Eddie Kinsella: Why patient safety must be special every day
World Patient Safety Day is a special event, but patient safety must be special every day. Healthcare systems are complex and current pressures on workforce and capacity increase the potential for things to go wrong. Sadly, there are still too many examples of adverse incidents and avoidable harm to patients, despite significant efforts to improve systems and processes for minimising risk in recent years. Each of those incidents may have a damaging consequence for the individual patient, their family, and often for the healthcare professionals involved.
Healthcare interventions by their very nature involve some degree of risk, but it is essential that informed decisions are made about the degree of risk and how such risk will be evaluated and managed carefully. In turn, that requires a true partnership between patients and clinicians, with shared decision-making at all stages offering the most valuable safeguard for all parties.
Patient-centred care is the bedrock of safe patient care. Patient-centred care requires effective engagement and communication between clinician and patient (and ideally includes families/carers too). Effective communication is best served by good listening skills, transparency, and honesty. Those attributes should be evident not only at an individual level, but also within every NHS organisation and across all parts of the healthcare system, including central government. In that way, an open, fair, and progressive learning culture can flourish, and everyone will be incentivised to take ownership for patient safety.
Sadly, a recent series of national scandals shows that we have a long way to go in the quest to achieve zero harm to patients. It is simply not acceptable at any level for patients and their families to be met with a culture of opaqueness, or even downright dishonesty, when seeking answers as to why loved ones have been harmed. It is equally unacceptable for a blame culture to prevail in any NHS organisation, as this acts as a very powerful disincentive to transparency and denies the opportunity for learning and improvement.
Strong partnerships between patients, families, and NHS staff offer the greatest prospect of achieving an effective patient safety culture, supported by safe systems and a commitment to continuous learning and improvement. The Royal College of Physicians and its Patient and Carer Network embrace that philosophy and work closely across the full spectrum of the patient safety agenda. A shared agenda, which has ownership by all parties, is the key to achieving the goal of ‘Do no harm’.
Further resources
Video
Using patient voice to improve medicine safety
PCN representative Cuthbert Regan and Jennifer Flatman discuss usefulness of the medication safety guide in hospital discharge.