Andrew Rochford: World Patient Safety Day 2024

I am writing this blog from my ‘sick bed’ at home 8 days after an elective total hip replacement. 30 years ago, I would have been hospitalised in a brace for 2-3 days and discharged home for several days ‘bed rest’. Now, in certain – I suspect non-NHS - centres, you can get a 3D printed hip inserted using robotic surgery and be discharged the same day. (For the inquisitive, I had a traditional lateral approach and was discharged the following day). Today, I have walked to the high street and read a paper over a coffee. Despite all the criticism, the modern-day NHS is incredible, when it works. However, I recognise that I am extremely fortunate, my physical health was good pre-operatively and I did not have to wait too long on the waiting list for my procedure. We know that this is not common and there are over 6 million individual patients on a variety of waiting lists at the moment.

Patient safety should be at the heart of all that we do as clinicians and yet the ‘noise’ in the system makes it harder rather than easier, and we remain a long way from having a patient safety culture embedded within the NHS. For example, I was interested that there was more focus on me being discharged having removed my TED stockings (‘they’re a drug and they’re not on your discharge medication list’) than there was on counselling me on the importance of the safety alert card for Rivaroxaban. My personal experience reminded me of the value of the RCP’s Medication Safety Discharge checklist.

Lord Darzi’s independent investigation of the NHS in England recognised that improvements have been made in patient safety; notably a reduction in avoidable harm such as pressure ulcers and an overall increase in error free care. But the report also pointed out that healthcare associated infection rates have plateaued (after a period of improvement), and the incidence of venous thromboembolic events have yet to return to pre-pandemic levels. We also know from work published by the Royal College of Emergency Medicine that the very serious delays we experience every day in urgent and emergency care can be directly associated with mortality. Furthermore, there has been significant focus on patient safety in maternity services in recent years that are acknowledged in the report. Lord Darzi highlights that this is not simply a matter of insufficient workforce capacity, and he includes an excellent summary of the situation from Dr Bill Kirkup that is supported by published evidence:

• Pressure and stress are at high levels which contributes to poor morale. This leads to burnout, absenteeism, high turnover, and the loss of trained staff. This dynamic impairs patient safety.
• Training in silos impairs teamwork which compromises patient safety. This is partly a result of divergent curricula for different staff groups that damage attitudes and a lack of focus on learning the skills for teamwork.
• Unstable working patterns and the lack of rest space impair teamworking and morale. Having dedicated space and refreshments benefits staff and improves patient safety.
• Leadership is crucial particularly Clinical Directors, but the Clinical Director role is poorly developed, supported and managed.
• Capacity for compassion is variable, sensitive to environment and pressure, but can be systematically improved.
• Transgressive behaviour is more common than admitted, which is very difficult to deal with, and damaging to morale and patient safety.
• Response to safety incidents is dominated by personal reactions; fear of blame by colleagues and others is a significant disincentive to investigation and learning; a culture of openness is essential to patient safety, but often lacking.

One of the key actions for the RCP’s Patient Safety Committee this year is to investigate how and why the NHS consistently struggles to learn from patient safety events; a piece of work that has been raised by our Patient Carer Network.

The scale of the challenge was highlighted for me by the Health Services Safety Investigations Body (HSSIB) report last year on retained swabs from invasive surgical procedures. The risks of retained swabs has been a patient safety issue since before 2010 when the National Patient Safety Agency published a rapid response report for retained swabs in maternity services (summarised in a BMJ article). It is clear from the HSSIB report that, more than a decade on, we have yet to learn and embed systems to consistently and reliably avoid harm. HSSIB recognises this and has released their own review of the situation in time for World Patient Safety Day which I highly recommend that you read. I would also recommend a recent publication from the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) which looks at key themes from all its reports. It highlights the importance of communication with patients, families and carers and that documentation, multi-disciplinary review, and early warning score monitoring are commonly inconsistent and inadequate.

On World Patient Safety Day 2024 I urge you to reflect on your own practice and that of your team. History suggests that it is individuals and teams who have the greatest opportunity to improve patient safety. While the RCP and others lobby for systemic change please support each other to ‘get it right, make it safe!’.