PSC launches new Patient Safety Principles
I am delighted to announce a major step in the improvement of patient safety with the publication of the Patient Safety Principles. The Principles follow our public consultation to which we received over 800 responses. They provide a framework for working collaboratively with patients as partners, planning, and decision-making.
Visit the Principles page here for details of the Patient Safety Principles, a toolkit on implementation, and resources to demonstrate your organisation’s support.
Updates
HSSIB report highlights challenges to managing safety systems
The Health Services Safety Investigations Body (HSSIB) has published a new report, Safety Management: Accountability Across Organisational Boundaries, highlighting significant challenges in managing patient safety risks across multiple healthcare providers. This report highlights that there exist no overarching safety management principles to ensure a consistent collaborative report across healthcare providers and ICBs.
The investigation examines how safety is managed when care transitions between providers, particularly within Integrated Care Systems (ICSs). It reveals inconsistencies in how patient safety risks are identified, escalated, and managed—often leading to delays in care, confusion over responsibility, and undue burdens on healthcare professionals and organisations.
The findings of the report include:
- A misalignment between national expectations and ICBs’ ability to manage patient safety risks effectively, due to resource constraints and data usability challenges.
- Variability in how patient safety risks are escalated at regional and national levels, with limited feedback mechanisms in place.
- A lack of integrated patient safety data, making it difficult for ICBs to proactively identify risks spanning multiple providers.
Key Recommendations
HSSIB has made a safety recommendation to the Department of Health and Social Care and NHS England to use the findings of this report to shape the upcoming 10-Year Health Plan and NHS Quality Strategy. This includes embedding safety management principles into healthcare to improve cross-organisational patient safety.
Additionally, safety learning points have been highlighted for Integrated Care Boards (ICBs), urging them to:
- Ensure collaborative working across health and care providers when commissioning services to improve patient safety.
- Develop greater expertise in analysing safety data and intelligence to identify and address risks across multiple providers.
The Patient Safety Commissioner welcomes this report and encourages policymakers, NHS leaders, and healthcare professionals to engage with its findings to help shape a safer, more transparent, and patient-centred healthcare system.
For the full report and recommendations, visit https://www.hssib.org.uk/patient-safety-investigations/safety-management/investigation-report/
New analysis reveals reduction in valproate prescribing
Prescribing of valproate has reduced significantly following the introduction of a quality improvement programme that promotes safety and patient choice.
New analysis presented to the National Patient Safety Committee shows:
- a 53% reduction in initiation in girls aged 0-12
- a 60% reduction in 13-54 women started on valproate
- a 65% reduction in women re-starting valproate after a break of 6 months
- at least 9 out of 17 mothers have active management of valproate if it was prescribed during pregnancy
- and hospital admissions for women with epilepsy aged 13-54 have not been affected by these changes.
The quality improvement programme follows a recommendation by the PSC in 2023 which was accepted by NHSE in January.
Review finds safety recommendations system ‘untenable’
The current situation on recommendations for safety and quality in healthcare is untenable according to a new review.
The DHSC-commissioned review was published by HSSIB on behalf of a group of ALBs. It concludes that the substantial number of recommendations made to the healthcare system means providers struggle to prioritise and implement recommendations.
It found that the lack of structure around the creation and implementation of recommendations as well as the lack of monitoring of actions means many are not improving patient care while continuing to burden providers.
Some recommendations duplicate or contradict others and most are not costed, which may affect providers’ ability to implement them and means there is a lack of information to support prioritisation decisions. Some may be of limited relevance to certain providers and could promote inequalities by negatively impacting certain patient groups if implemented. There is a lack of monitoring of the actions planned or taken to address recommendations.
Welcoming the report, the PSC said: ‘It is becoming increasingly clear to the public that vital recommendations for urgent changes to be made to keep the public safe are simply not being acted upon, leaving persistent risks unaddressed and patients and staff vulnerable.
‘It is essential that the public can have the confidence that recommendations commissioned from independent safety bodies, reviews and Inquiries are properly co-ordinated and followed up with tangible actions. Patients deserve a healthcare system where safety is a top priority, where lessons are learned, and avoidable harms are removed. It is unacceptable that findings which could prevent harm or injury can be neglected for decades.’
The review recommends further work to look at setting up a repository for recommendations, a monitoring system and a route of escalation for recommendations that are not implemented.
PSC welcomes new guidance on valproate usage by men
Men taking valproate and their partners are being advised to use effective contraception according to new guidance from the MHRA. It recommends that male patients and their partners use effective contraception during valproate treatment and for at least three months after stopping the medication.
It follows a study which reports a possible association between valproate use by men and a small increased risk of a range of neurodevelopmental disorders in their children when compared to men prescribed other medicines for the same conditions (lamotrigine or levetiracetam).
Though the risk is much lower than the risk of neurodevelopmental disorders in children born to mothers who take valproate during pregnancy, and the MHRA has long advised against the use of valproate by women able to have children unless there is a Pregnancy Prevention Programme (PPP) in place, this new advice acknowledges that valproate use in fathers is also associated with risk to children as well.
The full guidance can be found here
New summary of key patient safety surveys
The 2024 edition of Patient Experience in England is now available from Care Opinion.
As well as summarising the key findings from last year’s large scale patient surveys, the report looks at wider research covering issues such as equity and accessibility as well as studies on patient voice and safety. It is available at Patient Experience Library
NHS England launches new primary care patient safety strategy
NHS England has released a new primary care patient safety strategy. Although the National Patient Strategy pertains to all sectors, this new strategy provides specific focus on primary care and sets out national and local commitments. View it at NHS England » The NHS Patient Safety Strategy
The latest blog from the PSC:
‘The Safety Gap must be closed’
People with sensory impairment face challenges and no more so then when it comes to managing health conditions with devices that are not designed for them and medicines they have difficulty using. I have been contacted by many patients with vision or hearing loss who experience...
The latest guest blog:
’How the National Joint Registry supports patients undergoing surgery’
At the heart of the National Joint Registry is an organisation that looks after the best interest of patients undergoing joint surgery. It does this by recording, monitoring, analysing, and reporting on the...
The latest blog from the PSC
‘The Safety Gap must be closed’
People with sensory impairment face challenges and no more so then when it comes to managing health conditions with devices that are not designed for them and medicines they have difficulty using. I have been contacted by many patients with vision or hearing loss who experience...
Implementing Martha’s Rule
As Martha’s Rule is introduced into the health system, colleagues who have pioneered the initiative in the UK and globally outline their experience in a series of blogs.
Demos head Polly Curtis, a member of the Martha’s Rule oversight group, outlines her involvement in the group.
I am the chief executive of Demos, a cross-party think tank that works to put people at the heart of policy making to improve how policy is developed as well as trust in politics. Think tanks sit outside government and are hives of ideas of how to improve the country, so it is…
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