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by Rachel Grace
Last reviewed: May 2018
Patient safety should be at the forefront of
everything we do when we deliver any care or treatment:
‘First do no
Since the 1990s the patient safety movement
has grown and gained momentum and there has been a move away from a
culture of blame and towards an approach that promotes openness and
learning from errors.
Ensuring that patients are safe involves risk
assessment, the identification and management of patient-related
risk, and the reporting and analysis of incidents. It also requires
the capacity to learn from and follow up on incidents, and to
implement solutions to minimise the risk of them reoccurring.
This module summarises key topics from the
literature, provides definitions of patient safety and harm, and
looks at some of the lessons that should be learned from recent
failures in healthcare. These include findings relating to the Mid
Staffordshire NHS Foundation Trust and to Winterbourne View
hospital. Various models of patient safety are outlined, including
the linear ‘Swiss cheese’ model and various non-linear models.
A key theme is the value of reporting,
investigating and learning from incidents. This module looks at
guidelines, initiatives and tools for ensuring that this happens
both locally and nationally to prevent further harm. It also
identifies the most commonly reported types of incident within
mental healthcare and highlights particularly relevant ‘Never
Events’, i.e. types of serious incident that are wholly preventable
if recommendations made at a national level have been
Other modules in this
Clinical audit in mental health practice
by Robin Burgess
QI essentials by Dr Genevieve Holt and Dr Amar
theory: conceptual frameworks in a changing context by
Professor David Crowther and Dr Miriam Green
Forthcoming module in this
History of quality improvement in
Related Advances articles
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