Education and training are fundamental prerequisites to the development of any patient safety culture in any healthcare system. Healthcare staff must be given time to learn and reflect on the causes of adverse healthcare events that have resulted in patient harm. They must also be able to reflect on risks and understand the quality, accountability and regulatory systems that impact on their work. There are a host of other topics to be considered as well. Education and training in patient safety can involve various academic disciplines, including law, management, psychology and sociology besides clinical health, science and technology. A key issue is always going to be the nature of a patient safety syllabus and curriculum as people will have different and diverse views on what the content should be. The recently published NHS National Patient Safety Syllabus 2.0 provides important content and guidance (Academy of Medical Royal Colleges (AOMRC), 2021). A key plank of the NHS Patient Safety Strategy (NHS England/NHS Improvement, 2019) is to create a system-wide patient safety syllabus, education and training framework for the NHS, and this syllabus forms part of that ongoing work.
National Patient Safety Syllabus
The National Patient Safety Syllabus is to be welcomed as it combines and integrates several important patient safety-related disciplines into a well-focused and proactive syllabus. The syllabus reflects systems and human factors thinking and contains tools and approaches. It is detailed, well-structured and clear, covering the following domains:
- Systems approach to patient safety
- Learning from incidents
- Human factors, human performance and safety management
- Creating safe systems
- Being sure about safety.
The syllabus explains that the rationale used in developing the domains embodies a spiral of learning, with each domain building on and deepening the work carried out in previous domains:
‘The syllabus is being translated into discrete learning modules that will form a curriculum. These will be discrete for the purposes of educational design, but inevitably the skills in different domains will integrate in different ways in a behavioural context depending on the demands of each situation. From the curriculum, staff will be able to select those modules of most significance to their work …’
Systems approach to safety
The various sections in domain 1 are the safety landscape, systems approach to safety, safety and resilience, organisational culture and organisational learning, patient, carer and public involvement in patient safety, medico-legal education and professional responsibilities and patient safety regulations and improvement.
In terms of medico-legal education and professional responsibilities, sections under this heading include:
‘2. Explains the ethical and clinical issues involved with patient care, including the withholding or withdrawal of care, and with the rights of the patient to refuse care.’ ‘3. Complies with legal requirements in patient confidentiality and information governance.’ ‘4. Recognises the legal issues surrounding clinical negligence, compensation and the accountability of individual practitioners.’
The law and patient safety
When I saw the first draft of the syllabus last year (AOMRC, 2020) I was concerned to see that medico-legal education was missing. Clinical negligence and other legally related issues need to be in any national patient safety syllabus to provide essential context for any discussion about patient harm and redress, and I said as much in my response to the public consultation on the draft. I am pleased to see that in the second version the law and clinical negligence now expressly features in domain 1, along with several other medico-legal topics including consent to treatment, patient confidentiality and mental capacity. The law acts as a mechanism of transparency and accountability in health care and it is a central mechanism for dispute resolution and redress. All health professionals studying patient safety need to know the essential legal context for issues otherwise they do not receive a full picture of what is involved in developing a patient safety culture and in protecting patients and themselves.
Learning lessons by studying past clinical negligence cases
Having a section on clinical negligence in the NHS National Patient Safety Syllabus will assist in the process of developing an NHS patient safety culture. This will be done through highlighting the nature and type of patient failures that have resulted or could result in clinical negligence claims being made.
A key obstacle to the development of a proper patient safety culture in the NHS has been a seemingly perpetual failure on the part of some NHS staff to learn from what are often repeated clinical errors. This continues to happen and is vividly illustrated by what can be termed common ‘Never Events’ such as retained foreign bodies and wrong site operations in surgery, wrong patient, wrong limb, wrong operation, wrong drug and so on.
Learning from incidents
The syllabus states that domain 2 provides a methodological approach, describes systems-based interventions, guidance for managing human performance and its variations, and essential systems for avoiding blame. Matters discussed are investigating patient safety incidents, designing system-based interventions, managing human performance in patient safety incidents, avoiding blame and creating a learning culture.
Human factors, human performance and safety management
In domain 3, human factors are introduced with special relevance to patient safety. There is a focus on task management, the role of humans in safety systems, communication and other non-technical skills, process reliability in clinical practice and safety assurance.
Creating safe systems
According to the syllabus, domain 4 describes proactive safety techniques to prevent patient harm. An understanding of the strengths and weaknesses of safety interventions is built. The effect of contextual factors on safety is described and a focus on safety culture is promoted. Topics are risk evaluation in clinical practice, mapping techniques to identify risks to patients, improving system safety and evaluating safety culture.
Being sure about safety
Domain 5 continues the application of proactive safety techniques to prevent harm to patients; understands the strengths and weaknesses of safety interventions and the effect of contextual factors on safety; evaluates dimensions of safety culture. Topics are integrating human factors, risk, escalation and governance in patient safety, creating a culture of patient safety and the safety case. A glossary of terms is also given.
A new NHS patient safety tool
The syllabus represents what has been patently missing in NHS efforts to develop a patient safety culture, namely a comprehensive, coherent patient safety syllabus for all NHS staff. This is work in progress and work will continue to define, the syllabus states, specific curricula for different staff groups and the building of supporting educational materials.
Patient safety education and training materials
The investigation reports of the Care Quality Commission (CQC) and publications of NHS Resolution, the Parliamentary and Health Service Ombudsman and the Healthcare Safety Investigation Branch (HSIB) are just some of the organisations that will be able to contribute essential case study teaching and learning materials for the National Patient Safety Syllabus and curricula.
HSIB thematic analysis
The HSIB (2021) has recently announced that it will publish a national learning report on its analysis of the first 22 HSIB national investigations to identify recurring patient safety themes. There will also be an exploration of the 85 recommendations made by the HSIB to address these. HSIB states that the analysis has found three broad themes of patient safety risks: access to care and transitions of care; communication and decision making; and checking.
CQC investigation reports
CQC investigation reports will also form essential patient safety learning materials that can be used with the NHS National Patient Safety Syllabus and curricula. The investigation reports present a unique real-time view of good and bad practice in health and social care. The investigation reports can be used as case studies for discussion as they pick up issues across the syllabus domains. The investigation reports chosen for discussion can then be mapped across the domains, highlighting several issues such as medico-legal education and professional responsibilities (1.6), patient safety regulations and improvement (1.7), improving patient safety (4.3), and evaluating safety culture (4.4).
For example, a recent investigation report details why the CQC (2021) has told trust leaders to improve medical care services at Weston General Hospital. Areas of concern included the following:
- Concerns that despite risk assessments, staffing shortages ‘created a risk that deteriorating patients were not always recognised in a timely way’
- Issues relating to managing patient safety incidents: ‘Staff mostly recognised incidents but did not always report them. Lessons learnt were not always shared with staff.’
- Concerns over ensuring competence: ‘The service did not always ensure staff were competent for their roles. Not all staff had the training to cover the scope of their work. Patients did not always have their assessed needs, preferences and choices met by staff with the right skills and knowledge.’
In terms of positive findings, these included:
- Good record keeping and record management
- Demonstrating compassion, anticipating patients' needs, upholding people's privacy and dignity.
Conclusion
The NHS National Patient Safety Syllabus maintains an important potential to bring about positive systemic change to patient safety practice, management, education, training and policy development in the NHS. The syllabus brings about a renewed focus on teaching and learning in patient safety, which will undoubtedly save lives and advance positive culture development and change.
It is good to see medico-legal education and professional responsibilities now included in the second iteration of the syllabus. This was a glaring omission from the first iteration. To support the syllabus and developing curricula there is already a valuable tranche of patient safety teaching and learning materials available from organisations such as the CQC and HSIB.