Questions are the answer? Seven questions every board member should ask about patient safety

NHS boards play a key role in ensuring the care given is safe and risks are reduced.

Board members can identify gaps in their safety culture, and work to improve it, by answering seven key questions set out in the joint NPSA, NHS Confederation and Appointments Commission factsheet:

• Questions are the answer! Seven key questions every board member should ask about patient safety (pdf, 539 KB)

References, tools and guidance to support the seven questions:

Question 1: Does everyone understand the importance of patient safety?

A clear and explicit view of patient safety is the foundation for setting goals and standards.  Patient safety is everyone’s responsibility and everyone needs to understand what it means for them.

• Patient Safety First Campaign (England)

• 1000 Lives Campaign (Wales)
• Seven steps to patient safety
  
  

Question 2: Do we really have an open and fair culture?

Staff are less likely to report errors or raise safety concerns if they are punished or blamed. Most errors are as a consequence of weaknesses in the system which then affect the performance of the individuals within that system.

• Manchester Patient Safety Framework (MaPSaF)
• Incident Decision Tree
  
  

Question 3. Are we actively encouraging reporting of incidents?

Organisations that report more incidents usually have a better and more effective safety culture. We can’t learn and improve if we don’t know what the problems are.

• Organisation Patient Safety Incident Reports

Question 4. Do we get the right information?

Learning from all sources of data together provides an organisation with a true reflection of where things are going wrong and what is needed to prevent minor incidents from becoming more major and serious incidents.

• Patient safety incident data

Question 5. Are we always open when things go wrong?

Communicating effectively with patients and their carers is a vital part of dealing with errors or problems in their treatment.

• Being open when patients are harmed

Question 6. Do we learn from patient safety incidents?

The response system is always more important than the reporting system. A robust methodology should be in place to ensure incidents are thoroughly investigated so that all contributing factors and root causes are identified and any
recommendations are implemented successfully.

• Root cause analysis

Question 7. Are we actively implementing national guidance and safety alerts?

A resilient organisation strives to continuously improve safety practices rather than being content to keep one step ahead of regulatory sanctions. It is vital to learn lessons from outside the organisation as well as from local information.

• NRLS alerts, Rapid Response Reports and guidance