Andrew Rochford: The importance of World Patient Safety Day
The World Health Organisation defines patient safety as 'the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with health care to an acceptable minimum' (1). Since 2019, World Patient Safety Day has been celebrated on 17 September, an annual ‘call for action’ on patient safety across the world.
‘An organisation with a memory’ (2) was published by the Chief Medical Officer, Sir Liam Donaldson in 2000, more than a generation ago. There have been so many technological advances during that time and considerable effort made to improve patient safety in the UK. For example, the National Early Warning Score (NEWS2) celebrated it’s 10th anniversary last December (3) and the revised National safety standards for invasive procedures (NatSSIPs 2) were published by the Centre for Perioperative Care in January of this year (4). However, the data remains stubbornly unchanged; around 1 in every 10 patients is harmed in health care and more than 50% of harm is preventable.
Medication-related harm affects 1 out of every 30 patients in health care, with more than a quarter of this harm regarded as severe or life threatening. Half of avoidable harm in health care is related to medications (5) and medication-related errors account for about 10% of reported incidents in the NHS. Work from the Medicines Safety Improvement Programme will be showcased in the Medicine+ conference this autumn.
This year sees the launch of the Patient Safety Incident Response Framework (PSIRF) and the Learn from patient safety events service (LFPSE). These changes are welcome but still rely on all healthcare professionals to be vigilant and proactive in reporting patient safety incidents. I encourage readers to look at patient safety information available on the NHS England website (6) as well as the resources on Medical Care Driving Change.
As a frontline clinician, The NHS has never felt so challenged. Demand is at an all-time high, the workforce demoralised and on-going industrial action suggests a winter of significant discontent. The Covid pandemic highlighted the stark reality of health inequalities and clinical outcomes; the on-going cost of living crisis continues to disproportionately affect those same communities the hardest. I would argue, therefore, that our need to focus on patient safety has never been greater.
- An Organisation with a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. Donaldson L. London, UK: The Stationary Office, 2000
- Clarke S. Celebrating 10 years of the National Early Warning Score. Clin Med (Lond). 2022 Nov;22(6):498
- Hodkinson A, Tyler N, Ashcroft DM, et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med. 202;18(1):1-3