Title: Patient Safety: Sixth Report of Session 2008–09: Volume I: Report, together with formal minutes

The Skinny: Identifies the need for improved patient safety systems in the NHS and emphasises that this should be the first consideration of NHS organisations.

Recommends:

• Measurement and evaluation using samples of patients’ case notes at periodic intervals to calculate rates of harm. (Trusts, NPSA)
• NHS organisations must recognise it is key that harmed patients and their families or carers are seen to be entitled to receive information, anexplanation, an apology and an undertaking that the harm will not be repeated.  PALS should be utilised as an independent service. The NHS Redress Scheme should be implemented to reduce litigation. (DH, Tusts)
• Develop an an open, reporting and learning NHS. NRLS collects large amounts of data but it is clear there is underreporting.  This is a result of the blame culture in the NHS.  Summary data from NRLS needs to be more avaialable. (NPSA)
• Clinical engagement and effective staffing levels must be in place to implement patient safety measures (Trusts).
• Technologies such as Automated decision support systems, Automatic Identification and Data Capture technology, and electronic patient records can help. (Trusts)
• Medical curricula must include, clinical pharmacology and therapeutics, diagnostic skills, non technical skills and root cause analysis and improve current provision in these subjects.
• Commissioning, performance management, and regulation should ensure the
  quality and safety of those services.  Report expresses concerns about PCTs abilities to do so.  DH should define the performance management role of SHAs.  there needs to be clarity on the relationship between commissioners, performance managers and regulators. (PCTs, SHAs, Regulators)
• Boards and managers need to focus on patient safety, specialist training should be implemented especially for Non-Executive Directors.
• Patient safety must always be the first priority regardless of other targets and initiatives the DH and Governemnt must provide leadership to ensure all recommendations are implemented and an effective fair blame culture that encourages responsible whistleblowing is in place in the NHS.

Publisher: TSO

Size of Document: 120p

Published: 03/07/2009