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National Patient Safety Agency

Government’s response to report sees patient safety at top of NHS agenda

14 October 2009


The National Patient Safety Agency has said the Government's response to the Health Select Committee's report will help to continue to place patient safety at the top of the NHS agenda as part of improving quality.


Chief Executive Martin Fletcher said: “This report and its response emphasises patient safety as a top priority for the NHS and will help build an even stronger safety culture of reporting and learning to prevent harm to future patients.


“The NPSA has been working collaboratively with the NHS and I am really pleased there has been much progress.


“The National Reporting and Learning System (NRLS) is at the centre of the NHS’ drive to understand risks and identify ways to improve safety.  As one of the most comprehensive patient safety reporting and learning systems in the world, the NRLS provides a unique safety knowledge resource for the NHS.


"The NPSA works with organisations across England and Wales to provide a range of tools for NHS boards to enable them to identify and learn from risks and set priorities for local action.


“Whilst we are pleased with the response and the good progress that has been made, there is still more to do to ensure patient safety remains at the heart at the NHS."




 Notes to Editors:



Media enquiries to the NPSA Press Office:

Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk

Dinah Lartey – 020 7927 9351 / Dinah.lartey@npsa.nhs.uk


The National Patient Safety Agency is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.npsa.nhs.uk.


The NPSA has a number of tools and resources available to support organisations to understand and to make changes to their working practices and safety culture with the aim of reducing harm to patients.


These tools include:


Seven steps to patient safety – a best practice guide to key areas of activity to ensure patient safety is being addressed in an individual organisation.



The Manchester Patient Safety Framework (MaPSaF) – a tool that helps organisations measure their progress towards making patient safety a central focus within an organisation. www.npsa.nhs.uk/nrls/improvingpatientsafety/humanfactors/mapsaf/


Being open – the NPSA’s Being Open policy and tools helps healthcare staff communicate honestly and sympathetically with patients and their families when things go wrong.




Root cause analysis (RCA) – the RCA toolkit provides a framework for reviewing patient safety incidents. Investigations can identify what, how, and why patient safety incidents have happened. Analysis can then be used to identify areas for change, develop recommendations and look for new solutions.



Incident Decision Tree (IDT) – the IDT tool has been created to compliment the NPSA’s RCA toolkit and to help NHS managers and senior clinicians decide whether they need to suspend (exclude) staff involved in a serious patient safety incident and to identify appropriate management action.



Foresight Training – this resource pack has been developed to improve awareness in nursing and midwifery of the factors that combine to increase the likelihood of patient safety incidents. The pack contains a range of training scenarios, paper and video-based, and supporting materials for use by a facilitator. www.npsa.nhs.uk/nrls/improvingpatientsafety/humanfactors/foresight/