The website of the Clinical Services Journal

Patients continue to be harmed by the failure to learn from unsafe care

The charity, Patient Safety Learning, has published a new report, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS’, which criticises failures to learn from incidents of unsafe care.

The report is an evidence-based summary of the failures over decades to translate learning into action and safety improvement. It highlights that avoidable unsafe care kills and harms thousands of people each year in the UK and costs the NHS billions of pounds for additional treatment, support, and compensatory costs. The report highlights how we fail to learn lessons from incidents of unsafe care and are not taking the action needed to prevent harm recurring.

The report focuses on six sources of patient safety insights and recommendations, ranging from inquiry reports into patient safety scandals, such as the recent Ockenden report into maternal and neonatal harm at Shrewsbury and Telford Hospital, to the findings of Coroner’s Prevention of Future Deaths reports. It calls on the Government, parliamentarians, and NHS leaders to take action to address the underlying causes of avoidable harm in healthcare and proposes recommendations in each policy area. Patient Safety Learning is calling for system-wide action in healthcare to transform our approach to learning and safety improvement. 

Helen Hughes, Chief Executive of Patient Safety Learning, said: “The report highlights the all too frequent examples of where healthcare organisations fail to learn lessons from incidents of unsafe care and not taking the action needed to prevent future harm. Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations...The healthcare system needs to understand and address the barriers for implementing recommendations, not just continually repeat them. Hope is not a strategy.”

This report has been published as part of the Safety for All Campaign, which calls for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. The campaign is supported by Patient Safety Learning and the Safer Healthcare and Biosafety Network.

Upcoming Events

AfPP Annual Conference 2022

University of York
8-11 September 2022

Infection 360: What's trending in infection prevention & control

Edgbaston Stadium, Birmingham
27-28 September 2022

IP2022 IS COMING TO BOURNEMOUTH IN OCTOBER 2022

Bournemouth
17-19 October 2022

UKHCA Conference: Listen Up

Pendulum Hotel and Manchester Conference Centre, Manchester
3rd November 2022

MEDICA 2022

Dusseldorf Germany
14th November - 17th November

Future Surgery 2022

ExCel, London
15th - 16th November 2022

Access the latest issue of Clinical Services Journal on your mobile device together with an archive of back issues.

Download the FREE Clinical Services Journal app from your device's App store

Upcoming Events

AfPP Annual Conference 2022

University of York
8-11 September 2022

Infection 360: What's trending in infection prevention & control

Edgbaston Stadium, Birmingham
27-28 September 2022

IP2022 IS COMING TO BOURNEMOUTH IN OCTOBER 2022

Bournemouth
17-19 October 2022

UKHCA Conference: Listen Up

Pendulum Hotel and Manchester Conference Centre, Manchester
3rd November 2022

MEDICA 2022

Dusseldorf Germany
14th November - 17th November

Future Surgery 2022

ExCel, London
15th - 16th November 2022

Access the latest issue of Clinical Services Journal on your mobile device together with an archive of back issues.

Download the FREE Clinical Services Journal app from your device's App store

Step Communications Ltd, Step House, North Farm Road, Tunbridge Wells, Kent TN2 3DR
Tel: 01892 779999 Fax: 01892 616177
www.step-communications.com
© 2022 Step Communications Ltd. Registered in England. Registration Number 3893025