Eleanor’s blog – February 2014

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In January Dr Mike Durkin, NHS England National Director of Patient Safety, launched a year of action for patient safety. This focus on patient safety is in response to the recommendations from both the Francis report and Professor Don Berwick.

Both Sir Robert Francis and Jane Cummings, the Chief Nursing Officer for NHS England, emphasised the central role that patient safety plays in health and social care, when they were interviewed on the Radio 4 Today programme on Thursday 6th February. Jane Cummings particularly emphasised the importance of taking into account the needs of patients and ensuring that the staff caring for them had the right attitudes as well as the right level of knowledge, skills and expertise to ensure patient safety. Her concern was the risk to patient safety if there was an over reliance on a formulaic approach which focused on numbers of staff on shift regardless of the circumstances.





The first priority is setting up 15 localised patient safety collaboratives. Collaboratives will be about continuous learning with a focus on potential ways to make care safer and will be inclusive, bringing together a wide range of people from both inside and outside the NHS, as well as patients, relatives and carers. Solutions for improving care will be shared locally and nationally so we can all benefit.

What do we mean by patient safety? Well anything related to patient care that makes care safe and which minimises the potential risks to a person’s wellbeing. For example, ensuring systems and practices maintain the required standards for the administration of medication to minimise errors (giving the wrong drug or dosage) or omissions (forgetting to give medication); minimise risks related to slips, trips and falls; ensure high quality and safe standards of care are consistently applied to reduce the incidence of avoidable infections (e.g. catheter related urinary tract infections), pressure ulcers, harm or abuse or other failures of care.

Not acting in ways that minimise risks to patient safety has consequences for all involved. For the person this might be delays in receiving appropriate treatment, avoidable pain, distress, discomfort, medical interventions or additional time receiving care. For organisations the consequences can be additional costs resulting from longer treatment times, more complex and protracted interventions and potential litigation. In addition it can result in a loss of patient confidence, a loss of reputation which can lead to an inability to recruit and retain staff and a reduction in the services they can provide to the local population, all of which can make the situation worse.








Although the patient safety initiative is NHS led it also applies to social care. It is clear that with an aging population with increasingly complex needs for care to be effective, an integrated health and social care approach is a necessity. Integrated working will mean practitioners will need to dissolve artificial boundaries, broaden their thinking and start valuing the knowledge and skills that each can bring to effective solutions for patient care.

Learning together through the patient safety collaboratives will hopefully act as an effective catalyst to stimulate this cultural shift and a greater level of person-centred care where the person is truly at the heart of everything.

So patient safety: it’s everyone’s business and responsibility whatever their role within an organisation.

It’s about putting the person at the forefront of our thinking and actions – considering what is in their best interests, and doing everything we can to ensure their comfort and wellbeing.

It’s about listening to and acting upon what people/patients/relatives/colleagues tell us as well as those often seemingly ‘throwaway’ remarks they make in passing because they don’t think they are important or don’t think that anyone else will consider them important

It’s about being alert and observant, recognising changes in the person/patient’s condition no matter how small or seemingly insignificant. For example, looking carefully for redness to ensure there is early recognition of risk, action and/or treatment to avoid the development of pressure ulcers; careful administration and recording of medication; undertaking accurate recording, reporting and interpretation of patient observations so potential problems are identified early with appropriate interventions instigated.

It’s about working as part of a team to promote and lead patient safety at whatever level you work at in an organisation. That means doing the right thing and speaking up when you identify a risk, an ineffective system or practice or a better way of doing something. For example, ways to improve catheter care to minimise the risks of infection.

It’s about committing to continuous learning and improvement to maintaining the right of every person to receive care safely
Find out about how you can become a leader in patient safety in your workplace and about getting involved in the work of your local collaborative.
Remember one day you or someone you love could be a patient and you would expect to receive care that was safe and of the best quality. The people in your care are no different so honour their trust in you and your organisation and make a commitment to make a difference, no matter how small, today and everyday……

So until next time…..