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Patient safety in the NHS

Patient safety improvements

After the publication of Robert Francis' report on the Mid-Staffordshire public inquiry, the Berwick Report into patient safety in the NHS, and the government's response to the Francis Report, Hard Truths, a range of initiatives are being put in place to support patient safety improvements in the NHS. 

The Patient Safety Collaborative Programme

This programme will see 15 localised teams – also known as collaboratives – spread across the country, with people from inside and outside the NHS working together to build local learning systems.

These teams will be capable of continually improving care on the front line, reducing the likelihood of harm to patients. NHS England is investing £60 million over five years to support these collaboratives.

For more information, read the blog about this programme by Dr Mike Durkin, national director for patient safety.

Patient Safety Thermometers and other patient safety measures

As well as recording pressure ulcers, blood clots, harmful falls and urinary tract infections associated with catheters, new "next generation" safety thermometers are being developed to look specifically at medication safety, mental health services safety, maternity services safety and paediatric services safety.

The NHS is also exploring new ways of measuring and learning about safety in general, including using a process of reviewing patients' medical notes to measure how often problems in care happen, how preventable they are, what harm (if any) is being caused, and what can be done to make improvements.

Patient safety priorities

A national programme is currently being developed to tackle patient safety issues that have been identified. It will include work to tackle: 

  • acute kidney injury (AKI)
  • caring safely for the acutely ill elderly
  • avoidable deterioration of patients
  • problems associated with patients being discharged
  • falls
  • problems with the process of handover of patients from one team to the next
  • healthcare-associated infections
  • medication and device errors
  • mental health care safety
  • pressure ulcers
  • problems with the transition between children and young people's care to adult care
  • venous thromboembolism (VTE)  avoidable blood clots

Sign up to Safety

Sign up to Safety is a new campaign with the ambition to make the NHS the safest healthcare system in the world, halving avoidable harm in the NHS over the next three years and saving 6,000 lives as a result.

The campaign is for everyone working in the health system. Organisations are asked to develop a plan that describes how they can contribute to this ambition, and individuals can also pledge their own personal action to reduce the causes of avoidable harm. 

Visit the Sign up to Safety campaign website.

The National Patient Safety Alerting System (NPSAS)

In January 2014 the new National Patient Safety Alerting System (NPSAS) was launched to strengthen the rapid dissemination of urgent patient safety alerts to healthcare providers via the Central Alerting System (CAS).

This alerting system also provides useful educational and implementation resources that support providers, helping them put appropriate measures in place to prevent harm, as well as encouraging and sharing patient safety best practices.

The alerting system comprises three stages:

  • stage one alert: warning – warns organisations of emerging risk; it can be issued very quickly once a new risk has been identified to allow rapid dissemination of information
  • stage two alert: resource – provision of resources, tools and learning materials to help mitigate risk identified in stage one
  • stage three alert: directive – organisations are required to confirm they have implemented specific actions or solutions to mitigate the risk

Learn more about patient safety alerts on the NHS England website.

The National Reporting and Learning System (NRLS)

The National Reporting and Learning System (NRLS) was established in 2003. The system enables patient safety incident reports to be submitted to a national database. This data is then analysed to identify hazards, risks and opportunities to improve the safety of patient care. More than four million incident reports have been submitted by healthcare staff since the NRLS was established.

In April 2010 it became mandatory for NHS trusts in England to report all serious patient safety incidents to the Care Quality Commission (CQC) as part of the CQC registration process. To avoid duplication of reporting, all incidents resulting in death or severe harm should be reported to the NRLS, who will then report them to the Care Quality Commission.

Find out more on the NRLS and NHS England websites.

Every report of death or severe harm is reviewed by clinical and patient safety experts within NHS England to spot trends, specific incidents of concern, or emerging risks to patient safety.

These reviews can then trigger a wider analysis of all related lower harm incidents in the NRLS, leading to actions to reduce the risk of harm. This is either done directly through a Patient Safety Alert or through sharing information with other organisations, who can use it for developing safety advice or clinical guidance.

Where any particular local safety concern is detected, processes are in place via NHS England area teams to seek assurance that the issue is known to the providers involved and their commissioners, and is being addressed.

Surgical Never Events Taskforce

Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures are implemented. They include incidents such as:

  • wrong site surgery
  • retained instrument post operation
  • wrong route administration of chemotherapy

The Surgical Never Events Taskforce was commissioned in 2013 to examine and clarify the reasons for the persistence of these patient safety incidents, and to produce a report making recommendations on how they can be eradicated.

This report was published in February 2014, and NHS England has now started work to consider how its recommendations can be put into practice and what resources are required.

Learn more about the taskforce's findings and next steps on the NHS England website.

Page last reviewed: 24/06/2014

Next review due: 30/09/2016