Patient Safety Learning Green Paper

In September 2018, we launched our green paper, 'A Patient-Safe Future'

We launched our green paper, 'A Patient-Safe Future’, in September 2018‘ for two 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.

Download a copy of our green paper.

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."

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