NHS Safety: Top Of The World

To achieve the goal of making the NHS the safest health service in the world, DAC Beachcroft looks at why we need to understand when the vast majority of things go right, as well as why a small minority go wrong.

The NHS has announced ambitious plans to make it "the safest health service in the world". The plans, announced in December 2018, propose major enhancement of the National Reporting and Learning System (NRLS), which receives over two million incident reports every year.

It proposes that the most important types of avoidable harm, such as medication errors or 'never events' (such as wrong side or wrong site), will be halved over the next five years. The focus will be on areas where litigation costs are highest - such as maternity - and where there is the greatest variation.

In the 15 years since the NRLS was introduced, its analysis of incident data has led to enhancements that have removed or reduced significant risks. And whilst the NRLS receives two million reports a year, it only reads those regarding significant harm and uses that information to search its database. A new patient safety incident management system will replace the NRLS and use artificial intelligence and machine learning to explore how to enhance what goes well, rather than just looking at what goes wrong.

LOOKING AT THE POSITIVES

While learning from mistakes is important, the NHS is being asked for a shift in philosophy from ensuring that "as few things as possible go wrong" to ensuring that "as many things as possible go right".

This perspective, known as 'Safety II', relates to the system's ability to succeed under varying conditions. "A Safety II approach assumes that everyday performance variability provides the adaptations that are needed to respond to varying conditions, and hence is the reason why things go right. Humans are consequently seen as a resource necessary for system flexibility and resilience," its proponents state.

Denise Chaffer, the Director of Safety and Learning at NHS Resolution, says learning from claims will also bear fruit. She cites opportunities for improvements - in areas including maternity services, reduction in cerebral palsy cases, prevention of needle-stick injury and suicide prevention - that have arisen from analysis of its claims data.

NHS Resolution's clinical research fellows carry out 'deep dive' analysis of closed cases to examine what went wrong and make subsequent recommendations. For example, the investigation into...