The updated Patient Safety Commissioner strategy, which I published in January, sets out 3 main aims:
- for patients to be seen as partners in a safety management system
- for patient voices to be included in their own care, and
- for patients to be included in the design and delivery of healthcare.
In our business plan for 2024/25 we are focusing on each of these areas. For the health system to work as a safety management system, it requires each part of the system to have a good understanding of the whole.
There are multiple organisations supporting patient safety of different sizes and remits and these may even be contradictory or overlapping. Without a comprehensive guide to these patient safety organisations, we risk each part saying that they have done their bit when patients continue to fall between the cracks. That is why we are going to create the Patient Safety Atlas of Powers to make it clear to the healthcare system which powers already exist and to set out the remits of each organisation.
We are also going out to public consultation on the Principles of Better Patient Safety to bring together and update the existing principles that have been set out by different parts of the healthcare system so we can have one overarching set of principles that bring the system together.
We are also considering the harms that happen through medication errors, with an estimated 237 million each year in the NHS. A handful of organisations have implemented Closed Loop Medicines Administration so that the right medicine is given to the right patient at the right time. They have seen substantial reductions in medication errors and if scaled up across England, this could have a huge impact on reducing harm to patients but also an impact on the workforce by freeing up time to care and on finances due to reduced length of stay and fewer hospital admissions.
When it comes to patients’ voices, we want patients to be at the center of their own care as well as partners in the design and delivery of healthcare. The Whitehead Review on health inequalities demonstrated that if we don’t take all patients’ views into account, there is a significant negative impact on patient outcomes. Patients with accessibility needs, whether due to sight loss, hearing loss or other needs, can face greater barriers to accessing safe healthcare. So we are going to explore what how the health system can help to overcome these barriers.