Stop the NHS patient safety policymaking and practice merry-go-round and act

It seems that there is never a week that goes by without a media report on a patient safety crisis event – and the frequency with which patient safety policy and practice reports are published is also notable. They emanate frequently from one of the myriad of national and international stakeholders in patient safety, an issue that is a global as well as an acute national problem.

The net result of all this patient safety publication activity is that it is increasingly difficult, if not impossible, for busy nurses, doctors and other health carers to keep up to date. There is seemingly not enough time to unpack and digest the latest report before another one comes along saying the same or similar things. A notable feature of patient safety and health quality reports over the years in the NHS is that they frequently say the same thing. These repeated messages include:

These are just some of the key messages that lie at the heart of efforts to develop an NHS patient culture. The message repetition pattern indicates that lessons have not been learnt properly. Practice has not changed sufficiently, with the same or similar mistakes being made again.