Patient safety and human factors: agencies

This section provides information on government bodies and other organisations which are relevant to patient safety and its different aspects.

You may also want to look at:

The agencies are arranged by country and listed alphabetically:

UK wide

Health Foundation
The Health Foundation works to continuously improve the quality of healthcare in the UK and aims to develop "the technical skills, leadership, capacity, knowledge and the will for change, that are essential for real and lasting improvement". The Foundation's Safer Patients Initiative ran from 2004 to 2008 as a large-scale programme and underlined the importance of addressing issues of harm and safety at organisational level. Information about the Programme, learning from it, case studies and information about the Foundation's related work on patient safety is available at Safer Patients Initiative. A network was developed from this initiative. The group "test, develop and explore ways of building improvement skills and making healthcare safer for patients" - see Safer Patients Network (This programme ended in 2012).

A current programme of work is Safer Clinical Systems which is focussing on improving clinical handovers and prescribing. The patient safety topic area also provides details of relevant Health Foundation publications and the work of the Foundation on particular programmes and research projects.

England

The key functions and expertise for patient safety developed by the National Patient Safety Agency (NPSA) transferred to the NHS Commissioning Board Special Health Authority on 1 June 2012. "The NHS CBA will harness the power of the National Reporting and Learning System (NRLS), the world's most comprehensive database of patient safety information, to identify and tackle important patient safety issues at their root cause". Further details of these organisations appear below.

The operational delivery of the National Reporting and Learning System (NRLS) has been transferred from the NPSA to Imperial College Healthcare NHS Trust (ICHT), with the NHS CBA retaining an oversight role. Health care organisations should continue to report patient safety incidents to the NRLS - see Report a patient safety incident.

Action against Medical Accidents
Action against Medical Accidents (AvMA) is the independent charity which promotes better patient safety and justice for people who have been affected by a medical accident.

Care Quality Commission
The Care Quality Commission is the health and social care regulator for England, established by the Health and Social Care Act 2008, and came into operation in April 2009. Its activities include the registration of health and social care providers, monitoring and inspection of all health and adult social care, regular reviewing to improve services and reporting the outcomes of this work.

Central Alerting System
The Central Alerting System enables alerts and urgent patient safety specific guidance to be accessed at any time. Safety alerts, emergency alerts, drug alerts, Dear Doctor letters and Medical Device Alerts issued on behalf of the Medicines and Healthcare products Regulatory Agency, National Patient Safety Agency and the Department of Health are available on this website.

Department of Health: Patient safety
The Department of Health patient safety pages provide information on their approach and long term strategy for assuring patient safety in all healthcare settings. There are also links to key patient safety documents.

Health Protection Agency (HPA)
The HPA is an independent body that protects the health and wellbeing of the population.
 
Health and Safety Executive (HSE)
The HSE is responsible for the encouragement, regulation and enforcement of workplace health, safety and welfare, and for research into occupational risks in England and Wales and Scotland.

Healthcare Quality Improvement Partnership (HQIP)
HQIP works in partnership with healthcare stakeholders to improve quality of care and provide value for money. HQIP also aims to support and enable a culture of quality improvement.

Infection Prevention Society
The Infection Prevention Society exists to promote the advancement of education in infection prevention and control for the benefit of the community as a whole, in particular by the provision of training courses, accreditation schemes, education materials, meetings and conferences. The IPS incorporates the Infection Control Nurses Association.

Medicines and Healthcare products Regulatory Agency (MHRA)
The principal aim of this agency is to safeguard the public's health. It does this by making sure that medicines and medical devices work properly and are acceptably safe, and by responding promptly when new concerns come to light.

National Clinical Assessment Service
The National Clinical Assessment Service (NCAS) works to resolve concerns about the practice of doctors, dentists and pharmacists by providing case management services to health care organisations and to individual practitioners. It aims to clarify concerns and make recommendations to help practitioners return to safe practice.

National Research Ethics Service
The National Research Ethics Service has a dual mission: to protect the rights, safety, dignity and wellbeing of research participants; and to facilitate and promote ethical research that  is of potential benefit to participants, science and society.

National Resource for Infection Control
A project developed by health care professionals, aimed at being a single-access point to existing resources within infection control for both infection control and all other health care staff.

NHS Commissioning Board Special Health Authority (NHS CBA)
The key functions and expertise for patient safety was transferred to the NHS CBA from the National Patient Safety Agency (NPSA). "The NHS CBA will harness the power of the National Reporting and Learning System (NRLS), the world's most comprehensive database of patient safety information, to identify and tackle important patient safety issues at their root cause".

NHS Institute for Innovation and Improvement: Safer Care
The Safer Care programme aims to build an NHS where every member of staff has the passion, confidence and skills to eliminate harm to patients. These pages include tools for safer care and patient safety news.

NHS Litigation Authority
The NHSLA is a not-for-profit part of the NHS, responsible for handling negligence claims made against NHS bodies in England. The NHSLA is also responsible for advising the NHS on human rights case law and handling equal pay claims.

NHS Patient Safety (formerly NPSA Patient safety website)
On 1 June 2012 the key functions and expertise for patient safety developed by the NPSA transferred to the NHS Commissioning Board Special Health Authority (the Board Authority). "The Board Authority will harness the power of the National Reporting and Learning System (NRLS), the world's most comprehensive database of patient safety information, to identify and tackle important patient safety issues at their root cause". Key information, guidance, tools and alerts continue to be made available by the Patient safety website.

Northern Ireland

In Northern Ireland the HSC Safety Forum is taking a lead in promoting shared learning and leadership in patient safety activities.

Department of Health, Social Services and Public Safety (DHSSPS): Safety, quality and standards: safety and quality policy
The Safety, Quality and Standards Directorate takes forward the Department's programme for improving the safety and quality of health and social care services delivered to people in Northern Ireland. This page within the DHSSPS website lists some of the initiatives covered by the policy and programme and signposts standards, guidance and legislation.

Department of Health, Social Services and Public Safety: Public health policy
The Public Health Policy Team is responsible for emergency planning and for health promotion, disease prevention and health protection.

Department of Health, Social Services and Public Safety: Clinical and social care governance support services (CSCG)
The CSCG Support Team has recently completed a four year work programme in which it developed a range of products which can be accessed via these pages. The work of the team is now closely aligned with the HSC Safety Forum which takes the lead in supporting safety and quality improvement in health and social care.

HSC Safety Forum
The forum was launched in 2007 to 'to promote a safety culture within health and social care organisations and share best practice, supporting organisations in implementing evidence-based interventions proven to reduce harm and save lives and measuring patient safety improvement'. The forum has a role in facilitating education and training, promoting collaboration and patient/client participation in safety work.

Northern Ireland Adverse Incident Centre (NIAIC)
This section within the Department of Health, Social Services and Public Safety website describes the work of the centre which is to "record and investigate reported adverse incidents involving medical devices, non-medical equipment, plant and building systems used in health and personal services in Northern Ireland". The section includes information on adverse incident reporting and information and updates about medical devices.

Northern Ireland Medicines Governance Team
The website provides access to current medicine safety policies, guidelines and safety memoranda and a 'Medication Safety Today' newsletter is also available.

Public Health Agency for Northern Ireland
The agency was launched in April 2009 and brings together a range of functions within health and social care which focus on improving health and wellbeing in Northern Ireland. This includes the former Health Promotion Agency and the Healthcare Associated Infection (HCAI) surveillance site.

Regulation and Quality Improvement Authority (RQIA)
'The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland, and encouraging improvements in the quality of those services.' The reviews undertaken by RQIA are based on the 2006 'Quality standards for health and social care'. In 2009 the duties of the Mental Health Commission were also transferred to RQIA. Reports based on the RQIA reviews and inspections can be viewed at: RQIA Review reports.

Scotland

The focus of patient safety activity in Scotland is the delivery of the Scottish Patient Safety Programme (SPSP) which is being implemented in every acute hospital in the country. The programme is being co-ordinated by Healthcare Improvement Scotland which also includes other initiatives on aspects of safety.

Health Protection Scotland (HPS)
Health Protection Scotland was established by the Scottish Executive to strengthen and co-ordinate health protection in Scotland providing expert and advice and support to government, NHS, other organisations and the public on health protection issues. HPS also aims to provide a knowledge base for health protection research and development.

Healthcare Environment Inspectorate (HEI)
The Healthcare Environment Inspectorate is part of Healthcare Improvement Scotland. It focuses on reducing healthcare associated infection (HAI) risk to patients through a rigorous inspection framework. The process involves announced and unannounced inspections of the acute hospitals. The Inspectorate also draws on and contributes to the broader improvement agenda across NHSScotland.

Healthcare Improvement Scotland: Patient safety
Healthcare Improvement Scotland has taken on the activities of the former NHS Quality Improvement Scotland and the Care Commission. The organisation's work programme involves the provision of guidance and standards, improvement and implementation support, assurance, scrutiny, measurement and reporting. It takes a lead role in co-ordinating the work of the Scottish Patient Safety Programme and also includes the Healthcare Environment Inspectorate and Scottish Medicines.

Incident Reporting and Investigation Centre (IRIC)
IRIC co-ordinates the investigation of adverse incidents on behalf of the Scottish Government Health Directorates. The Centre undertakes investigations involving medical devices and estates equipment and where necessary issues safety warnings such as Hazard Notices and Safety Action Notices. The Centre has close links with the Medicines and Healthcare products Regulatory Agency in England.

Quality Alliance Board
The Quality Alliance Board (QAB) supports and drives the implementation and delivery of the Scottish Quality Strategy. A Delivery Group for each of the strategy's three Quality Ambitions (safe, effective and person centred) will report to the QAB.

Scottish Patient Safety Programme
The Programme is co-ordinated by Healthcare Improvement Scotland. It aims to improve the safety of hospital care across the country and is being implemented in every acute hospital in Scotland. For details of the interventions the programme is focussing on over a five year period see: Aims of the Programme. The programme has reached the end of its first phase and an announcement has been made by the Scottish Health Secretary, Nicola Sturgeon, that the programme will be extended until 2015. This is reported in the Scottish Government website at: Patient safety programme extended.

Wales

In Wales 1000 Lives Plus, a five year national programme to improve the quality of patient care and reduce avoidable harm  across NHS Wales, is the focus of patient safety activity across Wales and is currently implementing a range of initiatives. The National Patient Safety Agency (NPSA) is also a key agency for patient safety activities in Wales but as from 1 June 2012 the key functions and expertise for patient safety developed by the NPSA has transferred to the NHS Commissioning Board Special Health Authority.

The operational delivery of the National Reporting and Learning System (NRLS) has been transferred from the NPSA to Imperial College Healthcare NHS Trust (ICHT), with the NHS CBA retaining an oversight role. Health care organisations should continue to report patient safety incidents to the NRLS - see: Report a patient safety incident.

1000 Lives Plus
1000 Lives Plus is a national improvement programme supporting individuals and organisations in improving patient safety and reducing avoidable harm across NHS Wales. It focusses on building capacity and sustaining and spreading improvements and involves every health board and trust in Wales as well as universities, charities, voluntary and other organisations. Activities encompass a number of different areas. For details see: Programme areas.

Care and Social Services Inspectorate Wales (CSSIW)
CSSIW encourages the improvement of social care, early years and social services by; regulating, inspecting and reviewing and providing professional advice to ministers and policy makers.

Healthcare Inspectorate Wales (HIW)
The Healthcare Inspectorate Wales (HIW) was launched in 2004 to implement a programme of inspection in relation to quality, national clinical standards and patient safety focusing upon clinical governance, patient care across agencies and sectors and strengthening public involvement. HIW focuses on inspection and investigation of NHS bodies in Wales and Welsh NHS funded care to ensure that quality, patient safety, clinical governance requirements and, from April 2006, national health care standards are complied with.

NCAS Wales
The National Clinical Assessment Service (NCAS) works to resolve concerns about the practice of doctors, dentists and pharmacists by providing case management services to health care organisations and to individual practitioners. It aims to clarify concerns and make recommendations to help practitioners return to safe practice.

NHS Patient Safety (formerly NPSA Patient safety website)
On 1 June 2012 the key functions and expertise for patient safety developed by the NPSA transferred to the NHS Commissioning Board Special Health Authority. "The Board Authority will harness the power of the National Reporting and Learning System (NRLS), the world's most comprehensive database of patient safety information, to identify and tackle important patient safety issues at their root cause". Key information, guidance, tools and alerts continue to be made available by the Patient safety website.

NHS Wales Informatics Service: Patient safety
Informing Healthcare is the Welsh Assembly Government's programme which was set up to improve health services in Wales by introducing new ways of accessing, using and storing information. Clinical risk management and the safety of patients is a key process in the development of Informing Healthcare products, and forms part of the wider quality assurance processes in the programme.

Public Health Wales
Public health Wales provides professionally independent public health advice and services to protect the health and wellbeing of Wales. This includes public health, health protection, child protection and services relating to the surveillance, prevention and control of communicable diseases. 

Welsh Healthcare Associated Infection Programme (WHAIP)
The WHAIP team is part of Public Health Wales and provides independent professional advice and information about healthcare associated infections to health professionals in Wales, to the Welsh Assembly Government and its advisory committee, the Welsh Healthcare Associated Infection sub group. The team also provides national leadership and support for the Welsh Assembly Government's strategies for healthcare associated infection, and is responsible for providing information to the public about healthcare associated infection.