“Get it right, make it safe!” – World Patient Safety Day 2024

World Patient Safety Day on Tuesday 17 September, organised by the World Health Organisation, seeks to raise awareness and promote collaboration between patients, health workers, policymakers and health care leaders to improve patient safety.

This year, “Improving diagnosis for patient safety”, seeks to emphasise the critical importance of correct and timely diagnosis in ensuring a patient’s safety and improving health outcomes.

At the Health Innovation Network, we are commissioned by NHS England to host the Patient Safety Collaboratives, whose role it is to support NHS organisations in adopting safety interventions and strategies, learn from excellence, and to support systems to continually improve.

The programme’s ambition is to continually reduce error, harm and death, to make the NHS comparable with the safest health care services in the world by 2025. Although the national strategy does not set a specific target, it estimates that there is potential for a minimum of 928 extra lives saved and £98.5 million in treatment costs saved.

Managing deterioration

Managing deterioration is a fundamental part of ensuring patient safety, and accurate and timely diagnosis imperative to this. At the Network we have supporting the roll out of managing deterioration tool called PIER (Prevention, Identification, Escalation and Response), which allows for earlier diagnosis through consistent approach to physical deterioration across England. Now in 100% of ambulance trusts, 99.5% of acute trusts and over 9,500(69%) care homes in England the use of this framework in turn has led to the avoidance of 44,969 emergency admissions to hospital. This year, we will be supporting the new focus on encouraging greater involvement from patients, families, and carers, in line with Martha’s Rule, building on the NHS England’s Worry and Concern Improvement Collaborative pilots, which tested different ways for patients, families and carers to escalate their concerns about deterioration.

Better for patients, better for services

Whilst Patient Safety is first and foremost about improving lives through reducing avoidable harm to patients, this example is evidence of the huge financial and productivity gains to be made by focusing on patient safety too.

Reducing harm, reduces demand on our services, and plays a vital role in supporting recovery of our health services. As the key organisation responsible for substantially increasing the adoption and spread of innovation across health and care systems, we support the programme through finding, testing and implementing new ideas, technologies and medicines that can support this ambition.

Here are some of the ways in which our work in Patient safety is improving diagnosis, reducing harm, and also supporting the productivity and recovery of health services:

Medicines optimisation

Our medicines safety programme, which aims to tackle problematic polypharmacy and use of opioids, has prevented 4676 significant harms from medicines, saving 518 lives.

By introducing structured medicine reviews in care homes as part of our medicines optimisation workstream, which have been shown to reduce the number of medicines a person takes by around 20% and when pharmacist-led SMR can result in a mean cost saving of £307 per patient, increased medication adherence and delivered a 40% reduction in Emergency Department attendances.

Maternity and Neonatal

Our work in maternity and neonatal, in particular our roll out of a £1 injectable intervention that reduces the chance of cerebral palsy by over a third and the adoption of the pre-term infant care bundle in 94% of MatNeo units in England, has saved 1198 babies’ lives and prevented 463 cases of cerebral palsy, saving the health and social care system £463m in costs avoided.

Digital intervention

Scan4safety ensures end to end barcode scanning. It released over 22000 clinical hours in a pilot in North Tees and Hartlepool and has delivered £3.2m cumulative savings between 2016 and 2018 at University Hospitals of Derby and Burton NHS FT. It has been spread to 40% of organisations in England.

Developing a pipeline for patient safety

The Health Innovation Network maintains a directory of ‘pipeline projects’ – innovations that have the potential for further testing, evaluating and spread. This provides an opportunity to scan for innovations that can help deliver national safety priorities and to develop programmes for future commissioning.

We are working to identify the safety benefits of the Health Innovation Network pipeline innovations, understand how many have a specific safety focus, and ensure that all of these innovations do not cause harm and are assessed for safety at an early stage. An area for future innovation may be around programmes being developed by the Patient Safety Commission, as a result of the Patient Safety Incident Response Framework (PSIRF). Individual organisations and ICBs are developing safety profiles and improvement plans. These are likely to be locally derived but themed nationally, and aligned to the national safety priorities.

Patient safety in partnership

Our patient safety plan 2024, Patient safety in partnership is our fifth update capturing the impact we’re having. It gives examples of a range of projects helping to translate the commitments of the NHS Patient Safety Strategy into practical activity ‘on the ground’.

This year, Patient Safety Collaboratives will be supporting the delivery of ‘Martha’s Rule’ with local partners as part of their long-established managing deterioration work. This has brought in a clearer system for patients and their families when they don’t feel that their voice is being heard.

Patient safety remains high on the agenda of all NHS and social care organisations in these changing times. We are working to measure our collective impact as 15 health innovation networks, and develop a pipeline of programmes for the future.