Patient safety problems exist throughout the NHS, as in all large complex health care systems in the world. However, it is not staff negligence, but the systems, procedures, environment and constraints faced by health care professionals that lie at the root of most safety problems.

Through our Safer Clinical Systems programme, we explored how approaches from other hazardous industries could be used to improve safety in the NHS.

Safer Clinical Systems shows the following:

  • Many health care systems and processes are unreliable and create the potential for harm to patients.
  • Processes need to be redesigned to help make care safer based on systematic analysis of the hazards along care pathways.
  • Small scale locally led improvement work has an important role to play in improving patient safety. However action also needs to be taken at an organisational and system level, to address problems beyond the control of clinical teams. Without it, there will be a limit to the level of improvement that can be achieved at the frontline.
  • Setting ambitious goals for patient safety without investing in developing systems that are capable of reliably delivering care is like asking drivers to drive vehicles more safely without investing in traffic lights, road signs or well-designed road layouts.  

In the Health Foundation's summary and analysis of the programme evaluation, we discuss these issues in more detail and suggest some practical recommendations for those leading improvement in safety.

About Safer Clinical Systems

Safer Clinical Systems is an approach for improving safe and reliable health care. It is based on principles adapted from high-reliability organisations, established risk management techniques from hazardous industries, and quality improvement methods.

The approach aims to improve patient safety not by imposing pre-defined solutions on organisations, but by developing their own capacity to detect and assess system-level weaknesses and introduce interventions to address them.

The Safer Clinical Systems approach was tested and developed over two phases of the Health Foundation's Safer Clinical Systems improvement programme.

The independent evaluation of the programme was carried out by a team from the University of Leicester, University of Birmingham, Imperial College and Johns Hopkins University.

Supplement: Safety Cases Working Group

The Health Foundation's Safety Case Working Group aimed to crystallise an understanding of safety cases – both in terms of how they are applied in other industries and how they might be applied in health care.

The group involved a broad range of individuals from health care policy, practice and regulation, together with academics with expertise in safety cases as well as those involved in developing safety cases as part of the Safer Clinical Systems programme.

The report, Exploring the potential use of safety cases in health care, summarises the working group’s conclusions, explores possible applications of safety cases in health care and provides recommendations for further work.

Further reading

Safer Clinical Systems

Developed as a five year phased programme, Safe Clinical Systems helps health care teams proactively identify potential safety breaches, enabling them to build better, safer health care systems.

Programme

Comments

Kennith



Have you read any good books lately? <a href=" http://oldbarnrescue.com/research-drug-sites-nolvadex.pdf#england ">tamoxifen cre jax</a> Tejada, who played primarily with the Oakland A’s and Baltimore Orioles, overcame an impoverished childhood in the Dominican Republic to become one of the best shortstops of his generation. But performance-enhancing drugs have overshadowed his career and accomplishments.



Jackson



I've got a very weak signal https://www.chineng.nl/oefeningen/chi-neng/oefeningen preco cialis no brasil Through social media, posting pics of what or where we eat, and what we do in our “leisure time” is part of how we define ourselves these days. I’ve had numerous clients use social media as a way of declaring their healthy goals, and letting others know that they’re striving to live a balanced, active life. You don’t have to become an evangelist, or record every minute of your life, but using social media to and “put yourself out there” in a healthy way can be a fantastic strategy for staying connected to your wellness goals.



Boris



I'd like to open a personal account <a href=" https://apc.co.at/index.php/buy-celebrex-uk.pdf#inspiration ">where to buy celebrex</a> LONDON, Aug 2 (Reuters) - New Zealander Ross McEwan wasconfirmed as boss of Royal Bank of Scotland on Fridayand immediately tasked with recovering British taxpayers' cashfrom one of the biggest casualties of the credit crunch.
<a href=" http://1disease.org/buy-cheap-topiramate.pdf#milk ">buy cheap topiramate 25mg</a> Dr Phil Peverley said he was so furious at patients who were &ldquo;hell bent on trying to prove they&rsquo;re really ill&rdquo;, that he thought about using the physicist as an example of someone who is not held back by their disability.
<a href=" http://www.casacuseni.com/how-much-does-propranolol-cost-per-month.pdf#midday ">inderal tablet 10 mg uses</a> "The dollar faces a lot of key event risk in the week aheadwith the release of the U.S. Q2 GDP report and the latest FOMCpolicy meeting on Wednesday, followed by the release of the U.S.employment report for July on Friday," said Lee Hardman,currency strategist at Bank of Tokyo Mitsubishi.
<a href=" http://www.mediarakkers.nl/index.php/tretinoin-cream-usp-01-rouses-point.pdf#teeth ">tretinoin gel microsphere .04 generic</a> As fun as it is to watch the Home Run Derby on TV, it’s a whole lot better to be there in person — and of course to actually catch a home run. But this year, it won’t be easy as Citi Field is one of the toughest stadiums for snagging a souvenir. But if you follow my basic strategies and work your way into one of these five hot spots, you’ll not only leave Citi Field will incredible memories, you might leave with a baseball as well.



Arnoldo



Lost credit card <a href=" https://www.amerion.nl/cheap-proscar-no-prescription.pdf#tea ">finasteride cheap pharmacy online</a> BSkyB, which has used the Premier League to build up itsbusiness over the past two decades, is paying 760 million poundsper season for its rights. BT has acquired its 38 games at anannual cost of 246 million pounds.
<a href=" http://www.bartoszkolata.com/prevacid-50-mg.pdf ">prevacid coupon november 2014</a> "The President expects this level of effort to be sustained not only in the coming weeks and months, but as far into the future as necessary," Carney said. "None of our men and women in uniform should ever have to experience the pain and degradation of sexual assault."
<a href=" http://intermixcomunicacao.com.br/buy-omeprazole-magnesium.pdf ">can i buy omeprazole in canada</a> The state government said in a statement it expects tocomplete the sale of Macquarie Generation, which represents some26 percent of the state's generation capacity, during the2013-2014 financial year.
<a href=" http://www.huntington-hilfe-salzburg.at/index.php/purchase-amlodipine-online.pdf ">purchase amlodipine besylate</a> “This is who I am,” says Wilds, who grew up in the rough-and-tumble neighborhood of Park Hill as well as the Stapleton Houses, where some of his friends were killed and gunshots often rang out. “I’m just a young kid from the Stapleton projects that’s trying to change the world.”



Andres



How much is a First Class stamp? <a href=" http://www.clusterlosser.nl/blog/?p=order-levofloxacin-online.pdf ">order levofloxacin online</a> "Call it dumb luck or coincidence but the announcement thatPresident Obama would nominate current Federal Reserve ViceChairwoman Janet Yellen to become the next Fed chairman haspushed the threat of US fiscal issues to the background," saidChristopher Vecchio, currency analyst at DailyFX in New York.



Larry



When can you start? <a href=" http://www.vdb.nl/is-150mg-of-wellbutrin-xl-enough.pdf ">150 or 300 wellbutrin</a> Immediately after the office opened, on June 18, Afghan President Hamid Karzai blasted the office because he said it was representing itself as a de facto Taliban embassy. The Taliban raised their flag and declared that the office belonged to the &#8220;Islamic Emirate of Afghanistan,&#8221; the name the extremist movement used for the country when it was in power there from 1996 to 2001.



Marquis



This is the job description <a href=" http://www.exerciseregister.org/bimatoprost-lash-enhancer-fda-recall.pdf#responded ">purchase bimatoprost ophthalmic solution</a> "Ample evaporation from very moist soils feeds into tropical cyclones inland, supplying energy to sustain cyclones that would otherwise decay," the study's lead author, Dr. Theresa Anderson, a UGA post-doctoral researcher, told me. "Knowledge of prior rainfall and soil moisture conditions can provide clues as to how a tropical cyclone might behave post-landfall".



Brianna



We need someone with qualifications <a href=" http://baskools.com/buy-tretinoin-gel-05.pdf ">where to buy renova
</a> Microsoft is still one of the world's most valuable technology companies, making a net profit of $22 billion last fiscal year. But its core Windows computing operating system, and to a lesser extent the Office software suite, are under pressure from the decline in personal computers as smartphones and tablets grow more popular.



Michale



Could you tell me my balance, please? <a href=" http://www.mediarakkers.nl/index.php/clomipramine-anafranil-in-india.pdf ">anafranil for ocd reviews</a> So what does he see as Britain&rsquo;s role in this more fragmented new world order? &ldquo;We should be at the forefront of shaping the world in our own image. We are the oldest established democracy, we&rsquo;re a country that believes in the rule of law, individual freedoms, free markets.&rdquo;



Juan



There's a three month trial period http://www.casacuseni.com/generic-bimatoprost-ophthalmic.pdf partition purchase bimatoprost cod next day delivery hay flannel Earlier on Monday the U.S. Federal Energy Regulatory Commission (FERC) ordered the energy company to respond to the allegations from its Office of Enforcement, threatening the company with fines and other charges near $29 million.
http://www.casacuseni.com/clindamycin-300-mg-cost.pdf spiders pleasure clindamycin 300 mg dose cartoon “I would never point the finger and say who was supposed to be here, who was supposed to be there,” Webster said. “It doesn’t really matter. As a cornerback I was always taught to have short-term memory. But when I go back and look at the film I know who was supposed to be where. We are honest with each other, so it may have looked a little worse than it seemed.”



Wilbur



Do you know the address? http://www.marymarygallery.co.uk/index.php/lopid-300-mg.pdf wallace kings lopid ud gemfibrozil 900 mg frames "However, it makes little sense for our universities to be spending millions of pounds more than they need to due to inefficient systems, particularly at a time when they are facing significant cuts in Government funding.
http://supergeniusstudio.com/help-buying-nexium.pdf decimal where can i buy esomeprazole
greatest Grayling added that it included charging for monitoring people who were back in prison and had had their tags removed, people who had left the country, and those who had never been tagged in the first place.



Rubin



Lost credit card <a href=" http://www.leadingtrader.com/order-orlistat-cheap.pdf#false ">order orlistat
</a> Romney says he would support tariffs against China (because we&#8217;re already in a trade war and losing it) but he has balked at even these small tariffs. His claim was that they run the risk of angering China.



Graig



I want to make a withdrawal <a href=" http://www.madegood.com/order-trental.pdf ">order trental online</a> The cholera protocol includes isolating suspected cases and tracing their activity and contacts, issuing water purification tablets, and other measures such as decontaminating the shoes of train and bus passengers.



Roberto



I'll send you a text <a href=" http://www.domzastare-starapruga.com/tetracycline-for-acne-worse-before-better.pdf ">magic mouthwash tetracycline</a> Pickens, apart from owning a fifth of Clean Energy Fuels,has been a vocal proponent of converting some of the massiveamounts of natural gas being produced in North America intotransportation fuel. Chesapeake is the second-largest U.S.natural gas producer.



Rosendo



magic story very thanks <a href=" http://www.toadsplace.com/wp/cheap-prednisone-20mg.pdf ">cheap prednisone 20mg</a> The only scare for Nova came with one out and a runner on in the ninth, when baseball's home run leader Chris Davis sent a soaring high fly to right field. Suzuki knew he had it — "absolutely," he said in English, laughing — so he gave a little deke as he drifted back onto the warning track to make it look as if the ball might be trouble.



Rudolf



Could I borrow your phone, please? <a href=" http://austintorpedoes.us/famvir-online-purchase.pdf ">famvir purchase</a> Outen is seeking to encircle the globe by bicycle, kayak and rowboat. She launched the 20,000-mile (32,190-kilometer) effort, called "London2London," on April 1, 2011, according to her Website. That year, she traveled 11,000 miles by kayak and bicycle across Europe and Asia to Japan, the site says.



Cyril



How do you spell that? <a href=" https://www.amerion.nl/cheap-rosuvastatin-in-india.pdf#continuous ">buy cheap rosuvastatin
</a> U.S. stocks opened mixed as traders balanced upbeat datafrom Germany and China with angst about the timing of FederalReserve tapering as more top Fed officials took to the speakers'circuit. The Dow Jones industrial average was down 0.07percent, the S&P 500 was down 0.27 percent and the NasdaqComposite was up 0.3 percent.



Darren



Could you send me an application form? <a href=" http://www.budas.lt/where-can-i-buy-flagyl-uk.pdf ">where to buy metronidazole or tinidazole</a> Ohio is the latest state forced to find alternate methods after pentobarbital's Danish manufacturer Lundbeck cut off supplies to customers likely to use it for executions, in accordance with Danish law and European human rights law.



Barney



When can you start? <a href=" http://door2doorcars.com/buy-propecia-tablets-uk.pdf#storage ">where can i buy generic propecia</a> NFL star Eli Manning said 'I do' to his college sweetheart Abby Mcgew during a sunset ceremony on the beach at the One&Only Palmilla in Cabo San Lucas, Mexico on April 19, 2008. About 60 loved ones flew to down South to attend the intimate nuptials in which the couple exchanged vows while standing on a platform in the sand as waves crashed over rocks behind them.



Rashad



Is there ? <a href=" https://apc.co.at/index.php/topical-spironolactone-s5-cream-buy-online.pdf ">buy spironolactone uk</a> The loss of sea ice offers tantalizing trade opportunities, because it could make the Northwest Passage navigable more often in summer. This sea route across the Arctic Ocean hugs Alaska's coast and can now be crossed only about every seven summers. Sought by explorers for centuries as a short-cut between Europe and Asia, it could be about 50% fewer nautical miles than a trip via the Panama Canal.



Enrique



How many days will it take for the cheque to clear? <a href=" http://www.toadsplace.com/wp/cheap-prednisone-20mg.pdf#slice ">cheap generic prednisone</a> "I think he's got a very good chance of winning. He can say, 'look I am young, I am not tainted', but of course he can also count on the influence his father's name brings," said Jayum Anak Jawan, professor of politics and government at Universiti Putra Malaysia.



Rodger



Another year <a href=" http://www.wrightwaystudios.co.nz/purchase-finasteride.pdf#physics ">purchase finasteride online</a> For now, he will settle for blowing away the dark cloud over his country, a proud sprinting nation. Some of Jamaica's most decorated sprinters have taken a fall: Asafa Powell, Sherone Simpson and Veronica Campbell-Brown all tested positive for a banned substance and weren't at the worlds.



Destiny



What are the hours of work? <a href=" http://www.huntington-hilfe-salzburg.at/index.php/purchase-generic-paxil.pdf ">purchase paxil</a> These props are simple &ndash; they're typically just sturdy, cotton straps with buckles. Lentz suggests making your own at home by knotting two neckties together. If you don't have neckties handy, find them for a buck at a thrift store, or make your strap from a bathrobe sash, she adds.



Mike



We were at school together <a href=" http://www.visionize.dk/buy-ventolin-inhaler-no-prescription-uk.pdf ">buy ventolin asda</a> "It's a constraint of the Mexican model because if you have an export model, it's all based on cost," said Enrique Alvarez, an analyst at IDEAglobal in New York. "Unfortunately, those costs have to stay low, so you never really have a great deal of expansion in the consumer class."



Mauricio



real beauty page <a href=" http://www.clusterlosser.nl/blog/?p=order-albuterol-inhalers.pdf ">albuterol online order
</a> It is speculated that this is a marketing gimmick to generate compassion and e.g. to influence the decision of the U.S. Supreme Court and the negative attitude of the Obama administration over the criminal Kirchner regime.



Kelvin



I don't know what I want to do after university <a href=" http://www.autovita.lt/index.php/order-clomiphene-citrate-online.pdf ">order clomiphene online</a> "Most of them are doing extremely well now but in the mid 1990s it was scratching a living, so I took a temporary job with the library just to eat. Then it got made permanent and I just drifted away from performing.



Charlie



I'd like to send this letter by <a href=" https://apc.co.at/index.php/buy-albendazole-on-line.pdf ">where can i buy albendazole in uk</a> TOKYO, Aug 2 (Reuters) - Asian shares advanced on Fridayafter brisk U.S. factory activity data and a commitment to easymonetary policy by European central banks and the FederalReserve buoyed Wall Street to record highs overnight.



Jayson



very best job <a href=" http://www.domzastare-starapruga.com/is-topamax-good-for-nerve-pain.pdf ">can i buy topamax online</a> Leaders of the continentwide African Union and the regional Southern African Development Community, or SADC, both urged the losing opposition candidates to exercise restraint over early results indicating a Mugabe lead and, however aggrieved they felt, to turn to legal channels to resolve disputes.



Snoopy



Hello good day <a href=" http://cordesfoundation.org/index.php/prilosec-cheapest-price.pdf#stamp ">omeprazole cheap uk
</a> The chain, whose donuts are named for Walt's top-notch "blue sky" methamphetamine, is among several Albuquerque businesses that have felt a rush to their bottom line with the success of the Emmy-winning show



Miquel



I'm not sure <a href=" http://www.bakken-young.com/index.php/nolvadex-uk-price.pdf ">nolvadex during trt</a> “We got the impression that the physician was pressured by the family in the emergency room. The father was very insistent about having the certificate, and to get rid of the problem, the doctor did it,” University of Montreal researcher Marie-Ève Bouthillier reportedly said.



Pages

Add new comment

* indicates a required field

Your email address will not be published on the site and will only be used if we need to contact you about your comment.

View our comments policy