Kennedys Patient Safety Forum

Held this year on the 75th anniversary of the NHS, and ahead of the transition to the Patient Safety Incident Response Framework (PSIRF) this Autumn, our annual patient safety forum provided the opportunity to explore what it is next for patient safety.

Offering personal reflections, guest speaker, Dr Denise Chaffer, Director of Safety and Learning at NHS Resolution, framed the discussion with a question that must ultimately underpin and guide continued efforts to improve patient safety through a just and learning culture, asking “what would we want for us?”  

Highlighting the importance of understanding error, Denise observed that a culture that does not support staff in communicating an error to those in leadership, will mean not hearing about any subsequent recurrence of the same error. To that end, role-modelling, visibility, and accessibility of those in leadership within healthcare organisations was identified as essential to ensure a supportive, just and learning culture that filters down.  

Key areas of discussion included what will be different in terms of the patient safety landscape in the short and medium term. Particular reference was made to technological advancements in the delivery of healthcare, and as well as recognising the benefits these can bring, the potential challenges these present were also considered in the context of informed consent and the potential risk of depersonalising care to the detriment of patients.

Another area explored focused on making the move from recommendations to implementation, with it unfortunately too often being the case that converting recommendations into valuable change does not occur. It is hoped that PSIRF will have a key role to play in this respect. 

The importance of involving staff in any changes and why they are being made, was underlined, together with the need to recognise the impact on staff and provide support when errors occur. Equally, patients and their families must be at the centre of all care decisions and when things have gone wrong, compassion and an open discussion with them are vital.

With the forum comprising representatives from the public and independent sector, it was also clear that the opportunity for greater sharing of learning, is significant.

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