This strategy sits alongside the NHS Long Term Plan (LTP) and the LTP Implementation Framework. Local system plans to deliver the LTP will include local elements of the strategy: opportunities to improve patient safety are greatest at the point of care. NHS England and NHS Improvement regional teams will support delivery. It is human to make mistakes so we – the NHS – need to continuously reduce the potential for error by learning and acting when things go wrong. In this spirit, we will report progress against this strategy annually and update it as needed.
Patient safety has made great progress since the publication of To err is human 20 years ago but there is much more to do. The NHS does not yet know enough about how the interplay of normal human behaviour and systems determines patient safety. The mistaken belief persists that patient safety is about individual effort. People too often fear blame and close ranks, losing sight of the need to improve. More can be done to share safety insight and empower people – patients and staff – with the skills, confidence and mechanisms to improve safety.
Addressing these challenges will enable the NHS to achieve its safety vision; to continuously improve patient safety. To do this the NHS will build on two foundations: a patient safety culture and a patient safety system. Three strategic aims will support the development of both:
- improving understanding of safety by drawing intelligence from multiple sources of patient safety information (Insight)
- equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system (Involvement)
- designing and supporting programmes that deliver effective and sustainable change in the most important areas (Improvement).
The actions the NHS will take under each of these aims are set out below:
- adopt and promote key safety measurement principles and use culture metrics to better understand how safe care is
- use new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system
- introduce the Patient Safety Incident Response Framework to improve the response to and investigation of incidents
- implement a new medical examiner system to scrutinise deaths
- improve the response to new and emerging risks, supported by the new National Patient Safety Alerts Committee
- share insight from litigation to prevent harm.