Evidence: How safe are clinical systems? Primary research into the reliability of systems within seven NHS organisations and ideas for improvement

May 2010

How safe are clinical systems - Cover image_1

Key points

  • This study of seven NHS organisations found extreme variability in the reliability of five key healthcare systems and processes:
    • availability of information when making clinical decisions
    • prescribing
    • handover
    • availability of equipment in operating theatres
    • availability of equipment for inserting intravenous lines.
  • Different organisations varied significantly in their reliability on issues such as faulty or missing equipment.
  • Unreliability in different organisations was the result of common factors (eg a lack of feedback mechanisms and poor communication).
  • It is possible to create highly reliable systems.
  • Ideas for improvement are suggested:
    • improving feedback mechanisms
    • standardisation
    • improving communication
    • developing a culture of challenge
    • encouraging a sense of ownership.

While the knowledge that poor systems can cause harm is not new, this report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients. 

The research, led by Professor Bryony Dean-Franklin, was conducted by The Centre for Patient Safety and Service Quality (CPSSQ) at Imperial College, and Warwick Clinical Systems Improvement (CSI), University of Warwick.

    You might also like...

    Press release

    Significant investment needed as waiting list for routine hospital care continues to grow

    Press release

    Health Foundation response to the publication of NHS England’s monthly performance statistics in...

    Event

    Webinar: How will the public mood shape care after the pandemic?

    Event

    This event, co-hosted with Ipsos MORI, looked at how public perceptions, expectations and priorities...

    Kjell-bubble-diagramArtboard 101 copy

    Get social

    The NHS is beginning to show promising signs of recovery after the strain placed on it by COVID-19. But latest… https://t.co/3qxzdaUAaP

    Follow us on Twitter
    Kjell-bubble-diagramArtboard 101

    Work with us

    We look for talented and passionate individuals as everyone at the Health Foundation has an important role to play.

    View current vacancies
    Artboard 101 copy 2

    The Q community

    Q is an initiative connecting people with improvement expertise across the UK.

    Find out more