Professor Don Berwick of the Institute for Healthcare Improvement (IHI), which he co-founded in Cambridge (Massachusetts), is expected to release plans to create a “zero harm” culture in the NHS in England today.
Prof. Berwick, being a world expert on patient safety, was asked by ministers to look at systems in the NHS in the light of problems at Stafford Hospital etc. His view is that no harm should be the norm in healthcare, as it is in the airline industry.
Triggle, N. (2013). Health safety expert to reveal ‘zero-harm’ NHS manifesto. London: BBC Health News, August 6th 2013.
This relates to:
Berwick Review of Patient Safety
This report highlights the main problems concerning patient safety in the NHS and makes recommendations. It was commissioned in response to breakdowns of care at Mid Staffordshire Hospitals. Key recommendations include:
- Recognise the need for systemic changes in NHS culture.
- Drop blame culture, and instead trust the goodwill and good intentions of staff.
- Recognise the importance of working with patients and carers to achieve results.
- Treat quantitative targets with caution. The primary goal is better care.
- Insist on transparency as being essential.
- Ensure that responsibilities for safety and improvement are clearly understood.
- Promote career-long learning for NHS staff, aimed at applying best practice, quality control, quality improvement and quality planning.
- Pride and joy in work should be motivators for NHS staff, not fear.
- Wilful or reckless neglect or mistreatment of NHS patients should be made a criminal offence; roughly equivalent to the offence which applies currently to vulnerable people under the Mental Capacity Act. Blame and fear do feature here somewhat, but presumably only as a last resort.
A promise to learn, a commitment to act: improving the safety of patients in England. National Advisory Group on the Safety of Patients in England. London: Department of Health, August 6th 2013.
A BBC commentary:
Triggle, N. (2013). How many reviews does the NHS need? London: BBC Health News, August 6th 2013.
NHS Safety Thermometer Data: July 2012 to July 2013
One year of data from the NHS Safety Thermometer is now available. The NHS Safety Thermometer is a measurement tool designed to support patient safety improvement by recording incidences of four harms:
- Pressure ulcers.
- Urinary tract infections (UTIs) in catheterised patients.
- New VTEs.
NHS Safety Thermometer: Patient Harms and Harm Free Care (England July 2012-July 2013). London: Information Centre for Health and Social Care, August 7th 2013.
[A brief reference to this item features in Dementia and Elderly Care: the Latest Evidence Newsletter (RWNHST), Volume 3 Issue 9, August 2013].
Safety Thermometer Data (October 2012 to October 2013)
The NHS Safety Thermometer is a local improvement tool for measuring, monitoring, and analysing patient harm and / or “harm free” care. The following document from the Health and Social Care Information Centre (HSCIC) presents data, to October 2013, from the NHS Safety Thermometer.
Safety Thermometer Data: October 2012 to October 2013. London: Health and Social Care Information Centre, November 2013.