A promise to learn, a commitment to act

The NHS has made significant improvements in patient safety in recent years – hospital rates of MRSA are 24% lower than they were in 2011; pressure ulcers are 22% lower compared to the same time last year (August 2012), while injuries from falls decreased by 18% over the same period.1 Despite this progress, there have also been examples of high profile cases where hospitals have failed to deliver safe, dignified care for patients. Most notably, the events at Mid Staffordshire have prompted a need to examine how lessons can be learnt and identify how other healthcare organisations can avoid making the same mistakes. A more recent investigation of Trusts with high mortality rates, by NHS Medical Director Sir Bruce Keogh, identified a number of problems shared across the 14 ‘outlying’ organisations. These included: a failure to act on data or information that showed cause for concern, the absence of a culture of openness and a lack of willingness to learn from mistakes. All but two Trusts had ‘never events’ i.e. serious, largely preventable patient safety incidents that should not occur. However, of particular concern was the fact that a number had multiple never events relating to similar themes, such as retained foreign objects post-operation, where the investigating team were not assured that lessons had been learnt in response. As part of the Government’s response to the issues of patient safety, identified in these high profile investigations, Professor Don Berwick, a renowned international expert in patient safety, was asked by the Prime Minister to conduct a review. The resulting report, A promise to learn – a commitment to act: the Safety of Patients in England, was published in August this year, following five months of intensive work to examine the lessons for NHS patient safety from healthcare and other industrial systems throughout the world. Led by Prof. Berwick, the National Advisory Group on the Safety of Patients in England concluded that patient safety problems exist throughout the NHS, as with every other healthcare system in the world, but NHS staff are not to blame. In the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems. “In any organisation, mistakes will happen and problems will arise, but we should not accept harm to patients as inevitable. By introducing an even more transparent culture, one where mistakes are learnt from, where the wonderful staff of the NHS are supported to learn and grow in their capacity to improve the NHS, and patients are always put first, the NHS will see real and lasting change,” commented Prof. Berwick. The report identifies a number of key areas that need to be addressed in order to drive improvement in the safety of patient care:

Patients first: A key message of the report is that ‘incorrect priorities cause damage’. It warns that quantitative targets should be used with caution. While such goals can have an important role en route to progress, they should never displace the primary goal of better care. The central focus must always be on patients. Patients and carers must be empowered, engaged and heard. In some instances, including Mid Staffordshire, clear warning signals were not heeded – especially the voices of patients and carers. Complaints systems also need to be continuously reviewed and improved.

Culture of learning: The advisory group further emphasised the need for staff to be supported to develop themselves and improve what they do. The report states that the NHS needs to adopt a culture of learning – this cannot come from regulation, but from ‘countless, consistent and repeated’ messages to staff, so that goals and incentives are clear and in patients’ best interests. The mastery of quality and patient safety sciences and practices should be part of the lifelong education of all healthcare professionals, including managers and executives.