Jonathan Hazan Blog - The Launch of Patient Safety Learning

  • 19th October 2017
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By Jonathan Hazan

Patient Safety Learning was launched at an event at the King’s Fund in London on 21 September 2017.

The launch event was the result of many conversations between me and members of our steering group.

For me, personally, the seeds of Patient Safety Learning were sown many years ago. Working in the field of incident reporting and learning for so long has of course meant that everything I have done in my career has been linked to patient safety. Because of the nature of Datix, most of my dealings had been with healthcare providers. But an important part of my understanding of safety came when I first met some of the people who were directly affected by the issues that we are now trying to focus on.

Now with the launch of Patient Safety Learning, I am pleased that some of these people are on our steering group and I was also delighted that they were able to attend our launch event. It is important that we have the participation of academics, clinicians and other specialists in patient safety. But it’s equally important that we involve patients, relatives and healthcare workers whose lives have been changed by safety issues.

That’s why our keynote speech was given by Julie Bailey, who lost her mother Bella in the Mid Staffordshire disaster and who has done so much to change the healthcare landscape so that patient safety has been given the prominence it deserved. I also felt honoured that some of the other Mid Staffs families were able to attend the event. I’m pleased to report that Julie has accepted our invitation to join our steering group and she will be an important voice ensuring that the needs of patients and families are foremost.

A key element of Patient Safety Learning’s work will be working with healthcare providers to ensure that patients and families are treated appropriately when an incident occurs and are given the opportunity to be fully involved in investigations and quality improvement work. Murray Anderson-Wallace has produced a series of podcasts with us on this topic and he spoke about this project at our launch event. The podcasts are available on our website and are well worth a listen. Murray made the point that previous patient safety initiatives have not been radical enough and we are fortunate that he is on our steering group.

Representing another strand of our work, Alison Leary spoke about how the data from local Datix systems can be used to bring about real improvements in care. For some time, I have been concerned that organisations have not been making the best use of the data in their Datix incident reporting systems and local systems contain a vast seam of untapped data that could be used to great effect. Alison and her team have shown that the data from Datix can be used for effective workforce planning, ensuring that the right numbers of staff are deployed to improve safety in the right areas at the right time. We will be doing more projects of this type to help healthcare providers get the greatest possible value from incident reporting data and we are pleased that Alison is on our steering group to help with this.

Maria Dineen is another member of our steering group and she gave a talk on her approach to patient safety investigations. Too many investigations are done poorly, using inconsistent methods, and come up with recommendations such as “rewrite the policy” or “train staff”. Maria’s methods are highly practical and focus on results. Findings such as “Staff failed to follow the policy” are replaced with far more detailed analyses. An excessive reliance on “action plans” was highlighted by Robert Francis in his inquiry report and replacing actions with objectives is a way of avoiding this and making sure that improvements actually occur as a result of incidents. Improving the way people carry out investigations will be a key area of our work at Patient Safety Learning and we are delighted to have Maria work with us on this.

There are many important patient safety improvement projects happening throughout healthcare and social care, but most of these are done at a local level in individual organisations. Some of them have been shown to have a real impact, but too often they stay in the local organisation and others cannot benefit from them. At our launch event, we showcased another important element of our work, which is to facilitate the sharing of improvement projects on a national and international basis. Carl Macrae, another member of our steering group, is leading this work, but he was unfortunately unable to attend, so Charles Vincent stepped in at the last minute to talk about this project.

The speakers at our launch event represented the different facets of the work of Patient Safety Learning and the presentations were well received. There is much work to be done, but we are confident that with our excellent steering group and initial support from Datix to help get us off the ground, we will be able to achieve some great things.


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