Overview of patient safety

Patient safety is defined by NHS Improvement as ‘the avoidance of unintended or unexpected harm to people during the provision of healthcare’.

Since the inception of modern-day medicine, patient safety has been paramount. The phrase ‘first do no harm’ is often attributed to the Hippocratic Oath but the actual text from 2,500 years ago demands doctors to swear ‘I will utterly reject harm’. More recently, Florence Nightingale stated in her Notes on Nursing: What it is, and what it is not (published 1858) that ‘the very first requirement in a hospital is that it should do the sick no harm’.

When one examines healthcare in the current century in more detail, it would be fair to say that in the United Kingdom and at a global level the focus on patient safety has reached unprecedented levels. One only has to look at the NHS as a barometer to see how patient safety has taken centre stage over the last twenty years. In many ways the publication of An Organisation with a Memory by the Chief Medical Officer in 2000 popularised patient safety. Many relevant initiatives and documents have since followed, among them Lord Darzi’s Report High Quality Care For All (2008) that stated care must be ‘personal, effective and safe’ and Donald Berwick’s review into patient safety (2013) entitled A promise to learn – a commitment to act: improving the safety of patients in England.

Since the turn of the century and in recent times, patient safety has rarely been out of the spotlight. Sadly, over the last two decades the NHS has experienced a steady run of high-profile failures where patient safety has been willingly or unwillingly compromised: Bristol Royal Infirmary Inquiry, Shipman Inquiry, Morecambe Bay Inquiry, Francis Inquiry, Winterbourne View scandal etc. With the NHS increasingly under media scrutiny and patients encouraged to seek legal representation, it is not surprising that patient safety is top of the healthcare agenda and it is hard to see that ever changing in the future.

To help try to make healthcare safer, the NHS has spent significant sums of money setting up many bodies and initiatives over the last two decades. In many ways the creation of the National Patient Safety Agency in 2001 was the standard-bearer for what has followed since. The purpose of the NPSA was to reduce risks to patients receiving NHS care and to improve safety. The NPSA used data from the National Reporting and Learning System to identify key trends as well as creating many resources and training opportunities.

It is impossible to list all the various initiatives set up in the NHS since the creation of the NPSA in 2001 but patient safety alerts, national clinical audits and revalidation have all been designed to identify problems, raise standards and make care safer. Many former and current NHS bodies have also had patient safety firmly in their sights including: NHS Institute for Innovation and Improvement, Central Alerting System, Academic Health Science Networks, NHS Improvement and the Care Quality Commission.

Data indicates that reporting of patient safety incidents continues to rise. Certainly, during the last decade healthcare professionals have been encouraged to report incidents and raise concerns. As more and more emphasis is placed on patient safety one would expect reporting of incidents to continue to grow especially in light of Duty of Candour regulations and the introduction of Freedom to Speak Up Guardians. While increased reporting of incidents is vital in helping the NHS to understand why mistakes happen and to learn from them, we should not underestimate the scale of the task at hand. In 2013, Don Berwick (pictured above) and his team conducted a detailed review of patient safety in the NHS and concluded that the NHS must place the quality of patient care, especially patient safety, above all other aims.

Following on from the work of Berwick and his team, in 2018 the NHS carried out a major consultation of all stakeholders to find out views on how patient safety investigations are conducted. This culminated in the publication of the Patient Safety Strategy in 2019, available here. The new strategy represents a landmark shift in terms of how patient safety is managed within healthcare teams with more focus on understanding systems / human factors and a move away from blaming individuals. Going forward the emphasis will be on learning and improving, plus getting patients and family members much more involved.

The Patient Safety Incident Response Framework (PSIRF) was trialled by over 20 early adopter sites before publication of many documents in August 2022. PSIRF is unquestionably the biggest change to how patient safety will be managed in the NHS since its inception in 1948 and all Trusts are expected to implement PSIRF and phase out the Serious Incident Framework.

There are lots of ways to find out more about PSIRF and CASC have contributed to these:

  • Short film on the importance of PSIRF, click here
  • Access NHS England documents and resources on PSIRF, here
  • Read a short CASC blog detailing how we created a PSIRF poster, click here

Despite all these recent national reviews and initiatives, it is disappointing to see more recent examples of system failures and very poor care. 2022/23 has been a particularly turbulent time with focus on Donna Ockenden’s (pictured above) report into maternity care at Shrewsbury and Telford NHS Trust (2022), Dr Bill Kirkup’s review into maternity and neonatal services in East Kent (2022) and the damning verdict on the crimes of Lucy Letby at Countess of Chester Hospital NHSFT (2023).



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