In this blog to mark World Patient Safety Day 2023, Patient Safety Learning sets out the scale of avoidable harm in health and social care, highlights the need for a transformation in our approach to patient safety and considers the theme of this year’s World Patient Safety Day, ‘Engaging patients for patient safety’.
Today is the fifth annual World Patient Safety Day, one of the World Health Organization’s (WHO’s) official global public health days established in 2019 by the 72nd World Health Assembly.[1] Its aim is to increase public awareness and understanding of patient safety and encourage actions by governments, organisations and individuals to reduce avoidable patient harm.[2]
Avoidable harm in health and social care
What do we mean by patient safety?
Simply put, patient safety is concerned with avoiding unintended harm to people during their care and treatment. WHO describes this as follows:
“Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviours, technologies and environments in health care that consistently and sustainably lower risks, reduce the occurrence of avoidable harm, make error less likely and reduce its impact when it does occur.”[3]
Modern healthcare is increasingly complex and there are many ways that avoidable harm can occur during care and treatment —it is estimated that one in every ten patients is harmed while receiving hospital care.[4] This harm can be caused by a range of patient safety incidents, and more than 40% of these incidents are preventable.[5]
NHS England has stated that prior to the Covid-19 pandemic, there were around 11,000 avoidable deaths in the UK annually due to safety concerns, with thousands more patients seriously harmed.[6] However, in practice this figure is likely to be a serious underestimate, particularly as the situation has worsened due to the of impact of post-Covid pressures on primary care, social care and hospital care.[7]
Reducing avoidable harm should be a top priority for governments, organisations and individuals for a number of reasons. Firstly, every avoidable death and disability is an unnecessary tragedy for patients, families and healthcare professionals. In addition, patient harm comes at a huge financial cost, with the Organisation for Economic Co-operation and Development (OECD) estimating that in high-income countries the direct cost of treating patients who have been harmed during their care approaches 13% of health spending.[8] Excluding safety lapses that may not be preventable, this figure is 8.7% of health expenditure.[9]
Patient safety as a core purpose
Given the scale and awareness of avoidable harm in health and social care, why does it continue to persist?
The need to make significant improvements to patient safety is well-established in health and social care. However, despite this knowledge, and the hard work of many people involved in the sector, avoidable harm continues to persist at an unacceptable rate. Avoidable harm in healthcare is driven by our failure to address the complex systemic causes that underpin this.
In our report, A Blueprint for Action, Patient Safety Learning sets out the need for a transformation in the health and care system’s approach to patient safety.[10] This outlines how too often, patient safety is typically seen as a strategic priority, which in practice will be weighed (and inevitably traded-off) against other priorities. To transform our approach to this, we believe it is important that patient safety is not just seen as another priority, but as a core purpose of health and care. Underpinned by systemic analysis and evidence, the report identifies six foundations of safe care of patients and practice actions to address them:
- Shared learning
- Professionalising patient safety
- Leadership
- Patient engagement
- Data and insight
- Culture
Engaging patients for patient safety
So how does engaging patients for patient safety fit into this?
The theme of this year’s World Patient Safety Day draws on one of the seven strategic objectives of the WHO Global Patient Safety Action Plan 2021-2030, ‘Patient and family engagement’. Setting out the importance of this for patient safety, it says:
“Patients, families and other informal caregivers bring insights from their experiences of care that cannot be substituted or replicated by clinicians, managers or researchers. This is especially so for those who have suffered harm. Patients, families and caregivers can serve as vigilant observers of a patient’s condition and can alert health care professionals when new needs arise. Given proper information, the patient and family can help to be the eyes and ears of the system.”[11]
At Patient Safety Learning, we agree with this sentiment, and identify patient engagement as one of our six foundations of safer care in A Blueprint for Action. We believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account.
To highlight the importance of engaging patients for safety, we have been sharing a range of different blogs, resources and interviews in the run up to World Patient Safety Day. They are centred around four different aspects of patient engagement which are outlined below.
Shared decision making at the point of care
A key objective of this year’s World Patient Safety Day outlined by WHO is to:
“Empower patients and families to be actively involved in their own healthcare and in the improvement of safety of healthcare.”[12]
When looking at reviews of patient safety incidents and experiences shared by patients after their treatment, far too often we find that patients are not being empowered in this way. In a blog for International Women’s Day earlier this year we specifically looked at one specific aspect of this, the impact of failures of informed consent in women’s health.[13]
As well as improving processes around consent prior to and during care and treatment, another key part of improving the way that patients are included in their care is by creating a far greater focus on shared decision making, the joint process where a healthcare professional works together with an individual to reach a decision about their care.
The Patient Information Forum (PIF) and the Patients’ Association published an important report on this in April, Removing barriers to shared decision-making.[14] Based on a co-production project which ran throughout 2022 in the Nottingham and Nottinghamshire Integrated Care Board, this report includes a set of recommendations for national action. Much work is still required to embed these principles across the health and social care system, along with the accompanying cultural change vital to implement them.
Engaging patients for system improvement
Patient experiences are a key source of patient safety insight. They are valuable in helping to identify patient safety problems, understand the causes of these issues and put in place measures to prevent them happening again.
In a new interview this week, we spoke to James Munro, Chief Executive of Care Opinion, the UK’s non-profit online feedback service for health and social care. In this he highlights the value of patient feedback in boosting morale and enabling organisations to make real patient safety improvements.[15] He also describes the power of the unique perspective patients have on safety and asks how we can use this insight to shift culture and provide safer care.
Care Opinion is just one of the routes through which patients can share their experiences of harm and make their voices heard. In a blog on the hub, Richard von Abendorff talks in more detail about other approaches, noting that:
“Safety improvement rather than simply complaining (often seen as an administrative process) is what so many patients and families most want to see so others do not suffer the same way as their loved one”[16]
As part of its Framework for involving patients in patient safety, the NHS have created a new role for patients to be involved in supporting and contributing to a healthcare organisation’s governance and management processes for patient safety, Patient Safety Partners.[17] Last month we published an account of a recent workshop run for Patient Safety Partners at Kingston Hospital, exploring the potential for these new roles and how they may develop over time.[18]
However, these different routes to contribute and gather patient insights are only effective if our health and social care system acts on them appropriately. In another interview on the hub, Jono Broad discusses how we approach involving patients and families at a system-level and some of the barriers and challenges to patient involvement and engagement.[19]
Engaging patients when things go wrong
A theme that emerges repeatedly in inquiries and reports into serious patient safety incidents is a failure to listen to patients, family members and caregivers when they raise concerns, and subsequently not involving them in investigations after harm has occurred.
In a new interview on the hub this week, we spoke to Derek Richford about how East Kent Hospitals University Foundation Trust and other agencies engaged with his family following his grandson Harry’s death in November 2017. As well as outlining how a culture of denial at the Trust affected his family, he talks about individuals and organisations that acted with respect and transparency. He also highlights what still needs to be done to make sure bereaved families are treated with openness and dignity when a loved one dies due to avoidable harm.[20]
The NHS has acknowledged that engaging patients and families after incidents of harm is an area that needs significant improvement, and emphasises its importance both in the the NHS Patient Safety Strategy and its new Patient Safety Incident Response Framework (PSIRF).[21] [22] While these policies and proposals contain a number of commendable ideas, translating them into practice remains the key challenge. To be successful, organisations will need resources, commitment and a willingness to proactively seek the insights of patients and families with lived experience.
Patients as advocates and campaigners
As highlighted in Derek’s interview, when avoidable harm occurs, too often health and care providers and regulators are slow to identify or act on patient safety concerns. In the Independent Medicines and Medical Devices Safety Review, Baroness Cumberlege noted the shocking degree of avoidable harm to patients over a period of decades, stating:
“… patients should not have to campaign for years or even decades for their voices to be heard. Patients should not have to find the evidence to say whether the treatments they are being offered are safe and will leave them better off than before. They should not have to join the dots of patient safety. But when they do just that, they deserve to be listened to with respect.”[23]
As we have seen in cases such as harm related to mesh surgery and major maternity scandals, such as the recent case of East Kent, we are often reliant on the persistence and tenacity of harmed patients and families to both highlight serious concerns and to prompt the subsequent patient safety investigations and inquiries that take place.[24] [25]
To underline the important role that patient advocates and campaigners play in improving patient safety, we spoke to three people campaigning for patient safety improvements:
- Sandra Igwe – CEO of The Motherhood Group
- Tim Edwards – campaigner for improvements in pulmonary embolism care and diagnosis
- Soojin Jun – co-founder of Patients for Patient Safety US
In a video, they each talk about their experiences of engaging with the system and the challenges they have faced, as well as offering advice for others seeking to campaign for change in healthcare.[26] The insights they share help evidence the need for healthcare organisations and frontline staff to work with patients, their families and campaigners to improve safety and reduce inequalities.
Share your experiences on the hub
This blog highlights some key issues that show the important role of involving patients for patient safety, what happens when this is not the case and where improvements can be made. However, this is not an exhaustive list and we are always keen to highlight and amplify voices on these issues.
- Are you a patient with experience around patient involvement or engagement for patient safety you would like to share?
- Or perhaps you are a healthcare professional looking to share your frontline insights to help improve patient safety?
You can share your thoughts with us by commenting below (sign up here for free first), submitting a blog, or by emailing us at [email protected].
References
[1] World Health Assembly, WHA 72.7 – Global action on patient safety, 28 May 2019. https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_R6-en.pdf
[2] WHO, World Patient Safety Day 2023: Engaging Patients for Patient Safety, 17 September 2023. https://www.who.int/news-room/events/detail/2023/09/17/default-calendar/world-patient-safety-day-2023--engaging-patients-for-patient-safety
[3] WHO, Patient safety – About us, Last Accessed 14 September 2023. https://www.who.int/teams/integrated-health-services/patient-safety/about
[4] WHO, Patient Safety, 13 September 2019. https://www.who.int/news-room/fact-sheets/detail/patient-safety
[5] de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA., The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216–23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569153/
[6] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. https://www.england.nhs.uk/patient-safety/the-nhs-patient-safety-strategy/
[7] WHO, Implications of the COVID-19 pandemic for patient safety: a rapid review, 5 August 2022. https://www.who.int/publications/i/item/9789240055094
[8] OECD and Saudi Patient Safety Center, The Economics of Patient Safety. From analysis to action, 21 October 2020. https://www.oecd-ilibrary.org/social-issues-migration-health/the-economics-of-patient-safety_761f2da8-en
[9] Helen Hughes, Improving patient safety: a financial imperative, Healthcare Financial Management Association, 17 May 2023. https://www.hfma.org.uk/news/blogs/blog-post/improving-patient-safety-a-financial-imperative
[10] Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. https://s3-eu-west-1.amazonaws.com/ddme-psl/content/A-Blueprint-for-Action-240619.pdf?mtime=20190701143409
[11] WHO, Global Patient Safety Action Plan 2021-2030, 3 August 2021. https://www.who.int/teams/integrated-health-services/patient-safety/policy/global-patient-safety-action-plan
[12] WHO, World Patient Safety Day 2023: Engaging Patients for Patient Safety, 17 September 2023. https://www.who.int/news-room/events/detail/2023/09/17/default-calendar/world-patient-safety-day-2023--engaging-patients-for-patient-safety
[13] Patient Safety Learning, Failures of informed consent and the impact on women’s health, 8 March 2023. https://www.patientsafetylearning.org/blog/failures-of-informed-consent-and-the-impact-on-womens-health
[14] Patient Information Forum and the Patients Association, Removing barriers to shared decision-making, April 2023. https://pifonline.org.uk/download/file/977/
[15] Patient Safety Learning, Patient Safety Spotlight Interview with James Munro, Chief Executive of Care Opinion, 12 September 2023. https://www.pslhub.org/learn/patient-safety-learning/patient-safety-learning-interviews/patient-safety-spotlight-interviews/patient-safety-spotlight-interview-with-james-munro-chief-executive-of-care-opinion-r10020/
[16] Richard von Abendorff, How can patients’ voices be heard and acted upon when they attempt to report incidents of harm?, 5 January 2022. https://www.pslhub.org/learn/patient-engagement/patient-stories/how-can-patients-voices-be-heard-and-acted-upon-when-they-attempt-to-report-incidents-of-harm-r5700/
[17] NHS England, Framework for involving patients in patient safety, 29 June 2021. https://www.england.nhs.uk/patient-safety/framework-for-involving-patients-in-patient-safety/
[18] Melanie Whitfield and Helen Hughes, Patient Safety Partners – A workshop at Kingston Hospital, 4 August 2023. https://www.pslhub.org/learn/patient-engagement/patient-safety-partners/patient-safety-partners-a-workshop-with-helen-hughes/
[19] Patient Safety Learning, The involvement of patients and families in a healthcare safety management system: In conversation with Jono Broad, 21 February 2023. https://www.patientsafetylearning.org/blog/the-involvement-of-patients-and-families-in-a-healthcare-safety-management-system-in-conversation-with-jono-broad
[20] Patient Safety Learning, “Getting the hospital to be honest with us felt like a battle from day one.” An interview with Derek Richford, 13 September 2023. https://www.pslhub.org/learn/patient-engagement/how-to-engage-for-patient-safety/%E2%80%9Cgetting-the-hospital-to-be-honest-with-us-felt-like-a-battle-from-day-one%E2%80%9D-an-interview-with-derek-richford-r10023/
[21] NHS England and NHS Improvement, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. https://www.england.nhs.uk/patient-safety/the-nhs-patient-safety-strategy/
[22] NHS England, Patient Safety Incident Response Framework, August 2022. https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-1.-PSIRF-v1-FINAL.pdf
[23] The Independent Medicines and Medical Devices Safety Review, First Do No Harm: the report of the Independent Medicines and Medical Devices Safety Review, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf
[24] Patient Safety Learning, Redress, research and regulatory reform are still needed: An overview of patient safety issues related to surgical mesh, 1 May 2023. https://www.patientsafetylearning.org/blog/redress-research-and-regulatory-reform-are-still-needed-an-overview-of-patient-safety-issues-related-to-surgical-mesh
[25] Patient Safety Learning, Will lessons be learned? An analysis of the systemic failures in the East Kent Maternity report, 17 November 2022. https://www.patientsafetylearning.org/blog/will-lessons-be-learned-an-analysis-of-the-systemic-failures-in-the-east-kent-maternity-report
[26] Patient Safety Learning, Campaigning for safety as a patient, family member or advocate, 11 September 2023. https://www.pslhub.org/learn/patient-engagement/how-to-engage-for-patient-safety/campaigning-for-safety-as-a-patient-family-member-or-advocate-r10031/
