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Avoidable harm still ‘too high’ in UK healthcare

More transparency needed, say authors

Jo Carlowe

Tuesday, 08 March 2016

Avoidable harm to patients is still too high in healthcare in the UK and across the globe.

This is the finding from two reports, launched today, by researchers from Imperial College London. 

Both reports, produced by NIHR Imperial Patient Safety Translational Research Centre (PSTRC), provide evidence on the current state of patient safety and how it could be improved in the future. Its authors conclude by urging healthcare providers to embrace a more open and transparent culture to encourage continuous learning and harm reduction.

The first report, focusing on the National Reporting and Learning System (NRLS), says the system requires refinement and renovation, so as to take advantage of new technologies and recent behavioural insights. For example, it recommends app-based technologies that offer a simplified platform to engage staff in the incident reporting process.

In particular, the report reiterates problems around under-reporting of safety incidents, and reveals structural concerns within the NRLS, that have inhibited its usefulness as a tool to drive safety improvement.

Professor Ara Darzi, Director of the NIHR Imperial PSTRC and senior author of the reports said: “For too long the mind-set has been that patient harms are inevitable, and that nothing can be done to prevent them. But keeping patients safe is a fundamental part of care. Although we currently face many changes – such as increasingly complex patient cases and limited resources – we must focus on creating safer environments for patients. This should involve a systems-based approach, and coordinating action across all levels of the political and health systems. We also must ensure patients and staff are integral to any solution, and not just seen as victims or culprits.”

Erik Mayer, lead author of the report, from the Department of Surgery and Cancer at Imperial, explains: "The UK has one of the biggest incident reporting systems in the world. But despite this, evidence suggests that as little as 5% of patient safety incidents are reported. This is often related to the culture of institutions and the culture of medicine. For instance, staff may witness an incident that should be reported, but are hesitant to do so for fear of repercussions.”

Furthermore, the information produced by the system is difficult to analyse, making it hard to spot dangerous trends or problems, say the authors.

“At the moment there is no standardised method to code or group the reports. So, for example, a delay in a medication being given may be recorded in a number of different ways, depending on the hospital. We need to standardise this and ensure that we have an improved approach to incident reporting.”

The second report, ‘Patient Safety 2030’, suggests a ‘toolbox’ for patient safety. This would include: using digital technology to improve safety; providing robust training and education, and strengthening leadership at the political, organisational, clinical and community levels. Other points in the ‘toolbox’ include effective and high-quality education and training; strengthening measurement methods, including incident reporting, and exploring new digital solutions.

However, the authors warn that interventions implemented to reduce avoidable patient harm must be engineered with the whole system in mind, and empower patients and staff to become more involved in preventing harm and improving care.

Ultimately, both reports issue a global call-to-action on patient safety: both for individual health systems to convert the evidence on how to improve patient safety into everyday practice, and for the global community of health systems to share learnings from each other's successes and failures.

Commenting, Dr Peter Lachman, Clinical Lead for the S.A.F.E programme at the Royal College of Paediatrics and Child Health, said: “At a time when there are an estimated 2,000 healthcare and non-healthcare related preventable deaths a year in the UK, it is absolutely vital that we all make a concerted effort to see these figures drop. We know that problems can arise from something as simple as varying quality in communication between hospital staff and patients. And as these reports both point out, a more transparent and shared culture is what is most needed to help reduce avoidable error in patient care.”

The publication ‘NRLS Research and Development Final Report’, funded by NHS England, will be presented today at the Royal Society in London. The report Patient Safety 2030’, funded by a grant from the Health Foundation, will be presented on March 9th at the Patient Safety Global Action Summit 2016.

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