Sign up to Safety
The vision is for the whole of the NHS to become the safest healthcare system in the world, aiming to deliver harm free care for every patient every time. Sign up to safety has an ambition of halving avoidable harm in the NHS over the next three years with the aim of saving 6,000 lives as a result.
Organisations are being asked to develop a plan that describes
how we will reduce harm and save lives, by working to reduce the
causes of harm and take a preventative approach. We are asked to
identify two or more national patient safety priorities, such as
medication errors or deterioration of patients (Appendix 1 shows
the complete table), and two or more local priorities to focus our
plans. We will then make public our plans and update regularly on
progress against it. The ambition was to have 60 organisations sign
up in the first 6 months, to date over 100 have joined the
While very few patient safety incidents result in a claim, all
represent potentially devastating consequences for patients and can
be very expensive for the NHS. The NHS Litigation Authority will
review trusts' plans and if the plans are robust and will reduce
claims, we will receive a financial incentive to support
implementation of the plan. Any savings made in this way have to be
redirected into frontline care.
As an organisations that signs up to the campaign we will be
able to draw on a variety of expert support to help ensure that we
realise the ambitions described in our plans. These include the use
of staff briefings and de-briefings, the use of communication
tools, increased skills in investigations and communicating with
patients, and the approaches to designing safe care using tools and
techniques from other industries, including checklists.
We are invited to set out what our organisation will do to
strengthen patient safety by:
- Setting out the actions we will undertake in response to the
five key pledges and agree to publish this on our website for
staff, patients and the public to see.
- Committing to turn our proposed actions into a safety
improvement plan which will show how our organisation intends to
save lives and reduce harm for patients over the next three
- Within our safety improvement plan we will be asked to identify
the patient safety improvement areas we will focus on. We will be
supported to identify two or more areas from a national menu of
high priority issues and two or more from our own local
The five key pledges are:
- Put safety first. Commit to reduce avoidable harm in the NHS by
half and make public the goals and plans developed locally.
- Continually learn. Make our organisation more resilient to
risks, by acting on the feedback from patients and by constantly
measuring and monitoring how safe our services are.
- Honesty. Be transparent with people about our progress to
tackle patient safety issues and support staff to be candid with
patients and their families if something goes wrong.
- Collaborate. Take a leading role in supporting local
collaborative learning, so that improvements are made across all of
the local services that patients use.
- Support. Help people understand why things go wrong and how to
put them right. Give staff the time and support to improve and
celebrate the progress.
The ideas listed below relate to what we believe the vision of
our Trust to be and incorporating our quality strategy is;
Put Safety First
Safety is the trust's number one priority and this is
demonstrated by the actions that we are taking.
- Managing the deteriorating patient. By
implementing technology to support the deteriorating patients
project, the hospital at night and patient handovers, sepsis bundle
and AKI (Acute Kidney Injury).
- Establish patient safety champions. To have a
robust process in place to support all of the work that we are
undertaking and continue to reflect on our learning from events
when things go wrong.
- Establish a clinical safety group. We will
instigate case reviews of patient deaths and have up to date
reporting on our Mortality and Morbidity to determine any harm
events that may have been a contributing factor.
- Patient involvement. We are fully committed to
supporting patients to be involved in their care and we aim to work
with patients, carers and staff to build this culture together in
the "Do I know what is happening to me" project
- Implementation of the SAFER bundle. We will
introduce a SAFER (Senior Review, All patients having an estimated
date of discharge, Flow, Early Discharge, Review) flow bundle to be
developed and launched Trust-wide. The work will focused on the
timely and safe discharge of patients from our wards
We want to improve systems for learning from complaints, claims,
serious incidents and inquests in doing this we will take the
- Take a proactive approach to the feedback from our patients and
their carers by extending the work on sharing and Friends and
Family free texting comments, feeding back the outcomes of claims,
serious incidents and inquest to improve safety and the patents
- Engage and undertake external audits and look at developing an
external review panel for our complaints.
- Training for our staff around human factors, including
effective team working and reducing errors for all those involved
in delivering patient care by implementing a simulation suite.
- Continue to implement learning from the "perfect week".
- Strengthen our clinical governance structure and learning from
unexpected deaths and near misses.
- Learn from other organisations including root cause analysis
training and sharing of Never Events.
The Trust has a policy to support our duty of candour and we
will ensure through training that staff are fully aware of their
obligations and how to break the news of when something has gone
wrong. We will do this by:
- Implementation of business unit training for staff in the duty
We will continue to collaborate with others by:
- Having a clinical link to provide the leadership in developing
our links with the community projects on early intervention of
sepsis and AKI which will incorporate our links with working on the
UCLH 6C's project.
- Develop our working with ARH Partnership and UCL partners on
clinical safety projects.
- Initially we will develop our non-elective 7 day pathway to
reduce the risk to our high risk patients by developing early
senior clinician review seven days a week, handovers between day
and night staff and developing the hospital at night project.
This will then form a foundation for the full seven day working
We make learning from harm and acknowledging duty of candour
available for all of our staff by
- Ensuring that the training is available during evenings as well
as during the day
- Support our staff during the inquest process and offer training
sessions on RCA, action planning, preparing reports as well as
inquest simulation training
- Develop an online portal for case studies of serious and
critical incidents to be posted to develop the sharing and
- Participate in both national and regional learning events.