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Many years on from the Mid Staffordshire report, avoidable patient harm continues to occur in the UK (and the rest of the world). There continue to be new inquiries and reviews into serious patient safety scandals, all with recurring themes, including failure to listen to patients or learn from previous investigations, a corrosive blame culture, a lack of effective leadership and an unresponsive regulatory framework.

In their ‘Blueprint for Action’, Patient Safety Learning proposes a number of causes for continuing gaps in patient safety, including:

• Patient safety is not regarded as a core purpose by leaders  
• We don’t pay enough attention and take action to design healthcare to be safe for patients and for the staff who work within it
• We don’t learn well enough, to share or act on that learning for patient safety
• Staff working in healthcare are not ‘suitably qualified and experienced for patient safety 
• Staff are not properly supported by leaders and specialists in safety design and human factors
• Patients are not sufficiently engaged in their safety during care and after harm
• We don’t have good ways of measuring and performance managing whether or not we are providing safe care
• A culture of blame and fear undermine our ambitions to design and deliver safer care

The ‘Blueprint for Action’s’ answer to this is six evidence-based actions to directly tackle the causes of unsafe care: 

1. Shared learning for patient safety

If we share learning about patient safety, we will equip more people with tools, insight and thinking that they can use to make patients safer.  

2. Leadership for patient safety 

If we create a model of leadership for patient safety that is shared system-wide, we can ensure that organisations are led consistently to deliver and improve safer care for patients.  

3. Professionalise patient safety 

If we professionalise patient safety, we ensure that everyone is informed and skilled in patient safety - including human factors and systems thinking. We can set and reasonably expect consistent standards of safer patient care.

4. Patient engagement for patient safety 

If we engage patients in patient safety, we can make health and social care safer as patients can offer continuity of insight through the stages of their care.

5. Data and insight for patient safety 

If we have better data and insight into patient safety, we can understand our performance, make better decisions and take more effective action to improve patient safety.

6. Just Culture

If we have a culture for patient safety, we greatly increase the openness and transparency needed to operate our organisations safely.

These actions are a handy ready reckoner for all human service organisations. Do you have a comprehensive patient safety system in place that includes these evidence-based actions to support safer care?

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All accessed 29/6/2023:

PSL. The Patient-Safe Future: A Blueprint for Action. Patient Safety Learning, UK, 2019. https://www.patientsafetylearning.org/resources/blueprint