To celebrate World Patient Safety Day 2024, which this year focused on improving diagnostics for patient safety, I spoke with and learned from global patient safety leaders at the Patient Safety Movement Foundation, the World Health Organisation, the Women in Medicine International Network, and the HSJ Patient Safety Congress.
During this time Lord Darzi published his report into the state of the NHS in England.
Many of his themes were echoed by global partners: deficiencies in listening to patients and families, a shortage of healthcare staff, productivity restricted by layers of protocols, and incorrect and delayed diagnosis. Patient safety is held back by invisibility, inertia and income by health boards and national bodies in a degraded system.
It is a huge mistake to ignore the voices and views of patients, who are the largest immobilised workforce out there, and working in partnership with patients improves care and keeps people safe. Patient feedback is gold and we need to work out how to mine it. Staff face barriers to sharing information including the discomfort of discussing diagnostic errors and the shame and silence when incidents occur.
Harm scars patients and clinicians, it knocks our confidence, making us feel like personal failures. So patient harm is cloaked in obscure language such as known complications, iatrogenic harm and hospital acquired, making it difficult to compare international patient reported outcomes. The presence of secrets mean that organisations are not transparent and there is no learning or improvement so harm persists and there is a lack of accountability.
Apart from the cost to lives and to patients and families, the cost of harm to the economy is something everyone should be talking about. Preventable harm costs 1% of GDP. Harm caused by medication errors leads to 16% of hospital admissions and costs £2 billion annually in England alone.
But we are changing the paradigm in England with the introduction of Martha’s Rule. We are shifting the power balance towards people and communities, as my role was established to do. We are amplifying patients’ voices in PSIRF and the National Patient Safety Strategy. What is missing is accountability – we need a clear line of sight when decisions are made, a thread of accountability that can be followed back to the source. The decisions that are being made today in Westminster, Whitehall, Wellington House, in the board rooms, wards and in community services will impact on patient safety for good or ill. Each decision risks removing a strand from the thread, not immediately obvious as the source of future harm, but removal of further strands means the thread will someday snap.
After listening to the experience of patients I have retraced some of these threads in neurology and psychiatry services with valproate prescribing and with women’s health leaders about painful outpatient procedures. The threads have led me to some unexpected places where decisions made without an evidence base and without patients at the table have been adopted as standards and have led to untold harm. And the people whose decisions weakened the system hold no accountability, are not aware of this and do not take responsibility.
Across the world, all agree there are no quick fixes and no one thing that can be done to put this right. If we are going to shift the paradigm, we need to widen our horizon and reject the status quo.
We must move from paternalism to partnership. If we want radical transformation of healthcare, we need global cooperation on safety. How would healthcare look if it followed the route of Spotify? With global cooperation to set global standards of care, available to everyone in real time on the cloud and always up to date with the best evidence? Where payments are only made when best practice is followed? Where we remove the barriers to communication by removing outdated titles such as ‘doctor’? Where we use AI to help improve diagnosis, accuracy of documentation, provision of information to regulators, free up senior leadership time and apply the duty of candour.
The Darzi report highlights healthcare problems which are the same around the world. If we can learn from global partners, achieve global cooperation, and tackle patient safety by working in partnership with patients and staff, we can create a new and safer system for the future. It is up to us.
Here are the problems – it is up to us to solve them, Here are the opportunities – it is up to us to seize them.