The annual World Patient Safety Day took place on 17 September 2021. Iconic buildings in many parts of the world were lit up in orange in support of the day, and special lectures, seminars and other events took place. This year's theme was patient safety issues in mothers and newborns. Stakeholders were encouraged to look at solutions to the problem, undertake research and adopt best practices. Public engagement was also a focus.
The World Health Organization (WHO) has stated some very stark statistics:
‘Approximately 810 women die every day from preventable causes related to pregnancy and childbirth. In addition, around 6700 newborns die every day, amounting to 47% of all under-5 deaths. Moreover, about 2 million babies are stillborn every year, with over 40% occurring during labour.’
Most stillbirths and maternal and newborn deaths are avoidable, WHO states, provided safe and quality care is given by skilled health professionals working in supportive environments (WHO, 2021).
The oxygen of publicity
The annual World Patient Safety Day is a useful global clarion call and opportunity for patient safety stakeholders, non-governmental organisations, governments, health systems, health carers, the public and others to jointly tackle pressing patient safety issues and needs. Publicity is given to patient safety issues on a global scale, which is a good thing.
Patient safety is everybody's business wherever we are in the world. We and our families are all consumers of health care and therefore we have a vested interested in ensuring the safety of the health system that will treat us.
Beyond World Patient Safety Day
Celebrating World Patient Safety Day involves stakeholders and groups reaffirming commitments to patient safety and the importance of the provision of good quality health care. There is rhetoric, political statements, affirmations and promises. This is a good thing, but we also need to see beyond all these promises and good sentiments—beyond the rhetoric. To see all this cemented into good patient safety practices and long-lasting, sustainable NHS culture change.
Never Events in the NHS
In September, the same month as World Patient Safety Day took place, NHS England and NHS Improvement (2021) published a provisional report on Never Events that occurred between 1 April and 31 July 2021. Some 131 serious incidents appear to meet the definition of a Never Event. The report stresses that this number may change as local investigations are completed.
When the Never Events in this report are analysed, the full shocking nature of them is revealed. These events should never have happened and are unforgivable by any measure of the word. The fact that some are common Never Events that have been repeated, compounds the severity of the problem. Yes, we have World Patient Safety Day, and we rightly celebrate that, but we also have dire patient safety failings at home. These events stubbornly persist in our health system. Never Events inject a harsh reality into any NHS celebration of NHS patient safety good practice. Clearly very poor, harmful practices are occurring.
Wrong site surgery
There were 56 Never Events in the Wrong Site Surgery category, and these included:
- Biopsy from wrong breast: 1
- Embolisation to the wrong area of the kidney: 1
- Flexible sigmoidoscopy intended for another patient: 1
- Gastroscopy intended for another patient: 1
- Injection to wrong eye: 4
- Wrong side spinal surgery: 1
- Wrong side ureteroscopy: 2
- Wrong site block: 15
- Wrong skin lesion biopsy: 1.
Retained foreign object post-procedure
There were 28 Never Events in the retained foreign object post procedure category. These included:
- Laparoscopic specimen bag: 1
- Part of a drill bit not identified as missing at the time of the procedure: 1
- Raney cranial clip: 1
- Scalpel blade: 1.
Other categories of Never Events discussed in the report include, among others, wrong implant/prosthesis, and the unintentional connection of a patient requiring oxygen to an air flow meter.
The report includes a section giving the Never Events by healthcare provider. Looking at the list, by my count, there are four hospitals in that list that had five Never Events each listed during the period of this report, between 1 April and 31 July 2021.
These Never Events speak for themselves in terms of the severe nature of the patient safety failings involved. Healthcare staff are seemingly not learning the lessons of past adverse healthcare events and changing practice accordingly.
Healthcare Safety Investigation Branch national learning report
In the same month as World Patient Safety Day, the Healthcare Safety Investigation Branch (HSIB) published a national learning report—an analysis of HSIB's first 22 national investigations (HSIB, 2021). In this analysis, HSIB highlighted several key patient safety failings in the NHS and suggested ways of dealing with the problems identified—a new mindset. The report also contains some interesting and perhaps telling observations on HSIB's own role in the NHS patient safety infrastructure.
The report states that HSIB identified three recurring patient safety themes:
- Access to care and transitions of care (when patients move between care providers or care settings)
- Communication and decision making
- Checking at the point of care.
These three themes, HSIB states, represent:
‘The most significant threats to patient safety that HSIB has found, based on its investigations, so far.’
The report goes into some detail on each of these themes and draws conclusions along with recommendations. HSIB also investigated the 85 safety recommendations made in the 22 investigations and grouped them into one or more of the categories below:
- Identification of patient safety hazards
- Improving the management of known patient safety risks
- Monitoring of patient safety performance
- Evaluation of patient safety interventions
- Training and education for patient safety
- Promotion of patient safety.
When discussing the recommendations, HSIB makes a telling observation:
‘HSIB does not want to be seen as a regulator as that may cause conflict with its purpose of improving patient safety through effective and independent investigations that do not apportion blame or liability. However, it is known that there has been a variable response to its safety recommendations, which is exacerbated by the complexity of [the] regulatory landscape in which healthcare sits.’
HSIB states that monitoring of the impact of its recommendations is required.
Tramlines and guidelines
HSIB thus acknowledges that there has been a variable response to its safety recommendations in the NHS. These recommendations seemingly have not been universally welcomed and implemented. The NHS maintains a complex and sometimes overlapping regulatory and governance regimen, which has been the case for as long as I can remember, well over 25 years or more, and it shows no signs of reducing. This compounds the problem of making sure HSIB's recommendations are implemented.
That said, recommendations may not always be appropriate in every case—they should not always be regarded as fixed ‘tramlines’. Sometimes the patient's condition may contraindicate the implementation of a particular recommendation. Evidence-based recommendations and guidelines are to be welcomed in terms of standard setting and patient safety but the professional decision-making autonomy of the nurse and doctor must also be respected.
One is left to ponder how the monitoring of the impact of this ‘recommendations gap’ will be addressed in the future.
The clarity of messages
A more general point that can be made is the clarity of HSIB messages in its national reports, such as the one discussed here. I would say, as an educator and lawyer, that its reports are generally complex and difficult to read and digest, with lots of different models and theories being used in order to draw conclusions and make recommendations.
From an academic and evidence-based research perspective, the reports are excellent. I would query, though, how all this sits with the nurse and doctor in a busy workplace, who may not have the time to read such in-depth work. The material does seem to be presented in a style and format that makes it hard to be read easily. The writing style of Care Quality Commission reports is excellent and would be a useful model to follow. This may then help HSIB recommendations to become more generally accepted.
Access to care and transitions of care
The access to care and transitions of care section of the HSIB report are of particular interest. For example, harm occurred when:
- Processes failed for patients requiring access to mental health services
- Transferring acutely unwell patients between hospitals and chronically unwell people between prisons
- Discharging patients from hospital who required new medication
- The healthcare system did not direct patients who required emergency care in a timely way
- Arrangements for patients who required urgent follow-up were not made.
HSIB also made the following point:
‘HSIB's work so far suggests that it may be beneficial for the NHS to explore how the application of safety management principles could build on the foundations developed by the NHS Patient Safety Strategy. The complexity of the NHS means that it is unlikely that having one single safety management system would be feasible and that a more integrated approach of multiple systems, as seen in other high-risk industries, may be necessary.’
Conclusion
These two reports highlight the immense challenges and opportunities facing the NHS. Unforgivable Never Events continue to rock the NHS. HSIB has identified key themes surrounding its investigations and provides helpful strategies to address the resulting patient safety issues. HSIB also points out that the reception to its recommendations has been variable. This is itself a challenge—to mobilise the NHS to develop a patient safety culture that actively learns from the errors of the past.