World Patient Safety Day 2023

The WHO World Patient Safety Day 2023 took place on 17 September 2023.  The theme this year is Engaging Patients for Patient Safety.  The WHO recognises patient safety as a global health priority and sees patient and family engagement as a key strategy to enhance this.

The WHO indicate that studies show patient engagement can lead to a potential reduction of harm by up to 15%, saving countless lives.  The World Health Assembly resolution (WHA72.6) on Global action on patient safety urges Member States to put in place systems for the engagement and empowerment of patients' families and communities in the delivery of safer health care.  It also encourages the development of a blame-free patient safety incident reporting culture through open and transparent systems that identify causative factors in patient harm.  The aim is to improve patient outcomes and reduce the costs associated with adverse events.  In addition patient engagement is also a fundamental principle of the Global Patient Safety Action Plan 2021-2030. 

This year's World Patient Safety Day theme is particularly relevant given the introduction of NHS England's new framework for healthcare safety investigations – the Patient Safety Incident Response Framework (PSIRF) – which is a contractual requirement for most healthcare providers.  The new framework is now in place with transition for organisations expected to be completed by Autumn 2023 and it sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents.  The PSIRF replaces the Serious Incident Framework (2015) and has 4 key aims:

1. Compassionate engagement and involvement of those affected by patient safety incidents
2. Application of a range of system-based approaches to learning from patient safety incidents
3. Considered and proportionate responses to patient safety incidents
4. Supportive oversight focussed on strengthening response system functioning and improvement

NHS England, together with the Healthcare Safety Investigation Branch (HSIB) and Learn Together,  has published a guide on engaging and involving patients, families and staff following a patient safety incident.  The guidance recognises that patients, their family members and carers may be the only people who have insight into every stage of a patient's journey in the healthcare system and the importance of compassionate engagement.  There are 9 key principles to be followed:

1. Apologies must be meaningful
2. The approach to engagement should be individualised
3. Timing is sensitive (and should also be individualised)
4. Those affected should be treated with respect and compassion
5. Guidance and clarity should be provided
6. Those affected are 'heard'
7. The approach should be collaborative and open
8. Subjectivity is accepted
9. There should be a strive for equality

An emphasis is placed on respecting the input of all contributions to the process.  Patients may have a different perspective from healthcare providers and their contribution should be considered carefully.  Specific training should be provided to those investigating patient safety incidents to optimise engagement and inclusivity in the process. 

Placing patients and their families at the heart of safety and learning is clearly the right approach to take and is to be welcomed. Embedding that learning culture into an organisation and listening to patients and their families is vital as we all strive to make healthcare safer for the future.