups are the primary vehicle for the
NHS England to spend its health budget.19 CCGs plan, agree and buy
(‘commission’) healthcare and some social care to meet local needs.
CCGs should therefore be a powerful force to ensure that healthcare is
designed and delivered to enable safe care. What mechanisms do they
use to commission care and ensure patient safety?
The NHS Standard Contract, published by NHS England, is used by
CCGs to commission healthcare services.
The Standard Contract20 is a template for commissioners to use with
providers when negotiating contracts locally. Each contract is developed
locally by each CCG and while some conditions are set centrally, CCGs
have discretion to negotiate schedules, obligations and conditions within
the framework of the Contract. The details of each contract therefore vary
from CCG to CCG and provider to provider. Each contract is held at local
level and decisions on how a particular contract is managed are made by
the relevant commissioner. There is no national oversight on how patient
safety is designed into these contracts although each trust has to produce
a quality report covering clinical excellence, patient experience and
patient safety. As part of this report, trusts are obliged to report on three

indicators of patient safety, with discretion about the ones that they
choose to report.
Because the 191 CCGs spend the bulk of the NHS budget,21 NHS
England has a statutory obligation to assess the performance of each one
through the CCG Improvement and Assessment Framework (CCG IAF).22
This assessment has consequences for each CCG. CCGs deemed to be
failing or at risk of failing may be subject to legally binding direction.23
For 2018/19, the CCG IAF set 58 metrics against which CCG
performance is to be assessed.24
Of these 58, only one explicitly refers to patient safety:24 “Evidence that
sepsis awareness raising amongst healthcare professionals has been
prioritised by CCGs.”
Three more IAF metrics, it may be argued, invoke patient safety under the
heading of ‘Provision of high-quality care,’ on the assumption that ‘quality’
in this instance includes patient safety.
The complexity of these funding and contractual arrangements and for
monitoring and reporting appear to make variations in patient safety
inevitable while at the same time making it harder to identify and address
the shortfalls that result.
Safety needs to be core to commissioning and the processes and
systems that it requires. It is not at all clear how this is the case today.
Planning and patient safety

The currently proposed long-term plan for the NHS is 120 pages long but
mentions ‘safety’ only 23 times. The eight times it mentions ‘patient
safety’ can be found all in section 6, in one paragraph (6.17.ix).25
Section 6 of the long-term plan also proposes major initiatives, such as
standardisation of procurement; new diagnostic provision; efficiency
programmes for community health, ambulance services, primary care and
mental health; efficiency savings and automation for dispensing
medicines; and standardisation of ambulance fleets. Each offers
opportunities and challenges for patient safety.
Of these priorities, only one makes a single reference to patient safety.
None emphasise safety or how these initiatives will serve to reduce
avoidable harm and save lives.
And while we acknowledge that NHS Improvement has been tasked with
developing a National Patient Safety Strategy, we remain struck that the
long-term plan makes no reference to the need for a national strategy for

patient safety, or to the need for co-ordinated leadership with a clear map
of roles and responsibilities.
If such thinking does not change, then patient safety will continue as it
has until now: seen as important, yes, but clearly a secondary
tier consideration.
If we are to achieve a patient-safe future, patient safety must be more
than a priority for an organisation. It must be core to its purpose, reflected
in everything it does.
The patient-safe future: patient safety as a purpose

In a patient-safe future, we will see patient safety as part of the purpose
of health and social care:
• Organisations take responsibility for patient safety and treat it as a

systems issue, owned by their leaders, patient safety experts, all
clinicians and support staff.
• Health and social care organisations measure how safe they are so
they can take corrective action.
• Organisations establish decision-making processes that demand
explicit, evidence-based assessment of the impact on patient
safety, selecting the option that offers the safest outcome for
patients or explaining why.
• Health and social care initiatives explicitly include a positive impact
on patient safety as an objective. They also include preventive
actions to mitigate risks to patient safety.
• Strategies for patient safety are woven through every aspect of any
plan for health or social care; a plan for health or social care is a
plan for patient safety.


4 Shared learning
“Currently, there are few easy or straightforward ways

for people or organisations to reliably share practical
knowledge and lessons about safety improvement
across a healthcare system.
Knowledge and improvements therefore often remain
trapped in the organisations—or individual units—in
which they are developed.”
Carl Macrae, 201826

4 Shared learning
Health and social care need to do more to learn for

patient safety
In A Patient-Safe Future, we made the case that healthcare is
systematically poor at learning from harm.
For example:
• Sometimes, when something goes wrong, we don’t always

analyse the issue effectively, so these investigations draw few
meaningful conclusions.
• Or when we analyse an incident, we draw the wrong conclusions so Only
that, for example, we blame people incorrectly
•
when a problem is, in truth, the result of a systems failure.
Or we analyse an incident correctly but don’t act on
35%
the recommendations. of recommendations into
safety incidents show how to
• Or we act on recommendations, but don’t track how, or if, our
reduce the chance of the
actions have worked.
incident recurring
• Or we do investigate correctly and act effectively and track the CQC 201627
results, but as we do not share these, no-one else can benefit from
our success.
• Or perhaps we try to share our results, but others do not have a
good, easy way to find out about them. This is part of what has
been called the ‘implementation gap’ in patient safety11 and is a
feature of Sir Liam Donaldson’s ‘orange wire’ test.28
This chain of failure has two effects.
The first effect is that different patients will be destined to suffer the same
kinds of harm over and over.
The second effect is that even when we do find effective solutions to
“When a patient safety incident
prevent avoidable harm, these are shared slowly, in piecemeal fashion, occurs, the important issue is
so that patients continue to suffer harm from problems that others have not who is to blame for the
already addressed. This results in a post-code lottery of unsafe care. incident but how and why did it
Learning for patient safety is compromised further by the ways our current occur. One of the most
data gathering, analyses and action are almost entirely concerned with important things to ask is what
is this telling us about the
addressing patient harm after it happens. We believe that health and
system in which we work?”
social care focuses on responding to unsafe care and the prevention of
Charles Vincent, 200229
future harm. While this is welcome, a sole focus on harm means that we
miss the important opportunity to design care for safety, to create the
cultural, organisational and system conditions for safer care and to learn
from those who have already started to do this.

4 Shared learning
If we are to secure a patient-safe future, we need to find ways of learning

how to deliver care safely, as well as avoiding harm. In the jargon, we
have to embrace and build on both Safety I and Safety II.30
Learning for patient safety is challenging

“There is no clear system for staff to learn from each other at a national
level. Local reporting systems are often poor quality and do not support
staff well. There are lessons that can be learned from other industries
with simpler and more transparent reporting systems, backed up by a
culture that drives good reporting.”
CQC, Opening the Door for Change, 201831
Learning, and the sharing of learning, for patient safety is a persistent

problem for a range of reasons (after Carl Macrae26).
Improving patient safety isn’t prioritised

Many staff might see the opportunity to improve safety but are either too
busy to research and develop new solutions or feel disempowered or
unsupported to do so.
Sharing learning isn’t easy to do
“One of the serious deficits in Clinicians, researchers and patients in different organisations lack the
the NHS of the past has been facilities and time to come together to discuss incidents and issues and
an inability to recognise that the think through possibilities. Collaboration networks exist face-to-face and
causes of failures in standards online, and there are conferences that focus on patient safety. But these
of care in one local NHS are expensive in time and cost, and people find it hard to come together
organisation may be the way quickly and easily to share experience and learning.
in which risk can be reduced
for hundreds of future We don’t know who else has experience of a safety problem
patients elsewhere.” Staff have few obvious and easy ways to locate and engage peers across
Building a Safer NHS for the health and social care system with experience of similar problems or
patients, 200132
who may have worked on similar problems themselves.
We don’t know who else has addressed a patient safety problem

Even if staff can carve out some time, they don’t have quick and easy
access to relevant information about similar problems, possible
approaches or tested solutions. They risk duplicating work that others
have already done.
Learning to improve safety is hard

Improvements and good practice are not shared
When an improvement happens, it is hard to let people in other
organisations know about it. The result is that good practice can remain

4 Shared learning
isolated in one location while other organisations carry on working in old

ways, exposing patients to the same avoidable harm and replicating the
same investigations when patients suffer.
Introducing a change in practice is hard

To develop, trial, validate, document, secure approval for, and
disseminate, change within the health and social care system takes a lot
of time, effort and confidence. Many staff are too busy to take this on or
lack the authority to lead such work. The Innovation Accelerator33 and
other initiatives have been set up to address this but the ‘implementation
gap’ remains persistently wide.
We don’t have a shared approach to thinking and

learning about safety
Different organisations think differently about patient safety
Leaders and managers in different organisations do not have a shared
and consistent understanding of patient safety. This can be seen, for
example, in the different attitudes and adoption shown across health and
social care for ideas such as human factors or Just Culture.
Different organisations learn differently

Mechanisms for organisations to learn from their performance and
improve34 do not operate consistently across health and social care.
We lack an easy, practical way to pass the orange-wire test

Mechanisms for rapid learning and action about safety-critical issues (to
address the ‘orange wire test’) either do not exist, or if they do, such as
with ‘safety alerts’,35 there is evidence that these can struggle for attention
against the avalanche of other information that bombards organisations
and clinicians daily.36
HSIB
Concerns about a number of these issues were part of the rationale
behind the establishment of the Healthcare Safety Investigation Branch
(HSIB) in 2017 and some of the investigations and excellent ways of
working that have followed.
The majority of investigations, however, continue to be conducted within
and by individual healthcare organisations largely beyond the immediate
remit of HSIB. As a result, many such investigations continue to reflect
the issues described above.

4 Shared learning
Complaints are an untapped resource for

patient safety
th
‘One of the most shocking failures in NHS care was documented on 6
February 2013 when Robert Francis QC published his Public Inquiry into
Mid Staffordshire NHS Foundation Trust. He found “a story of appalling
and unnecessary suffering of hundreds of people” and added: “They were
failed by a system which ignored the warning signs and put corporate
2
self-interest and cost control ahead of patients and their safety.”
He wrote: “A health service that does not listen to complaints is unlikely to
reflect its patients’ needs. One that does will be more likely to detect the
early warning signs that something requires correction, to address such
3
issues and to protect others from harmful treatment.”
“A complaints system that does not respond flexibly, promptly and
effectively to the justifiable concerns of complainants not only allows
unacceptable practice to persist, it aggravates the grievance and suffering
of the patient and those associated with the complaint and undermines
the public’s trust in the service.”’
Ann Clwyd and Tricia Hart, A Review of the NHS Complaints System, 201337
“66 per cent found their original report (of the investigation into their
complaint) incorrect, inconsistent or substandard. They found levels of
investigations below standard or that analysis was inconsistent or weak.”
Patients Association, 201538
“Having been involved in hundreds of policy and academic discussions

about the quality and safety of health services over the years, I have
found that the importance and value of complaints is seldom brought into
the conversation.”
Sir Liam Donaldson, 201839
Complaints made to the health service each year should be a powerful
208,626 resource for learning about unsafe care. But complaints appear to be a
largely untapped patient safety resource.
The number of written Complaints provide an opportunity to learn from something that has gone
complaints made to the NHS in wrong. A shortfall in the quality and safety of care that led to a complaint
the year to March 201840 should therefore act as a vehicle for remedial action, such as a review of
processes and procedures followed by changes to the service concerned.
When the service failure is of a kind that could, or did, occur in a number
of similar settings, the beneficial changes that should flow from
complaints need to happen both at the local level where the care was
provided and throughout the NHS as appropriate.

4 Shared learning
Investigations must be better

Only
Concerns about the quality of investigation, however, are not restricted
to complaints.
“SI (Serious Incident) investigation in the NHS varies in quality and

12%
generally is done poorly.” of incident investigations
NHS Improvement, 201740 indicated that they had involved
patients and families
One of the best sources for learning from patient safety failure is
supposed to be the investigation of serious incidents and near misses.
Only
“Rapid, routine and systematic investigation of adverse incidents locally is
essential to ensuring that local causal factors are understood and that
there is local responsibility for making improvements”. 35%
Public Affairs Select Committee, Investigating Clinical Incidents in the NHS41 of recommendations showed
how to reduce the chance of
If the quality of these investigations is wanting, so will be the learning that
safety incident recurring
follows.
Quality of investigations may fall short for a range of reasons:42 Only

•
•
Sometimes those doing the investigation lack investigative skills.
Sometimes investigations don’t properly consider the range of 39%
systems and human factors issues involved. of incident investigations
• It may be that investigations are not given the time they need to be included evidence of interviews
thorough, especially if an incident is similar to others that have with staff
happened before.
Only
• Or it may be that the organisation treats activities and issues other
than investigation as higher priorities.
In sum, the barriers to learning from, about and for patient safety are high 28%
and not easily breached. of investigations recorded a
risk assessment27
A patient-safe future: shared learning
“It is rare that organisations and professions try to learn from
communities, and yet there is much to be learned from how healthy
communities work.”
Steve Shorrock43
If patients are to be safer, we need people and organisations to share

learning when they respond to incidents of avoidable harm, and when
they develop good practice for making care safer.
In a patient-safe future, we will see patients, clinicians, managers and
health and social care system leaders share learning about safety
practice and performance to make care safer.

4 Shared learning
In a patient-safe future:
People are enabled to learn
• Learning is easy
When a new strategy, technique, tool, finding, method or process
helps make patients safer, other organisations and individuals learn
about it easily and quickly.
• We learn how to improve performance

At every level in the health and social care systems, we routinely
and systemically learn from their actions and so improve their
own performance.
• We know who we can seek advice from

When people working on patient safety want to discuss a problem
or seek new ideas, they quickly and easily engage peers across the
health and social care system.
Organisations enable learning
• Comparative performance encourages improvement

Organisations compare their patient safety performance with similar
organisations across the system.
• Patients are engaged for learning

Organisations initiate, facilitate, encourage and support learning for
safety with and by patients.
Improvement is supported
• Tools and research are easy to find

Information about investigations, incidents, strategies, tools or
solutions are found quickly and easily.
• We learn which safety strategies work best

People can learn about, assess and compare different patient
safety strategies, and know which ones have been proven to
be effective.
• When it works, we share how we did it

When a health and social care organisation develops and
implements an effective patient safety strategy that makes a

4 Shared learning
difference, they share the ‘what’ and the ‘how’ with others. We close
the ‘implementation gap’.
Investigations are consistently good
• Investigations into unsafe care and responding to complaints

are seen as important in learning to deliver safer care
Investigations have clear purposes and objectives that always
include engaging with patients, families and staff with empathy,
open communication, transparency and respect. When a
patient formally complains, their complaint is managed promptly
and respectfully.
• Patients have informed, active participation in investigations

Patients have access to patient safety information and processes
around patient safety, such as how investigations work and what
to expect.
• Investigations are done well

Investigations are efficient, prompt, rigorous and of a consistently
high standard. Investigations use a range of analytic approaches,
including systems thinking, critical thinking and human factors.
They also, where appropriate, use idiographic techniques from the
social sciences.
• Investigations make a difference to patient safety

Investigations yield specific conclusions that drive action that
delivers explicit improvement in patient safety performance.
Investigations are reviewed to validate both their conclusions and
how well the resulting actions made patients safer.
Action to enable shared learning

We seek to see:
• Organisations create a learning culture where they set and make

good on goals for learning from patient safety, report on progress
and share their insights widely.
• Organisations prioritise learning to improve patient safety and how
they learn from:
o Incident investigations and complaints
o Patients and their experiences
o Good practice within their organisations and others

4 Shared learning
o Evaluating their actions to improve safety

o Sharing their learning with others
• Organisations respond, and contribute, to shared learning systems
such as the Patient Safety Incident Management System (PSIMS) -
NHS Improvement’s replacement for the National Reporting and
Learning System (NRLS)44 – and, we hope, the hub from Patient
Safety Learning.
• Regional and local networks such as the Academic Health Science
Networks (AHSNs) and Patient Safety Collaboratives (PSCs)45
support and strengthen geographical and professional communities
to share learning and build on the ‘Sign Up to Safety’ networks.46
• Organisations encourage, support and remove barriers so frontline
clinicians and patients can share learning and learn from others for
safer care.
Patient Safety Learning will take action for

shared learning
We will:
• Publish a detailed report on shared learning to help organisations

take more effective action for improving patient safety.
• Celebrate learning from patient safety success through the Patient
Safety Learning Awards.
• Review current investigative practice to understand how health and
social care organisations investigate (including systems and human
factors thinking), how they learn from harm, turn recommendations
into action and support patients, families and staff. We will publish
this review and recommend action.
• Support health and social care organisations through support and
practical training.
We will create the hub: a digital learning and

community platform for shared learning
the hub will be the engine of Patient Safety Learning.
the hub will be a platform for the sharing of local, national and, in time,
international knowledge, skills, learning and experiences.
the hub will enable people to learn, share and develop key ideas and
techniques to improve patient safety, including:
• Accounts and narratives

4 Shared learning
• Alerts and recommendations

• Case Studies and exemplars
• Data and analyses
• Guides and guidelines
• Incidents and investigations
• Interviews and reflections
• Policies and procedures
• Processes and systems
• Reports and articles
• Safety improvement strategies and interventions
• Seminars and presentations
• Standards and regulations
• Toolkits and collections
• Tools and templates
the hub will foster communities of interest, and practice and give people a
safe place to discuss issues that may be of interest or concern to them.
It will provide a collaborative environment for people to come together to
build on improvements that have already begun and adapt solutions for
local implementation.
Users of the hub can discuss learning from investigations and the effect
of applying recommendations and/ or solutions to learn how to apply the
same solutions effectively.
We want to maximise the reach of the hub and encourage as many
people as possible to become involved in it, so it will be free of charge for
use by everyone: clinicians, patients, managers, policy makers,
regulators, researchers and members of the public.
We will nurture and grow the hub

We want users to find the hub useful, valuable and stimulating. To help,
we will:
• Provide editorial support to source, curate, commission and

develop content.
• Explore rapid patient safety information sharing.

4 Shared learning
• Support users in their conversations and ensure that for critical

elements, such as descriptions of tools for patient safety, certain
quality standards apply.
• Promote, encourage, and support the use of the hub to as many
relevant communities as possible.
• Support and encourage communities of interest to share knowledge
and support each other.
• Help communities connect within and beyond the hub.
• Explore ways for organisations to use and support the hub.
• Connect the hub to other sites to give our users the widest possible
access to learning for patient safety

4 Shared learning

“The standard you walk past

is the standard you accept.”
Gen David Hurley, 201347

“There is a strong link between the safety of services and the

quality of leadership.”
CQC, 201810
Patient Safety needs purposeful leadership

Good leadership is seen as the most influential positive factor in shaping
organisational culture in health care,48 but poor leadership can have the
opposite effect.49
While there are “…any number of ways trustees [Board Members]
can improve their oversight of safety,”50, 51 we are unaware of any
agreed, up-to-date, practical guidance as to which way is best under
which circumstances.
Frontline clinical staff and patients often work, and are treated, in
environments poorly designed for safety that are staffed by increasingly
overworked personnel. A key role of leadership is to recognise and
address these challenges.
To realise a patient-safe future, we need a model for leadership and
governance for patient safety in health and social care that sets and
requires high and consistent standards and behaviours of our leaders.
This can happen only if we define the competencies and training for those
leading for patient safety and the governance, standards and reporting for
the organisations they lead.
Who owns patient safety?

The publication of To Err is Human52 and of An Organisation with a
Memory53 put patient safety firmly onto the agenda of healthcare. One
reason we are now publishing A Blueprint for Action is that, in the 20
years since, some progress may have been made, but not enough.
When we look at the reasons why, it is easy to blame an absence of
leadership. But like the other foundations of patient safety we describe
here, leadership for safety is a systemic issue.
On this topic, we can but echo the Care Quality Commission:
The current patient safety landscape is confused and complex, with
no clear understanding of how it is organised or who is responsible for
what tasks.”
CQC, Opening the Door to Change, 201831
In other words, it seems that in health and social care, we don’t know who
is leading patient safety – worse, even if we did, we have not defined
what we need them to lead.

In part, this flows from our earlier observation that, currently, patient
safety is not regarded as part of the purpose of health and social care.
Regardless, however, we have not given our leaders a common view of
what it means to lead patient safety.
A framework and common standards

It is salutary to contrast patient safety with, say, fire safety. For fire safety
in healthcare organisations, we have established common purposes,
aims, policies and guidance on implementation, competences,
management, reporting, audit and regulation.54 We have exemplar fire
safety management systems with specified requirements for fire safety
management roles, competences, responsibilities, fire safety policies and
protocols, and we have standards.
We do not have such an approach for patient safety. Nor is it clear to us
whose responsibility it is to create it or require it.
As a result, while the mission statements of many health and social care
organisations aspire to the safe care of patients, each organisation does
so in their own way. Organisations lack a common framework and
standards for patient safety within which they all work.
Just as all health and social care organisations must demonstrate that
they work to common standards for fire safety, we contend that they all –
providers, regulators, commissioners and policymakers – should work
also to common standards for patient safety.
And, just as fire safety specifies clear roles such as board members and
specialists, roles for patient safety should be equally and consistently
clear, specified and managed within a clear governance framework, in
contrast to the situation that obtains currently.
In fire safety, risk assessment tools are developed, shared and used
consistently across organisations. This is not the case in patient safety.
A common framework for leading patient safety and shared standards for
governance and management of patient safety must be developed. It will
need to be led and managed by a body that can reflect and meaningfully
engage providers, regulators and commissioning bodies.
Without a map
Of course, if we are to implement a common framework for leading
patient safety and put it into practice, we need first to understand the
fragmented, disconnected patient safety landscape within which we
currently work. What are the roles and responsibilities for patient safety of
the different organisations who define, commission, design, deliver and
manage patient safety? Where is patient safety well-defined and led?
Where are the inconsistencies? Where do goals, objectives, standards

and governance work at cross-purposes, or are duplicative? Where are

the gaps?
At the moment, no-one has mapped this, so we just don’t know.
A patient-safe future: leadership for safety

What does leadership for patient safety look like? We propose the
following:
• Leaders know the risks to safety in their organisations and attend to

them. They require and support the design of safe care, not just
addressing harm when it occurs. They do so through formal
mechanisms of performance management, of governance
frameworks, of understanding culture and patient safety, and
reading and responding to reports.
• They ‘walk the talk’ to engage and listen to clinicians and
understand the community and patients. They actively seek insight
on whether staff and patients feel safe and, if not, they make sure
the organisation knows this and responds.
• Leaders model behaviour that challenges a blame and fear culture.
Instead. they strive to ensure a Just Culture and encourage and
prioritise learning, treating peers, staff and patients with civility
and kindness.55
• Leaders make the goals and standards for acceptable patient safety
explicit for their organisations, and then resource and support their
staff to deliver these.
• Culture, work and workload are discussed explicitly.56
• Governance and leadership frameworks for patient safety that
specify standards, action and behaviour are in place.
• Leaders measure and report on their organisation’s patient
safety performance.
• The explicit primacy of patient safety for leaders is reflected in the
time, resources and attention they give to it.
• Leaders assess and understand the effect of their decisions and
behaviour on patient safety outcomes.
• Leader recruitment, development and performance management is
underpinned by a competency framework that specifies the
knowledge, skills, attitudes and behaviours needed to lead for
patient safety.

• Leaders explicitly attend to, and seek improvement in, the

foundations of patient safety, namely:
o Shared learning for patient safety
o Leadership for patient safety
o Professionalising patient safety including standards for safer
care and competencies for all staff
o Patient engagement for patient safety
o Data and insight for patient safety
o A Just Culture that supports patient safety
• Leaders are supported by a consistent framework for all of the
above, based on shared research and good practices, and
underpinned by standards for effective leadership of patient safety,
shared across and between health and social care organisations.
Leaders understand that problems in delivering safe care are complex
and systemic in nature and, further, that specialist skills in human factors
and ergonomics are part of the solution.
We call for action to develop leadership for

patient safety
Below, we describe actions that we believe are essential if health and
social care is to have consistent, sustained and practical leadership in
order to progress to a patient-safe future.
We seek to see:
• A health and social care system-wide approach to patient safety so

that all organisations are clear on their collective and individual
roles and responsibilities for a patient-safe future.
• Publication of a map of health and social care organisations to
support the development of this system-wide approach to patient
safety. The map will identify roles, responsibilities and strategic
goals for patient safety, gaps and areas where further development
and clarity is required.
• Organisations prioritise patient safety, embedding clear and
published goals in their leadership and governance with
programmes to deliver improvements. Culture, work and workload
should be explicit.
• Organisations publish patient safety outcomes as strategic and
operational goals.

• Organisations have specialist patient safety and human factors

experts in executive and non-executive roles on the Board and
leadership teams.
• Organisations design and implement system, processes and
performance reporting to manage patient safety risks.
• Organisations use risk assessments to inform the development of
patient safety goals and improvement activities, including the design
and implementation of solutions to prevent harm.
• Integrated care systems explicitly prioritise patient safety in their
design, implementation and operation.
• Standards for patient safety are included in service commissioning
and care pathway design and culture; work and workload should
be explicit.
• Delivery standards for patient safety are included in service
commissioning and care pathway design and delivery.
• Leaders demonstrate through their action and behaviours that
they are ‘fit and proper’ people to deliver safe care, working to
the standards developed as part of a patient safety
competency framework.
We need effective leadership for patient safety

We believe that for health and social care to be transformed to deliver a
patient-safe future, we need a mechanism to ensure that all components
co-ordinate and collaborate.
We believe that an effective way to start defining such an approach is to
create a body of leaders to oversee the development, implementation
and evaluation of effective approaches, models and governance for
patient safety.
Its members should include frontline health and social care delivery staff,
setters of standards, such as commissioners, system and professional
regulators and policymakers. It should also include patient
representatives as full members.
This forum of leaders for patient safety may be developed from a body
that already exists, or it may need to be created afresh.
The forum of leaders for patient safety should emphasise a systems
approach and use of human factors.
The forum should draw on good practice from across health and social
care systems and elsewhere as appropriate.

If none can be found, it will develop pragmatic good practice, such as:
• A common competency framework for leadership of patient safety.

• Standards for leadership for patient safety, including leading a Just
Culture, at every level in an organisation.
• Governance mechanisms for patient safety.
• Tools for sharing and extending patient engagement for patient
safety and Just Culture for patient safety in organisations.
Patient Safety Learning will initiate discussions and activities to support
establishment of the forum of leaders.
Patient Safety Learning will make resources, such as the hub, available
for the forum to access sources of good practice, to test possible
solutions, to consult and to share the tools and good practice that it
chooses to publish.
What Patient Safety Learning will do

Patient Safety Learning will work with other bodies, including the
proposed forum of leaders, to:
• Publish a report for leaders to use to help take action to define,

develop, support and maintain leadership for patient safety. This will
include a leadership model and governance arrangements for
patient safety.
• Call for, and help to initiate, design and develop an overarching
body for patient safety (the forum of leaders for patient safety).
• Support the design, promotion, co-ordination, delivery and
evaluation of leadership for safer care.
• Explore with health and social care organisations how critical
leadership decisions can be more explicitly and routinely risk-
assessed for patient safety. Explore the value of using decision
support tools, such as safety business cases.
• Develop tools such as ‘how to’ guides, maturity models and self-
assessment frameworks to support organisational leadership for
patient safety and publish these on the hub.
• Offer consulting and training services to help boards and senior
leadership teams to improve their governance, systems and
capabilities to lead for patient safety.


"Have you set high standards…that make it clear what

level of performance you demand?"
Tom Peters57

“If you always do what you’ve always done, you always get what you’ve
always gotten.”
Jessie Potter58
“All persons involved in any…safety lifecycle activity, including

management activities, should have the appropriate training, technical
knowledge, experience and qualifications relevant to the specific duties
they have to perform.”
Health and Safety Executive (2007)16
Who owns standards for patient safety?

In the year to September 2018, just under two million patient safety
incidents were reported in the NHS using the National Reporting and
Learning System (NRLS). Given such volume, we might expect practices
and standards for learning from patient safety to be regular and routine.
Instead, everyday practices for patient safety learning appear
inconsistent. We observe a systematic and consistent failure to
implement the outcomes and learning from investigations into incidents of
unsafe care and patient harm.
If we, rightly, expect standards for patient safety, we need to be clear who
sets and owns these.
It is not clear where responsibility for patient safety standards rests in the
NHS. The NHS Constitution offers patients:
“…the right to be treated with a professional standard of care, by
appropriately qualified and experienced staff, in a properly approved or
registered organisation that meets required levels of safety…”17
It is not clear to us what is meant by ‘levels’ in this phrase. What are
these levels? What are the standards that should be set for patient
safety? Who issues the guidelines to ensure that these standards are
delivered? Who measures performance against them to ensure that
they are good enough? Who ensures that these standards are met,
or exceeded?
It is clear to us that no single organisation is responsible for defining,
communicating or evaluating the standards of safety for patient care. In a
complex health and social care system, this is not a just a regulatory gap,
it is a lack of clarity about leadership for patient safety. It reflects
confusion and an absence of ownership for setting standards for patient
safety. This needs to change.

A lack of a common framework to underpin

consistent care
The Care Quality Commission’s Regulation 12 places a patient safety
obligation on health and social care organisations.59
It states that “…the intention of this regulation is to prevent people from
receiving unsafe care and treatment and prevent avoidable harm or risk
of harm.”
It includes the following statements:
“Care and treatment must be provided in a safe way for service

users including:
• Assessing the risks to the health and safety of service users of
receiving the care or treatment
• Doing all that is reasonably practicable to mitigate any such risks”
Many organisations struggle to demonstrate how they meet these

obligations. One reason is that organisations have trouble complying with
another requirement of Regulation 12:
“…ensuring that persons providing care or treatment to service

users have the qualifications, competence, skills and experience to
do so safely…”
Despite this explicit obligation, many organisations lack a requisite

“This is not just about the
competence framework for patient safety. They lack the means to set and
education and training of
manage consistent standards for patient safety performance.
clinicians. To truly have a safe
NHS, all who work in it need to They also lack a consistent basis for defining the skills needed for patient
share a basic knowledge and safety, and hence to develop a training curriculum to address these for
understanding of what we mean all staff.
by patient safety and be
educated in some basic, As a result, people in similar jobs may have different skills and work to
common principles.” different patient safety standards. The standard of safety that patients
CQC, Opening the Door to experience may vary considerably from person to person, and from
Change, 201831 organisation to organisation.
Patients expect that they will receive consistently high standards of care.
It is reasonable for these to include high standards for the safety of
their care.
Organisations should adopt patient safety standards, identify sub-optimal
performance against these and act when such performance is identified.
We believe that health and social care currently lacks the means to meet
these expectations systemically and consistently. We need to
professionalise patient safety.

Raising standards: professionalising safe care

A profession has:
• Standards of education and experience that must be met.

• A code of conduct to regulate professional behaviour.
• Mechanisms for disseminating knowledge of good practice.
• (the ability to) advise government and regulatory bodies about
matters within their expertise.
(after Nilsson, H. What is a profession?60)
Many industries use professionalisation to raise standards and make

change happen in a consistent and replicable manner. It enables an
organisation to ensure that, as the Health and Safety Executive
stipulates, staff have the knowledge and skills they need to be ‘suitably
qualified and experienced’ to deliver safe care.16
Professionalisation of patient safety will help all staff whose roles affect
patients to offer safer care more consistently. Such staff include (but are
not restricted to) clinicians, support staff, managers, patient safety
specialists, non-executive directors, commissioners and others.
Staff need to know the key concepts, methods and practice of patient
safety. Many examples of good practice for patient safety exist in
individual organisations. While some of these are showcased through
bodies such as Health Education England (HEE) and the 15 Patient
Safety Collaboratives of Academic and Health Science Networks
(AHSNs), good practice is not shared consistently throughout health and
social care.
Patient Safety Learning proposes that 6 components are needed to
enable patient safety to be professionalised. Each component
complements the other. Together, they provide the knowledge and skills
that underpin necessary attitudes and behaviours, as well as supporting
organisational cultures that enable safer care.
These components are:
• Clear standards for safe care.

• Accreditation processes for safe care
• Leadership and governance for safe care
• An agreed competency framework to be used as the basis for
education and training
• Evidence-based training for all staff, with continual
professional development

• Specialist patient safety and human factors experts
New standards and accreditation for patient safety

Professionalising patient safety requires action across the health and
social care system. We want to see:
• Standards developed and implemented for patient safety

“The development and
performance, including:
availability of standards for
patient safety can…either o Shared learning
establish minimum levels of
o Leadership
performance or can establish
consistency or uniformity o Professionalising patient safety
across multiple individuals and
o Patient engagement
organizations…The process of
developing standards can set o Data and insight
expectations for the
o Culture
organizations and health
professionals affected by the • Regulators require and use these organisational standards and that
standards.” these will inform their regulation of patient safety.
To Err is Human: Building a • Guidance, resources and toolkits for patient safety shared across
Safer Health System, 200052 the wider health and social care systems. These are used to
enable, encourage and support organisations and individuals to
achieve higher standards of patient safety.
• In time, development of an accreditation framework for
patient safety.
In a patient-safe future, patient safety is a

core competency
In a patient-safe future, all staff can demonstrate that they are suitably
qualified and experienced to carry out their jobs.
Our vision of a patient-safe future includes a health and social care
system where:
• All staff demonstrate consistent behaviours, attitudes, skills and

principles for patient safety.
• All staff are managed to consistent standards of patient
safety performance.
• A competency framework that defines the behaviours, attitudes,
skills and knowledge required to deliver safe care to be developed
and implemented for all staff.

• This competency framework is used to develop a curriculum for

patient safety, so all staff working in health and social care have the
knowledge they need.
• All staff working in health and social care can demonstrate
their skills for safer care use (Kirkpatrick Level 4)61 using
accredited trainers.
• Health and social care organisations have sufficient access to
expertise and qualified resources. As a result, they adopt proactive
approaches to improving patient safety.
• Human factors and systems thinking inform the safe design, safety
management and approaches to investigating unsafe care.
• Organisations use robust, scientific approaches to the design and
implementation of patient safety improvement strategies.
• Core competencies for patient safety are used to define curricula
and design training and CPD programmes.
• Incident investigation and implementation of improvement strategies
are led to consistently high standards by people who have
undertaken recognised, accredited training which includes systems
and human factors expertise.
• There are sufficient staff to undertake patient safety critical tasks.
Evidence-based training for patient safety

The 2016 report by the Centre for Health Policy (CHP) at Imperial College
London, Evaluation of Education and Training Interventions for Patient
Safety, is the largest recent investigation into the evidence base for the
effectiveness of training interventions for patient safety.62
The report made a couple of striking findings. Patient safety training
should lead to demonstrably better patient safety performance, yet the
CHP study found almost no patient safety training which could
demonstrate that it made a difference to working practice.
(Kirkpatrick Level 4).62
We therefore advocate that any training design includes elements that
require participants to review instances of how, where and when the new
skills will make a difference to their work.
Further, we propose that training design includes follow-up and
reinforcement in-work within a short interval after training delivery to
support and encourage use of skills.
Such follow-up will offer a further benefit: it will enable the organisation to
identify, and hopefully eliminate, practical barriers to using the new skills.

Another finding of the CHP study was that respondents overwhelmingly

deemed four kinds of training to be effective for patient safety training:
• Simulation
• Small group discussion / experience sharing / face-to-face
• Practical / interactive training
• Multi-disciplinary teams (MDT)
Far fewer respondents regarded other forms of delivery, such as online
training, to be as effective.
The study further found that effective education and training for patient
safety is realised through two equally important elements:
• Knowledge and skills for patient safety and the management of

clinical risks, relevant to their role
• The ability to demonstrate the attitudes and behaviours needed for
a Just Culture
If we are to professionalise patient safety, it is not enough to set
standards, and define a competency framework. We need a standard of
training that enables and delivers a consistent, practical and
demonstrable standard of patient safety behaviour in the workplace.
Specialist patient safety and human factors experts

Professionalising patient safety requires action across the health and
social care system, including the development of specialist roles. We
want to see:
• Organisations have specialist patient safety and human factors

experts who are supported by appropriate resources and
governance. With clearly defined roles, these specialists have clear
reporting lines to the Board (both Executive and Non-Executive).
• These experts should support the re-design of systems, processes
and operations for safer working.
• These specialists support learning to improve safety from
investigations into unsafe care and from listening to, and engaging
with, patients, complaints, near misses, clinical reviews and audits.
• Local, regional and national networks of these specialists share
knowledge and improvement strategies, supported by the
frameworks in place to do so such as Patient Safety Collaboratives,
Academic Science Networks, NHSI regional teams and others.
• These roles are underpinned by a strong competency framework
and associated training programmes. Their role in setting and

modelling the highest standards for safety and human factor

performance is supported by learning from specialists such as
Healthcare Safety Investigation Branch (HSIB) and other industry
experts and academics.
• These roles being part of a career path in patient safety and human
factors with clinical and non-clinical staff encouraged to develop
their expertise and into specialist roles.
• Organisations and staff will have access to expertise, support and
advice on patient safety issues, with an emphasis on:
o Developing an open and fair culture and training in
patient safety
o Identifying, managing and reporting of patient safety incidents
and risks
o Running effective, rigorous and empathetic investigations
o Systems thinking and human factors
o Acting on, and learning from, safety incidents
and improvements
o Encouraging openness and sharing insight on unsafe care
including the support and protection to whistleblowers
o Support and governance for whistleblowing
Patient Safety Learning will take action to

professionalise patient safety
We will work collaboratively to:
• Publish a detailed report on professionalising patient safety to help

identify action needed to improve patient safety.
• Identify standards for patient safety to be used by regulators,
commissioners, service providers, etc.
• Support development of a competency framework for patient safety.
• Develop and provide training to address gaps in patient safety skills,
knowledge, attitudes and behaviours.
• Support development of an accreditation framework for
patient safety.
• Support health and social care organisations and offer
practical training.

“Hear the patient.

Empower the voice of the people we are trying to help.
They have more information than just about anyone
else in the system.”
Don Berwick1

“Often there is a focus on process, rather than identifying what a patient

wants and needs in terms of putting the situation right. Little is known
about the emotional and psychosocial harm stemming from medical
errors and adverse events. Yet emerging data suggest that these
secondary impacts may be just as harmful, or even more injurious, than
the underlying event.”
The Patients Association63
“You ignore at your peril the concerns of a mother.”

Margaret Murphy, 201864
The ways we address patient harm

can compound the pain
Over the past 20 years, a common factor in many patient safety scandals
has been a disregard for the voice of the patient. Patients and family
members who raise concerns have had their issues ignored or
discounted.
This disempowering of patients was cited as a contributory factor in the
2001 Bristol Royal Infirmary Inquiry,65 the Mid-Staffordshire Report in
2013,66 the 2015 Morecambe Bay Investigation in 2015,67 and the 2018
Report of the Independent Panel for Gosport.68
Numerous painful stories illustrate how organisations, after incidents of
harm, exclude patients and their families from investigations, learning and
improvement. This failure to listen frustrates harmed patients and can
make their pain worse,69 provoke unneeded litigation70 or require further
medical intervention.
“…emerging data suggest that these secondary impacts may be just as

harmful, or even more injurious, than the underlying event.”
ScienceDaily, 201871
“Emotional and other long-term impacts of harmful events can have

profound consequences for patients and families.”
Bell et al72
Nor is such harm restricted to patients and their families. Clinicians can
also suffer psychological harm as a result of being involved in patient
safety incidents.73
This suffering is a consequence of many of the factors we
describe elsewhere:
• A failure, or unwillingness, to listen and learn

• A lack of standards for care following an incident

• A failure of the leadership necessary to put the needs of

patients above, say, the desire of the organisation to avoid
admitting legal liability
• An unwillingness to involve patients and families in helping to
understand what went wrong
• No data recorded or analysed concerning secondary harm to the
patient as an issue leading to action
• A lack of formal support for patients and families who have suffered
incidents of avoidable harm
• A culture that seeks to close ranks, restrict information and
manage blame
If we are serious about patient safety, we must find ways to address such
causes to minimise the needless, secondary pain that patients, families
and clinicians can suffer in the aftermath of an incident of avoidable
unsafe care and harm.
We don’t systematically engage patients in their care.

Health and social care are still too often designed and delivered around
“The patient and family are the
the traditional idea that the patient is a passive participant in the care
only people who are present
throughout the continuum of process. The systemic model of healthcare is predicated on the use of
care. They are a repository of clinical expertise; a patient with a condition is moved like a passenger
critical information and, when through the health system until they are seen by a suitably expert
engaged and empowered, can person.74
play a significant role in This process assumes that the patient has little expertise to offer. In many
ensuring a positive health-care
cases, this assumption is wrong. Patients with a chronic condition, for
experience. For the same
example, will often be highly informed75. When children are patients, their
reason, engaging parents and
parents or guardians often have substantial information and insight into
families who have experienced
harm can provide insights and their condition.76
learning concerning system When health and social care does draw on this expertise such as, say,
failures.” when a patient history is taken, too often the history does not travel with
WHO, Patient Engagement for the patient, is mis-recorded or poorly communicated. This has led to
Patient Safety, 201313 many cases where the patient’s own reports of their condition, or reports
by parents or family members, are discounted.77
The assumption that patients are passengers in the care process is often
reflected in how their care is managed. Even when armed with their
records, patients may have limited ability to participate in their care
because they aren’t adequately informed about the stages of their
treatment journey and what they should expect to happen.
Responsibility for safe care rests with the care provider. If patients don’t
know what ‘good’ or ‘safe’ looks like, in terms of the care they should

receive, they will be unable to assess the care they are themselves
receiving.78 Patients are more vulnerable to receiving unsafe care if they
do not understand the care they should be receiving or if it is not
explained to them. In such cases, they are unable to question or Hospitals that involved
challenge the care they have received or should receive. patients and families in
handovers demonstrated
If patients were able to check their clinical information during the care
process, such problems might be reduced. However, patients typically do
not have immediate or direct access to their own medical records, test
results or diagnostic imaging results. They are less able to validate their
38%
fewer harmful medical
own understanding and so cannot act, should they wish to do so, as a errors, and
second check that correct protocols are being followed.
Patient care information, for example, can often be handed over between
clinicians and between organisations without the presence of, or any
46%
direct input from, the patient or their family. If mistakes are made or fewer adverse events7
handover information is incomplete, patients can’t correct them.
This needs to change. Patients need to be considered part of the team
that provides safe care.
Investigations are not part of patient care

There is a special case where active patient engagement is often ignored,
or discounted: the procedures that follow a serious incident of avoidable
harm or death of a patient.
There is evidence that when patients are left out from investigations, the
quality of investigation is compromised.79,80 Patients and families can be a
primary source of learning for safety.
Investigation and complaints processes, however, have often not been
designed around patient interests or patient care. These processes are
often seen to be insensitive, unresponsive and adversarial.37
This has a number of effects:
• Patients, families and staff may not be supported when things go Only
wrong.
• Despite assurance and guidance from NHS Resolution and others
about the need to apologise, staff often seem fearful or reluctant to
36%
do so.81 of investigations gave
patients a chance to
• Staff can be traumatised themselves by their involvement in the
discuss the report.27
serious harm or death of a patient.82,83 Few support services exist
for them84 and we know that some staff never recover and are lost
to the profession as a consequence.83
• Families and patients can find it hard to access information or
support on what options are available to them for finding out what

happened, to navigate a complex system through its various stages,

such as complaints, the medical examiner’s report, a coroner’s
inquest, serious incident investigation, litigation and inquiries.
When a serious incident of patient harm is investigated, patients too
often are not invited to contribute to the investigation, are ignored or have
their views discounted.
“Very few reports in our sample recorded the impact and outcome of the
incident for the patient or set out how this was managed through
additional care or support…reports showed a lack of perspective from the
patient or their family on the incident”.
CQC, Learning from Serious Incidents in Acute Hospitals, 201627
“I cannot think of a single case As a result, patient and family participation in the processes following a
I have reviewed where poor serious incident can be a distressing, frustrating, disempowering and
communication is not a factor exhausting experience, with support, care and funding often available
leading to poor health only through the charitable sector by organisations such as Action
outcomes and subsequent Against Medical Accidents (AvMA).
disputes: poor communications
between patients and In too many cases, this experience causes severe distress and
health professionals “ psychological harm to patients and families and to the clinical staff who
Finbar O’Callaghan, The Long have been involved in the incident.86
and Winding Road, 201585 Far from being processes of care for people who have suffered avoidable
harm, in too many cases these investigations inflict further harm to people
who should be receiving healing.87
This should not be allowed to continue.
Patients aren’t regularly considered as part of health

and social care governance
Patients aren’t properly involved in health and social care management
and policy. Many patients are unaware of opportunities to get involved in
safety at the organisational and policy level. When they do get involved, it
is often tokenistic. If their contribution is actively sought, then they are
often poorly supported or trained to contribute effectively.
Health and social care organisations’ governance typically does not
require patient engagement. Health and social care organisations require
governance that creates and requires patient engagement to improve the
performance of the organisations.88

The case for engaging patients in patient safety

is strong
The case for engaging patients in patient safety is more powerful than “Empowering patients to be an
simply evidencing the harm that poor post-incident care can cause. active participant (sic) of their
Simply put: patient engagement makes care better.90 treatment is not only shown to
Robust evidence shows that communication between clinicians and improve health outcomes, but
also effectively reducing safety
patients has a positive impact on health outcomes.91,92,93,94,95,96,97,98
lapses by up to 15%.”
Failure to adequately involve patients in their care also carries a OECD, Flying Blind, 201889
significant financial cost. For example, in 2015 Marie Curie UK used
figures from the NHS Litigation Authority to estimate that communication
failures between staff, and between patients and staff, cost the NHS
£200-300 million a year.85
Engaging patients in their care increases patient safety, reduces harm
and potentially reduces costs.
As we have seen, however, much is yet to be done to ensure that patient
safety can be optimised by the effective and consistent engagement of
patients and families.
A patient-safe future: patient engagement for

patient safety
We envision a patient-safe future where patients are actively engaged
throughout the care process and whenever things go wrong.
Patients and professionals are equipped and enabled to engage

in safe care
• Patients and health and social care professionals enable patients, if
they wish, to partner in all activities related to patient safety across
the system. Staff welcome and support this in practical ways.
• Patients and healthcare professionals have the knowledge, skills
and attitudes to understand why and how patients should be
involved, as well as how to involve patients as active partners in
patient safety activities across all levels of the health and social
care system.
• Patients and families have real-time access to the information
needed to allow them to engage in patient safety activities across all
levels of the system.

Governance supports, encourages and enables patient engagement

in patient safety
• The governance and delivery of healthcare services require patient
representation in order to support patient-safe health and social
care and hold healthcare organisations to account for patient safety.
• Organisations routinely measure patient engagement in patient
safety and evaluate the impact this has. Results are shared within
the organisation and between organisations for learning
and improvement.
• Regulators, policymakers and commissioners promote and support
practical mechanisms for effective patient engagement.
• Patients and patient advocates across the health and social care
system are supported by a central patient safety organisation. They
will be mentored and supported through an infrastructure that
provides support and co-ordination. This will enable patient
advocates to develop a collective voice, sharing wisdom, insight
and learning.
Patients, families (and staff) are supported and cared for at every
stage after an incident of unsafe care
Sincere apologies offered in the • Investigations fully involve patients and families.
wake of a medical error may • When patients or families experience harm because of patient
lead to a lessening of suffering safety problems, health and social care systems respond to provide
for both patients and physicians an apology, support, mediation and involvement in investigations,
in coping with the error and its with an open and honest explanation for what happened and why.
consequences, contribute to
improved relationships between • Patients and families feel engaged and supported whenever there is
physicians and patients such a patient safety incident. Access to appropriate support is enabled,
that these relationships are able funded and encouraged, including when such support is best
to continue, and reduce costs provided by third parties.
by preventing lawsuits and • Investigations openly and transparently provide explanations and
facilitate the settlement restorative justice.
of valid claims.
• Patients and families only need to use the complaints system or
J. K. Robbennolt, Apologies
instigate litigation if these systems fail.
and Medical Error, 200999
• Mediation is more frequently used to support families and staff to
find a way through the complexity of investigation and complaints
processes and to come to quicker and fairer resolutions.
• Patients, families and staff are cared for and supported when there
is unsafe care.

We call for action to engage patients in patient safety

If we are to have patients fully engaged in patient safety, organisations in
the health and social care system need to act.
We seek to see:
• Health and social care systems welcome and recognise the value of
patient engagement and involvement in patient safety.
• Organisations support patients to engage with them to help meet
standards, goals and objectives for patient safety.
• Organisations inform patients and the public about patient safety
performance against published patient safety goals, standards
and metrics.
• Patients become an integral part of an organisation’s governance
and leadership for patient safety.
• Organisations develop governance and operational roles for patient
engagement. These include, but are not limited to, patient
engagement and involvement:
o At the point of care “Patient safety systems are also
more likely to be effective if
o If harm occurs patients are actively involved.
o In investigating unsafe care Patients need to be
encouraged to play a greater
o In the design of service improvements part in their care to make sure
o In the boardroom that they remain safe when
treated by the NHS”
o In holding the organisation to account for delivery of patient
CQC, Opening the Door to
safety standards, goals, processes and objectives
Change, 201831
• Organisations fund, recruit, train and provide ongoing organisational
and personal support for patient representatives and advocates at
all levels.
• Organisations support their staff and leaders to have the
knowledge, skills, attitudes and behaviours to engage and involve
patients in patient safety.
• Organisations provide consistent support to patients, families and
staff when there is unsafe care:
o Physical, mental health and social care support when
it’s needed
o Information and honest explanations about what happened
and why
o Genuine and empathetic apologies

o Advice and guidance about what to expect and the options

available for support and redress

Patient Safety Learning will take action to help patients to engage for
patient safety. We will work collaboratively to:
• Publish a detailed report on patient engagement in patient safety to

identify action needed for improving patient safety.
• Develop a model and governance for patient engagement and
advocacy for patient safety for service providers, regulators,
commissioners and others.
• Initiate the development of three ‘harmed patient care pathways’ to
follow a death or serious incident of patient harm for:
o Patients
o Families / carers
o Staff
• Promote, share, implement and evaluate models for patient
engagement in patient safety.
• Support health and social care organisations through consultancy
and practical training.


"Health statistics represent people

with the tears wiped off.”
Sir Austin Bradford Hill100

Do we have the right data?

In practice, patient safety asks a single question of any organisation:
“How do we know that we’re safe?”

Professor Alison Leary101
Right now, can any leader in health or social care properly answer
this question?
It is not for want of trying. Many efforts have been made to give
healthcare organisations useful data on patient safety. These include:
• The National Reporting and Learning System (NRLS) is a central

database of patient safety incident reports in England. Plans are on
the way to replace this system with the Patient Safety Incident
Management System (PSIMS).44
• The Clinical Practice Research Datalink (CPRD) provides
anonymised patient safety records for public health research and
analysis, offering reports back to primary care providers. It includes
data from 6.7% of the UK population.102
• NHS Safety Thermometers employ point-of-care surveys that allow
clinical teams to collect, analyse and act on data relating a range of
specific conditions.103
• The Suspicion of Sepsis (SOS) Insight Dashboard gives clinicians
and managers insights to admissions, survival rates and lengths of
stay, enabling organisations to benchmark, prioritise improvement
strategies and monitor improvements over time.104
• Getting it Right First Time (GIRFT) is a national data-driven
programme to improve the quality of care by reducing unwarranted
variation and sharing best practice. It is being rolled out in 35
surgical and medical specialties and is supported by seven
regional hubs.105
• The Summary Hospital-Level Mortality Indicator (SHMI) is a
NHS Digital programme that models the mortality outcomes of
patient hospital care. The SHMI is the ratio between the actual
number of patients who die following hospitalisation at the trust
and the number that would be expected to die on the basis of
average England figures, given the characteristics of the patients
treated there.106
• The Leapfrog Hospital Safety Grade is a US programme that
grades hospitals according to their responses to questions
concerning their procedures and practices for aspects
of patient safety.107

Over and above these specific initiatives, individual organisations

have access to a range of patient safety information. Organisations
may, for example:
• Have information about the duration of investigations and outcomes

after serious incidents or near misses.
• Have information collated on complaints, not just the volume,
severity of concerns and response rate, but the insight from
these, and the learning that can and has been taken to improve
patient safety.
• See reports about the number of clinical negligence claims
outstanding, the number settled and the amounts of money to
be paid.
• Choose to access the narrative text of incident investigations as
well as quantitative data.
• Have information about the progress of specific initiatives towards
certain patient safety targets, such as infection control.
• Have potential access to significant qualitative and anecdotal
information about incidents, rumours and observations.
• Have access to information about whistleblowing.
The quantity, quality and relevance of such data varies by organisation,
as does the quality of analysis, review and action planning that results.
Data-rich, information-poor
Even with access to such data, an organisation’s ability to answer the
question, “How do we know we’re safe?” remains limited. There are a
number of reasons why:
• Almost all patient safety data refers to patient harm or performance

after harm has already happened. They provide what is commonly
termed ‘lagging’ information.108 Such data supports a patient safety
stance where the focus is to address harm that has already
been suffered.109
• Many organisations do not state specific systemic patient safety
objectives against which they can be measured. As a result,
we consider that their measurement of patient safety can
lack direction.109
• Only a few patient safety metrics (for example, the SHMI) offer
reference information to put an organisation’s performance in
context. In many cases, this is when organisations have no
reference information against which to compare their performance
and tell them if patient safety is improving or not.109

• We consider that many patient safety scandals (such as Gosport or

Mid-Staffs) might have been identified sooner if organisations had
more effective ways of viewing and addressing the totality of patient
safety performance information available.
These include, for example, qualitative data such as the numerous
reports, queries and flags raised by concerned staff, patients and
families but which did not lead to meaningful action early in the
events that led to these scandals.110
The proliferation of mobile and app technology for health and medical
care might seem to offer a way to harness data for patient safety. But as
few design standards for patient safety for apps exist, the challenge of
finding trusted, relevant sources for patient safety data from billions of
3.7bn
The number of health app
downloads is yet unmet.
downloads in 2017111
When it comes to patient safety, it seems, organisations are data-rich and
information-poor.
Setting goals for patient safety

“While we have, understandably, focused on specific, targeted initiatives,
we have not made wholesale and sustainable progress.”
Patricia McGaffigan, 201915
Goals for patient safety are often set to reduce harm related to a specific
condition or practice. Targets are set for infection control,112 or pressure
sores, or falls; actions are taken and after a time, harm levels for these
conditions reduce.
Such initiatives have led to some tremendous improvements and many,
many patients are alive and well today because of the great work of the
innumerable, dedicated staff who made these improvements happen.
Yet, as Patricia McGaffigan asserts above, such initiatives have not
led to patient safety nirvana. Despite such attention focused on specific
improvements, overall numbers of patients suffering harm stay
stubbornly high.2
Why?
When under pressure from reduced resources and increased demand,
organisations tend to direct their limited resources to tangible goals for
which they are obliged to be accountable.113
So, while we may see an improvement in specific output targets, this can
be at the expense of other patient safety activity, such as addressing the
systemic causes of patient safety failure.
Hard numbers drive out soft.

Of course, harm reduction must be embraced. But striving to reduce harm

is not the same as striving to be safe. In the jargon, it is the difference
between Safety I and Safety II.30
If we are to be sustainably safe, we think that initiatives with specific harm
reduction targets must be complemented by others that address systemic
causes of patient safety failure.
We support the setting of patient safety targets for specific issues and
conditions and expect these to have clear and actionable implementation
plans. We propose, however, that these are accompanied by goals that
address the systemic causes of patient safety failure:
• Shared learning
• Professionalising patient safety
• Leadership of patient safety
• Patient engagement for patient safety
• Data and insight for patient safety
• Patient safety culture.
Currently, few organisations set effective goals and objectives for
systemic causes of patient safety failure in a consistent and
compelling way.
Three questions for patient safety

performance measurement
Before we can answer the question, ‘how do we know we are safe?’, we
must first answer three other questions.
1 Against which patient safety objectives are we measuring

performance? What should we be measuring?
2 For whichever measures we choose to use, what level of patient

safety performance should we have? (What represents good or
bad performance?)
Some may wish to set a target of zero incidents. But even if it is
possible, perfect performance is likely to be many years away.
Organisations need to set reference data against which they can
determine if their performance is good, or not – and if they are
improving safety year-on-year.
3 What information tells us if we are becoming more or less safe before

harm actually happens? That is, can we have leading, as well as
lagging, information about patient safety performance?

Few organisations appear to have good answers to these questions. As a

result, most organisations will find it hard to understand, and so act
meaningfully, on their patient safety performance.
A patient-safe future:
Data and insight for patient safety
In a patient-safe future:
We measure patient safety performance effectively

• Organisations specify clear objectives for patient safety outcomes.
• They set performance standards for these objectives against which
they measure performance as part of formal governance and
reporting. These standards must be demanding, specific and
relevant to patients.
• Organisations use data analytics to identify possible evidence of
patient safety risks or potential precursors for such risks.
• They use performance information to identify, track and manage
specific risks to patient safety.
• Organisations use performance information to identify, track and
manage data for the active design of safety, as well as assessing
and addressing the risk of harm, and recording and reporting when
harm happens.
• They measure performance routinely against these standards and
objectives, using both lagging and leading indicators.
We identify shortfalls in patient safety performance

• When performance is shown to fall short, organisations take specific
action to address the shortfall and formally track the results.
• Organisations measure safety performance, and shortfalls in
performance particularly, not to blame, but to learn and improve.
Regrettably, we believe this will be challenging in the target-focused
performance culture of the NHS.
• Organisations set standards for, and measure the quality and
effectiveness of, the work they do to improve performance in cases
of patient safety failure.
We act to improve patient safety performance

• Every level of an organisation makes better decisions by using
reliable patient safety performance information.

• Organisations improve safety by raising patient safety

standards regularly.
• Organisations share their safety performance with others.
• They routinely and actively capture, assess, report and act on
qualitative information about patient safety from all sources, such as
reporting by patients and staff, including whistleblowing.
• They require that apps that claim relevance in health or wellness
demonstrate that they have been designed with patient safety as a
core principle in their design, development, testing and support.
• Organisations undertake research to identify appropriate and
effective metrics and data to monitor and manage safety actively, in
addition to risk and harm.
We propose improvements in patient

safety measurement
To improve patient safety performance, we seek to see:
• Health and social care systems develop models for measuring,

reporting and assessing patient safety performance. These should
also include qualitative data on performance and culture, and
insights from patients, frontline staff and the wider community.
• Patient safety performance data to be incorporated into risk
management systems and monitored by management teams,
boards and across the system.
• Patient safety performance measurement models to develop into
patient safety dashboards at department, board and system levels,
and incorporated into formal governance.
• Such dashboards to include reference or baseline information to act
as standards against which patient safety performance can be
measured and improvement / impairment tracked.
• Dashboards to include leading and lagging indicators of
patient safety.
• Dashboards to include information about reactive and proactive
activities to support patient safety improvement.
• Centralised systems for collecting data on patient safety incidents to
include insights and learning that follow from investigation and the
impact of resulting actions.
• Patient safety to be an integral part of AI development by, for
example, engaging with the Department for Business, Energy and
Industrial Strategy’s Grand Challenge Missions114 and others to
develop capabilities to support patient safety.

These may include, for example, identifying potential precursors to

patient safety incidents to enable the development of leading
indicators for patient safety.

We will:
• Publish a detailed report on data and insight to help take action

for improving patient safety.
• Convene a symposium of experts, expert users and patients to
start identifying critical data and insight needed to measure,
monitor and determine effective action for patient safety.
• Make recommendations for system-wide data and measurement
for patient safety, including organisational dashboards.
• Seek to work with technology companies and others to
develop, design and implement an effective set of patient safety
standards for ‘health’ apps, together with associated regulation
and governance.
• Develop associated tools, such as ‘how to’ guides, maturity
models and self-assessments frameworks, to support
organisational leadership.
• Work with health and social care data providers to design
programmes to implement patient safety performance
management and measurement.

9 Patient safety culture
(The single greatest impediment to

error prevention in the medical industry is…)
“…that we punish people for making mistakes.”
Professor Lucian Leape, 2009115

“You can (and should) identify and blame the error, the 'act or omission’
for the harm, but very often it is not appropriate or fair to blame the
'person' who carried out that act. There is a bigger picture when it comes
to why that person made that error. This distinction needs to be made
clear to everyone, the public and NHS employees.”
Jo Hughes, 2016116
“Culture eats strategy for breakfast.”

Peter Drucker (attr.)
Blame makes patients less safe

As A Patient-Safe Future describes, logic, research and innumerable
examples all point the same way: an organisational culture that seeks to
assign blame when things go wrong makes patient harm more likely to
happen again.
A blame culture:
• Incentivises people to cover up mistakes.

• Motivates people to lie, either by commission or omission.
• Encourages scapegoating, especially of people lower in the The medical paradigm
corporate hierarchy. demands that the practitioner
• Makes a single person responsible for a failure while practises to perfection, and if
downplaying or ignoring the systemic causes behind an incident. the person falls short of this
As a result, it makes it likely that the same problem will recur with high standard, then the person
a different person. is to blame.
S Radhakrishna, 2015117
• Sets standards for performance that are unachievable with the
resources provided.
• Inhibits learning and improvement.
• Is corrosive and undermines trust between colleagues.
• Encourages organisations to exclude or ignore patients or families
if things go wrong.
• Makes whistleblowing necessary, as reporting ‘bad news’
is discouraged.
• Increases the career risk to whistleblowers, as the culture defaults
to blaming (and often, shutting down) the messenger.
Evidence shows that improving safety culture impacts on staff safety
behaviours, and that improvement initiatives, in turn, improve culture. In
short, they form a virtuous circle.118,119
A culture less centred on blame, such as a Just Culture120 has a positive
impact on patient safety.

“For a safe organisation, staff need to be confident that doing the right
things – reporting incidents, near misses and concerns, being candid
about mistakes and talking openly about error – are all welcomed and
encouraged. They need to know that the organisation will focus on
system learning, not individual blame.
Of course, there must always be accountability in the rare cases where
individual healthcare staff have acted recklessly or have covered up.
The term ‘Just Culture’ describes a culture which successfully achieves
this balance.”
Patient Safety Learning, A Patient-Safe Future, 20183
A patient-safe future: Patient safety culture

In a patient-safe future, an organisation’s culture encourages and
supports patient safety.
The environment supports raising, discussing and

resolving concerns
“Create a culture where • The working environment actively promotes and supports the
clinicians and patients can improvement of patient safety. It encourages and enables learning
speak openly in the same room from staff and patients within their organisations and elsewhere in
and listen to each other.” the health and social care system.
Suzette Woodward, 2018121 • The working environment allows challenge and encourages raising
concerns, including whistleblowing, by anyone.
• Health and social care organisations measure organisational
culture to identify opportunities to sustain and progress an improved
safety culture.
• Successful improvements in patient safety are celebrated
appropriately and shared widely.
• Staff and patients feel safe and secure in reporting patient safety
concerns, near misses, and incidents, knowing they will be actively
welcomed and thanked for sharing their insight, and that action will
be taken for safer care.
The organisation is led, and managed, to support patients and

clinicians fairly and safely
• A charter of principles and standards sets fair expectations for how
health and social care professionals involved in a patient safety
incident are supported and treated.
• Health and social care professionals understand their responsibility
for patient safety.
• Organisations ‘take all reasonable and practicable steps’ to improve
the safety of patients.

• Work and workload are explicit so that staff are assured that what is
expected of them is achievable with the resources available.
• Patient safety risk assessments ensure that resource / safety
trade-offs are explicit and understood by decision-makers.
Organisations address incidents of unsafe care with empathy,

respect and rigour
• Following a patient safety incident, there is open and honest
disclosure to patients and their families. “Civil work environments
matter because they reduce
• Communication and engagement with harmed patients and their errors, reduce stress and
family members is prompt, complete, sustained, kind, supportive foster excellence”.
and empathetic. www.CivilitySavesLives.com122
• Following a patient safety incident, clinicians and affected staff are
given appropriate support. They are confident that the organisation,
professional bodies and the wider system will treat them fairly in
ways consistent with the principles of a Just Culture.
• Investigations begin with an initial intent to determine the systemic
causes of an incident, rather than assuming assignment of liability
or blame.
• Patient safety incidents are investigated consistently and rigorously
by suitably qualified, accredited and experienced personnel.
• Learning is shared widely for safer care across the health and social
care system.
We call for action to develop a culture for

patient safety
There have been many reports into how a Just Culture is critical to
improve patient safety. Now is the time to learn from these reports and for
all, not just the few, to take concerted action.
To make progress towards an effective culture for patient safety, we seek
to see:
• Health and social care organisations implement programmes to

eliminate a blame culture and introduce or deepen a Just Culture.
• Health and social care organisations develop and publish goals to
develop and sustain a Just Culture.
• Health and social care organisations measure and report their
progress towards a Just Culture.
• Staff can feel assured that they are working in safe systems and
that, when things go wrong, a system and human factors approach
will inform investigations and learning.

• Patients can raise concerns and provide insights into how to

make care safer, confident that their views will be welcomed and
acted upon.
• These organisational goals and programmes are informed by:
o Organisations reviewing and taking into account how
external factors (regulators / policy / commissioning / media)
tolerate / support / drive blame cultures in health and social
care organisations.
o Organisations reviewing how their current approaches
to patient safety and behaviour tolerates or supports a
blame culture.
o Regular safety culture assessments of staff and patients.
o Use of systems thinking and human factors.
o Specialist expertise to inform culture changes and learn from
those that are making good progress in this often challenging,
but essential, ambition.
o The design, implementation and evaluation of organisational
goals and programmes is shared widely for transparency,
accountability and learning.

To help organisations develop and implement a more effective culture for
patient safety, we will:
• Publish a detailed report on Just Culture to help take action for

improving patient safety.
• Provide, on the hub and elsewhere, tools, case studies and
resources to help organisations and teams learn, adopt and assess
Just Culture.
• Promote a Just Culture in everything we do and across all our
communications and engagement.
• Support health and social care organisations through support and
practical training.


10 About Patient Safety Learning
Our vision is for a patient-safe future

with patient safety as part of the purpose
of health and social care,
not something to be negotiated.
We believe that urgent systemic action is needed
to address the causes of unsafe care.

“We know why we need to improve patient safety. We better understand

what we need to do. We need now to focus on how we deliver a patient-
safe future.”
Helen Hughes
Chief Executive, Patient Safety Learning
We aim to make patients safer

Patient Safety Learning is a charity.
We help transform safety in health and social care, creating a world
where patients are free from harm.
We help health and social care systems and organisations enable safer
care for patients.
We identify the critical factors that affect patient safety and analyse the
systemic reasons they fail.
We listen to learn about what is needed to make health and social care
safer. We use what we learn to envision safer care and recommend how
to get there. And we act to help make it happen.
One of our greatest strengths is our independence. We speak truth
to power.
Evidence, vision and ambition

We are a small organisation with an ambition that stretches across the
whole of health and social care.
The causes of patient-safety failure are system-wide, and we need to use
and propose human factors thinking to understand them. We base our
thinking and conclusions on firm evidence.
The past 20 years has secured patient safety on the agendas of health
and, increasingly, social care. In this time, thousands of
recommendations have been made. The need now is for effective
systemic action to transform the safety of care.
Our mission matters to everyone, for every single one of us has been, or
will be, a patient or care service user. All of us want to be – all of us
deserve to be – cared for safely. Improvement in patient safety will come
with the hundreds of thousands of people every day who provide care
and try to make things better.
And so we collaborate with staff, patients and their families; those who
have suffered first-hand and who want their experience, their insight and
their learning to make a difference. By partnering with them, we aim to
achieve the transformation we all need.

We would like to partner with you too. Contact us to find out how together
we can aspire to a patient-safe future.
Learn more about us

Learn more about Patient Safety Learning and our goal of creating a
patient-safe future.
Visit our website at www.patientsafetylearning.org or contact us at
info@patientsafetylearning.org


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patient safety learning The Patient-Safe Future: A Blueprint for Action 1

Executive Summary ........................................................ 5

2 What we learned from A Patient-Safe Future........... 17

3 Patient Safety is a strategic purpose........................ 23

4 Shared learning ....................................................... 29

5 Leadership for patient safety.................................... 41

6 Professionalising patient safety ............................... 49

7 Patient engagement for patient safety ..................... 57

8 Data and insight for patient safety ........................... 67

9 Patient safety culture ............................................... 75

10 About Patient Safety Learning ................................. 81

patient safety learning The Patient-Safe Future: A Blueprint for Action 3

Patient Safety Learning is registered

Patient Safety Learning

4 The Patient-Safe Future: A Blueprint for Action patient safety learning

Place the quality of patient care,

Don Berwick, 20131

patient safety learning The Patient-Safe Future: A Blueprint for Action 5

Patient Safety Learning seeks to transform thinking

A Blueprint for Action describes the path to a

Patient safety is a major and persistent problem

Patient safety is part of the purpose of health and

Systemic causes of unsafe care

6 The Patient-Safe Future: A Blueprint for Action patient safety learning

• Organisations do not take ‘all reasonable and practical steps’ to

• We don’t learn well enough, share or act on that learning for

• Staff working in healthcare are not ‘suitably qualified and

• A culture of blame and fear undermines our ambitions to design and

Foundations of patient safety

patient safety learning The Patient-Safe Future: A Blueprint for Action 7

Action: shared learning for patient safety

Action: professionalise patient safety

Action: leadership for patient safety

8 The Patient-Safe Future: A Blueprint for Action patient safety learning

• Develop practical models of leadership and governance for

Action: patient engagement for patient safety

patient safety learning The Patient-Safe Future: A Blueprint for Action 9

Action: data and insight for patient safety

Action: culture for patient safety

We can all play a part

• Patient Safety / Risk Managers

• Frontline clinical and care staff

• System regulators, such as CQC and MHRA

• Professional regulators, such as the GMC, NMC, HCPC and many

• Department of Health and Social Care

• The Healthcare Safety Investigation Branch (HSIB)

• Networks representing provider organisations

• Think Tanks, such as the Kings Fund, Health Foundation

• Patients and the public

• Commissioners and funders

10 The Patient-Safe Future: A Blueprint for Action patient safety learning

• National Patient Safety leaders, such as NHS Improvement

• Academic Health Science Networks

• Patient Safety Collaboratives

• Researchers and academics

• Human Factors experts and safety system designers

• Freedom to Speak Up Guardians

• Professional societies and associations