- Published: Wednesday, 02 January 2019 08:00
- Written by News Editor
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A report from the Care Quality Commission looks at NHS safety culture and the need for transformation. They have been working with NHS Improvement to look at issues in NHS trusts that contribute to ‘Never Events’ taking place. They visited 18 NHS trusts and carried out one-to-one interviews, visited different services and reviewed policies and procedures.
Never Events are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed. The CQC wanted to understand what makes it easier – or harder – for the people and organisations in the NHS to prevent Never Events. They also wanted to see what could be learned from other industries and countries.
The CQC concluded:
- Never Events continue to happen despite the hard work and efforts of frontline staff.
- Staff are struggling to cope with large volumes of safety guidance, they have little time and space to implement guidance effectively, and the systems and processes around them are not always supportive.
- Where staff are trying to implement guidance, they are often doing this on top of a demanding and busy role that makes it difficult to give the work the time it requires.
- In terms of the wider system, we have found that the different parts at national, regional and local level do not always work together in the most supportive way. There is a lot of confusion about the roles of different bodies and where trusts can go to get the most appropriate support.
- Also, we found that education and training for patient safety could be significantly improved. Staff are either not getting the training they need at undergraduate level or they are not given the time to do appropriate levels of training on patient safety once they have entered their clinical careers.
- Everyone who has a role in health care or who receives health care in England should recognise the importance of making patient safety a top priority and the extent of the cultural change needed to make this a reality.
To download go to: https://www.cqc.org.uk/publications/themed-work/opening-door-change
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