Patient safety and human factors: England

A key aim of the vision for the future described in the White Paper Equity and excellence: Liberating the NHS is to help ensure that "patient safety is placed above all else at the heart of the NHS" (Department of Health 2010, p.21). The policies set out in the White Paper have been give effect by the Health and Social Care Act 2012.  

The key functions and expertise in England for patient safety developed by the National Patient Safety Agency (NPSA) has now transferred to the NHS Commissioning Board Special Health Authority (NHS CBA) as from 1 June 2012 (National Patient Safety Agency 2012).
 
The National Reporting and Learning System (NRLS) made available through the NPSA has since 2003 enabled patient safety incident reports to be submitted to a national database allowing for analysis and the identification of risks and hazards. The operational delivery of the NRLS has been transferred from the NPSA to Imperial College Healthcare NHS Trust (ICHT), with the NHS Commissioning Board Special Health Authority retaining an oversight role. Health care organisations are asked to continue to report patient safety incidents to the NRL at: Report a patient safety incident. 

The learning from the NRLS has contributed to the development of resources which include alerts, guidance, activities and learning tools and these continue to be made available at: Patient safety resources.  

A key initiative around the delivery of harm free care has been piloted by Safety Express, the Department of Health's Quality, Innovation, Productivity and Prevention programme (QIPP) Safe Care work stream. It focuses on the delivery of harm free care with the particular aim of reducing harm from pressure ulcers, falls, catheter acquired urinary tract infections and blood clots (venous thromboembolism or VTE). The work has been brought together in the Harm Free Care website which provides a range of tools and guidance to assist frontline health care staff to achieve harm free care. Visit: Harm Free Care.

Measuring harm and harm free care is from the patient's perspective. The focus is on counting patients 'protected from harm' and determining how many patients have none of the harms identified above and thus are harm fee from these conditions.

More information about policy, programmes and guidance is available at UK resources. You can find out about:

• current and recent campaigns, programmes and networks
• key agencies - government bodies and other organisations
• policy and strategy in the different UK countries
• details of guidance and tools.

For further information relating to quality improvement and other clinical governance issues in England visit the Clinical Governance resource.

For fortnightly updates on patient safety and other themes you can register for the Quality and safety e-Bulletin.

References

These items were last accessed on 19 November 2012. Some of them are in PDF format - see how to access PDF files.
 
Department of Health (2010) Equity and excellence: Liberating the NHS, London: DH. 

National Patient Safety Agency (2012) Transfer of patient safety function to the NHS Commissioning Board Special Health Authority, NPSA website.