Health Care Risk Report Vol 14 Issue 8 July/August 2008

This issue of Health Care Risk Report (HCRR) focuses on the 60th anniversary of the NHS and has a distinctly ‘patient safety’ theme.

The tone is set in the Forword by Ann Keen MP, parliamentary under-secretary for the NHS, which is titled ‘Patient safety is our priority.’

Pat Anderson, editor of HCRR, reports from May’s Patient Safety Congress that patient safety is now a priority for MPs, managers and clinicians. As Pat says, David Nicholson, Chief Executive of the NHS, has “now made clear to NHS Chief Executives that quality and safety [is] central to their role….” He also said that the English patient safety campaign would not be part of performance management as this would “be the best way of killing it.” Pat completes finished her article on the English national patient safety outlining the national director, Stephen Ramsden’s, view that the campaign would be “led by the service for the service” and that its cause would be “to make the safety of patients  highest priority”, and its aim would be “no avoidable death, no avoidable harm.”

Martin Fletcher, CEO of the National Patient Safety Agency outlines three key patient safety challenges for the next 60 years – building stronger partnerships with patients; the opportunity – and risk – of new technology; and the opportunity for better design for safety.

Brian Capstick provides a short article on learning from incident reports. He concludes that the way forward is to have better quality data on incidents being recorded, and this date should include an account of how much incidents are costing the NHS.

Jackie Cresswell provides a useful summary and timeline around patient safety in the NHS, starting with the establishment of Action for Victims of Medical Accidents (now Action against Medical Accidents, or AvMA) in 1982, and ending up with the patient safety campaign launches in Wales and April in 2008.

Other articles include:

– 60 years of health and safety in the NHS;
– The NPSA’s ‘Foresight Training’ for nurses, which aims to enlighted nurses on factors that can predispose to errors; and
– Patient safety heros: a tale of ‘comic strip’ posters at Barts and the London NHS that include ‘good’ characters such as ‘Reporting Man’ and ‘Detective Investigation with his Root Cause Analysis Droid’, and ‘evil’ characters such as ‘The Punisher’ and ‘Blame Monster’. Intriguing, no?

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

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