Patient Safety Learning publishes new Green Paper


  • 16th September 2018

Healthcare services around the world today are characterised by an uncomfortable but glaring truth: everyday people are harmed and killed not because of their underlying condition but because of avoidable problems in how their healthcare is delivered.

Since launching Patient Safety Learning in September 2017, we’ve been engaging widely with patients, clinicians, regulators, academics, policy makers and politicians. We have been discussing and reflecting on where patient safety is today and why, despite considerable global efforts, the problem of avoidable patient harm persists.

A Patient-Safe Future

Today we launch our new green paper – ‘A Patient-Safe Future’ (See our press release here). We have written this paper for 2 reasons:

Firstly, to help us develop our strategy and work programme to ensure we are focused on areas that will help make a real difference and secondly, to develop a clear and consistent message about how the wider system needs to change to better support patient-safe care.

The paper focuses on:

  • Patient safety today: an overview of the patient safety landscape
  • The persistence of patient harm: a diagnosis of why problems continue
  • The future: what a patient-safe future looks like
  • Our role: how Patient Safety Learning proposes how to help make a difference
  • System wide proposals: our thoughts on changes that we believe are needed in the wider healthcare system

We’ve made some bold proposals for change; focusing on leadership, better use of patient safety data, culture, improved mechanisms for sharing learning and the pressing need for healthcare organisations to adopt and implement the kind of professionalised approach to safety that we see in other high-risk sectors.

We propose that healthcare needs to move away from a reactive approach to avoidable patient harm, towards a pro-active approach where healthcare leaders, staff, policy makers and regulators work together to create the conditions that support and enable safe care.

You can download a copy of our paper here.

Our consultation

Between now and November 2018 we will be engaging widely with as many people as we can to discuss the ideas within the paper. Details of how you can get involved will be published on our website. We are also inviting feedback on our paper via an online survey which is available here. We also welcome reflections and suggestions to us directly through [email protected]

The consultation will run until the end of Nov 2018 and we will use this feedback to inform a White Paper that we will publish in January 2019.

Our first annual conference

On the 26th September, Patient Safety Learning are hosting our first annual patient safety conference at the Kings Fund in London. We have an exciting programme that includes talk from patients, front line clinicians, national leaders and world-renowned patient safety experts. Our conference also includes a presentation and panel session further exploring the themes of this paper.

The conference is open to anyone with an interest in patient safety and tickets are still available here.

We hope that you will read our paper and let us know what you think.

Helen Hughes, CEO.

Supporting Statements

The Green Paper is being widely welcomed across the healthcare system and supportive statements include:

“A Patient-Safe Future is a masterful and comprehensive guide to what it really takes to assure the continual improvement of patient safety in health care. It's a highly readable resource that pulls together decades of research and experience, offering a truly science-based roadmap to the system we can build together. It will be useful for everyone who wants safer care - professionals, executives, Boards, patients, families, and communities.”

-Donald M. Berwick, MD, MPP, FRCP, KBE, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, Boston, Massachusetts, USA

Peter Walsh, the Chief Executive of Action and Against Medical Accident (AvMA), said:

“A Patient-Safe Future is a must read for anyone who is passionate about patient safety. It is insightful and thought provoking – a valuable contribution to thinking on patient safety”

Rob Behrens, the Parliamentary and Health Service Ombudsman, said:

“Our casework demonstrates all too often how defensiveness can inhibit NHS Trusts from identifying mistakes and learning from them. We fully support the proposals in this Green Paper, which highlights the need for a continued focus on patient safety across the NHS. We are committed to working with Patient Safety Learning and partners across the system to ensure this focus is maintained.”

Charlie Massey, Chief Executive of the General Medical Council, said:

Increasing pressure on the health service poses a real risk to patient safety and to the wellbeing of doctors, and new thinking is urgently needed to address these risks and identify new opportunities, not least in the context of NHS England's 10-year-plan.

The GMC exists to protect patients and is already working hard to support the profession in delivering safe high quality care. But too often our out-dated legislation prevents us from doing more, with too much emphasis on lengthy fitness to practise procedures when a quicker, local response would be better for everyone. That is not only a barrier to creating a just, learning culture when things go wrong for patients and doctors, but means we cannot invest our resources as we would want in better medical education, learning and the prevention of errors through positive learning cultures in medical teams. We welcome this green paper and the bold ideas it sets out and look forward to supporting a constructive discussion on how it can be taken forward.”

Aidan Fowler, NHS Improvement, National Director of Patient Safety:

“We welcome the green paper from Patient Safety Learning and share the vision for a safer future for healthcare. We are committed to working collaboratively with organisations with an interest in patient safety to help ensure the NHS improves for all.”

Professor Ted Baker, Chief Inspector of Hospitals for Care Quality Commission said:

“There are some powerful messages in this report that chime with what we know and have seen. The continuing focus on patient safety is vital to the future of health and social care, and we welcome the information and resources that will enable providers to continue improving.”

Matthew McClelland, Director of Fitness to Practise at the Nursing and Midwifery Council (NMC) said:

“A Patient-Safe Future makes a very welcome contribution to the important discussion around how the health and care system can learn from patient safety incidents.

“As the regulator of nurses and midwives, we know that occasionally mistakes happen and things can go wrong. We agree that learning – not blame – is the best way to prevent mistakes from happening. We’ve recently outlined a new to approach to resolving complaints about nurses and midwives. It puts people at the heart of our work and looks not only at the mistake, but also at the factors that contributed to it.”

Denise Chaffer, Director of Safety and Learning, NHS Resolution said:

"NHS Resolution has been promoting learning from harm in the NHS and we welcome this green paper as a further contribution to the debate, we very much support working together across the system to support improvements in safety and learning from harm."

Green paper


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