Patient safety should be at the forefront of everything we do when we deliver any care or treatment:
‘First do no harm.’
Since the 1990s the patient safety movement has grown and gained momentum and there has been a move away from a culture of blame and towards an approach that promotes openness and learning from errors.
Ensuring that patients are safe involves risk assessment, the identification and management of patient-related risk, and the reporting and analysis of incidents. It also requires the capacity to learn from and follow up on incidents, and to implement solutions to minimise the risk of them reoccurring.
This module summarises key topics from the literature, provides definitions of patient safety and harm, and looks at some of the lessons that should be learned from recent failures in healthcare. These include findings relating to the Mid Staffordshire NHS Foundation Trust and to Winterbourne View hospital. Various models of patient safety are outlined, including the linear ‘Swiss cheese’ model and various non-linear models.
A key theme is the value of reporting, investigating and learning from incidents. This module looks at guidelines, initiatives and tools for ensuring that this happens both locally and nationally to prevent further harm. It also identifies the most commonly reported types of incident within mental healthcare and highlights particularly relevant ‘Never Events’, i.e. types of serious incident that are wholly preventable if recommendations made at a national level have been implemented.