The HSJ Patient Safety Congress and Awards convenes more than a thousand NHS and independent health and social care leaders, clinicians, patients and patient representatives each September. As the main UK healthcare safety conference, it serves as a barometer for the patient safety field and explores challenges and enablers for safety improvement.
The 2024 event was Jonathan鈥檚 fourth Congress in 12 years and Emma鈥檚 first. What did we learn and what does this mean for paediatrics? Read on for our reflections on three key themes...
From separate groups to collective ownership
Our overriding impression was that there were three distinct groups at the Congress with corresponding separate conversations and networking happening in parallel: leading safety academics and experts; national NHS leaders and safety managers; and key players in the movement for patient, parent and carer advocacy. All had relevant and thought-provoking messages for reflection (more on this below), but there was minimal integration between the groups.
This may reflect the patient safety movement outside of Congress, alongside a possible fourth group: those working in healthcare who don鈥檛 spend their time focusing predominantly on safety. These discrete groups must be integrated if we are to create collective ownership on safety for all.
What鈥檚 new (or not) in safety?
The prevailing message from safety specialists and academics was challenging: a warning cry that we are no safer than we were 25 years ago despite significant work on safety.
There is a history of funding and defunding safety efforts without integrating learning, a predominant focus on reacting to past harms and investing in linear harm reduction interventions, rather than a truly systems approach to managing risk.1 2 We have a wealth of knowledge, understanding and evidence of the value of systems approaches and human factors approaches, but are not using it. Why is that?
NHS leaders and safety management specialists outlined key programmes from national strategies. They provided helpful updates on efforts on a range of - mainly English - top-down improvement programmes, including , , and the implementation and embedding of the .
The patient and carer advocacy discussions from varied leaders in this field, including representatives from and , felt more peripheral than the previous year, though no less important. Themes of restorative justice, collective healing and true collaboration for improvement are still there but we are still working out how to connect these with more traditional, directive models of healthcare.
We are living in Groundhog Day
We listened to powerful talks but were reminded of Groundhog Day 鈥 a famous movie of a cynical weatherman getting trapped in a time loop. This was also the title of the keynote plenary on day 1 from Sir Iain Kennedy, with similar themes and challenges to those we have known about for decades. This is less a reflection on Congress, but a reality that these challenges and topics persist.
For example, the parallels between the care of Martha Mills and Sophie (daughter of Carolyn Cleveland, ) are clear, except they are 10 years apart. Hierarchy amongst staff and between staff and service users, the importance of psychological safety and civility, the pitfalls of blame and our inability to safely share error and failure were themes as prevalent this year as in the early 2010's.
...embracing discomfort...recognising that acknowledging and living with risk is necessary to create a culture of safety
One topic in several talks was that risk is inherent when working in complex systems, let alone when such systems are buckling. advocated for a risk management approach to safety rather than zero harm. Again, this is something that they and many other safety experts have been describing for decades.3 4
Andrew Murphy-Pittock, Education Director at HSSIB, described acknowledging the discomfort of working in a degraded and pressured NHS as akin to wearing a 'hairshirt'. We feel his analogy relates to other key Congress messages of embracing discomfort, both when challenging incivility and in recognising that acknowledging and living with risk (rather than with an assurance of safety) is necessary to create a culture of safety.
This leads us to ask the question: how do we break out of this Groundhog Day (but without having to spend the rest of our life with Andie MacDowell!)? This is a question that Professor Murray-Anderson Wallace and Nick Downham posed in their session and , though in more academic terms.
We are trying to improve healthcare safety, but it doesn鈥檛 appear to be working. Does this mean we are taking the right approach, but need to do it better? Or will this simply make the wrong approach 'less bad'? We are often focussed on the extremes of the curve 鈥 exceptional and substandard practice. Would it help to look more at what everyone in the middle is doing to stay safe despite complex pressures? Perhaps we need to take a different approach...
Two ways we can start to strengthen our safety culture
- Change what鈥檚 in your influence and model the behaviours you want to see. 鈥淓veryone wants to change the world, but no one wants to help mum do the dishes!鈥 Start small, with civility and humble curiosity.
- Forget your Christmas jumper - can your whole team try donning hair jumpers? Rather than looking for assurances of safety, how can you and your team lean into the reality that risk cannot be avoided, but rather managed? Try some of the to consider safety for all.
For more information on safety in paediatrics and child health, please visit our . And look out for our new Safety eBulletin, which will be emailed every two months to members opted in get College updates (you can check your contact preferences on your online account).
- 1Illingworth J, Shaw A, Fernandez Crespo R, Leis M, Fontana G, Howitt P, Darzi A. Global State of Patient Safety 2023. Imperial College London (2023).
- 2Wallace MA, Downham, N. Improving Quality in Healthcare: Questioning the Work for Effective Change. Sage (2023).
- 3Page鈥疊,鈥疘rving鈥疍,鈥疉malberti鈥疪, et al Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. BMJ Quality & Safety鈥2024;33:738-747.
- 4Page鈥疊,鈥疘rving鈥疍,鈥疉malberti鈥疪, et al Health services under pressure: a scoping review and development of a taxonomy of adaptive strategies. BMJ Quality & Safety鈥2024;33:738-747.