Today (17 September) marks the first World Patient Safety Day, an important initiative led by the World Health Organisation. The slogan for the day is ‘Speak up for Patient Safety’.
Creating a culture where staff are empowered to speak up is important. Equally important to keep patients safe, is that serious incidents – and the complaints that often follow them – are treated as an opportunity for learning.
NHS organisations and their staff must take accountability for making improvements to patient safety. But accountability has too often been taken to mean ‘blame’. If staff fear being blamed, it is much harder to understand what went wrong, why, and how to reduce the chances it will happen again.
The importance of learning from mistakes
Sadly, our investigation reports frequently illustrate the negative impact that repeating rather than learning from mistakes can have on patient safety.
One example is the case of Mr R, who was admitted to a mental health ward in Chelmsford, Essex on 7 December 2008. He died 20 days later after staff found him in an unresponsive state in his room at the Linden Centre, in what was then the North Essex Partnership NHS Foundation Trust.
Four years later, in November 2012, another 20-year-old man was admitted to the Linden Centre. Like Mr R, this young man also died shortly after his admission to hospital. Again, staff found him in an unresponsive state in his room.
At North Essex Partnership NHS Foundation Trust, learning from serious incidents did not take place, so mistakes and system failures were repeated. Our investigation report, Missed Opportunities, found that at least ten investigations, inspections and inquests were carried out before the Trust started to make measurable improvements in the safety and quality of care.
Creating a culture of positive accountability
Our 2016 report, Learning from Mistakes, focused on the learning to be taken from the tragic death of a three-year-old boy from sepsis in 2010. The report highlighted the need to end the fear among NHS staff that they would be punished or their reputation would be damaged as an immediate consequence of admitting that an error may have occurred.
To do this requires a culture of positive accountability where staff feel confident to speak up and find out what went wrong. Whether the cause was human error, system failure, or both, organisations and staff can then take action to reduce the chances that the same thing will happen again.
Positive accountability starts with being willing to accept that something might have gone wrong. It means:
- being open to inviting and listening to the experiences of the other people involved – including patients, their families and carers – to understand what happened
- using that process as an opportunity to learn and taking steps to use that learning to improve care
- measuring the impact of those improvements, so patients and staff can be assured that learning truly has taken place and patient care is safer.
An essential step towards improving patient safety
It is too early to say why learning and accountability did not take place at North Essex Partnership NHS Foundation Trust. NHS Improvement will be carrying out a review of what went wrong at the Trust and the learning that can be taken from this.
What is clear, though, is that learning and accountability do not have to be in opposition. In fact, the quality and safety of NHS care services are more likely to improve following a serious incident or complaint if learning and accountability go hand-in-hand.
World Patient Safety Day is an opportunity to shine a light on creating a 'learn not blame’ culture as an essential step towards improving patient safety.
Find out more about World Patient Safety Day.
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