The new NHS Patient Safety Strategy has a big hole in it

In August 2018, I expressed my concern in Clinical Pharmacist that the NHS, described as ‘an organisation with a memory’, was losing its patient safety memory and not addressing many important risks effectively[1]
. Other reports from the Care Quality Commission[2]
and the Healthcare Safety Investigation Branch[3]
also identified shortcomings in how patient safety was being managed in the NHS in England.

A new NHS Patient Safety Strategy for England was published in July 2019[4]
. There are some proposals that I can support (for example, broadening the ways to acquire, exchange and analyse patient safety data, and developing a universal safety curriculum for all NHS staff). But just like in James Reason’s ‘Swiss cheese model’ (used to illustrate the flaws in barriers to prevent errors[5]
), there is a significant hole in the new NHS Patient Safety Strategy that will leave patients at risk of known errors, many of which involve medicines.

The new strategy says that the existing reporting system and a new national reporting system will be analysed by NHS Improvement for new and unknown risks to patient safety, and patient safety alerts will be issued to assist the NHS in addressing these risks.

The document also states that patient safety alerts are not an appropriate response for known, ‘wicked’ risks. This raises uncertainty over the status of previous alerts published by the National Patient Safety Agency and NHS England; for example, those concerning strong potassium infusions, methotrexate, wrong-route errors and omitted medicine doses.

Although there is evidence that implementation of patient safety guidance published in previous alerts has been poor in the NHS[6]
, where is the evidence that the guidance in previously published alerts was not effective if implemented as intended?

What are these “wicked” risks that are supposed to be well known? They would be better known if there was greater transparency by NHS Improvement of the 2 million patient safety incidents reported to the National Reporting and Learning System each year. What are the most frequently reported risks and most severe harms in each category? What safeguards are in place for these risks?

The majority of these “wicked” risks are not addressed by the National Patient Safety Improvement Programme. How will the NHS respond to patients and their families harmed by these “wicked” risks in the future? NHS Improvement needs to provide guidance on how known risks that are not part of the National Improvement Programme should be managed in the NHS in future.


David Cousins, independent consultant in safe medication practice


A spokesperson for the NHS said:

“Actually, the NHS is a world leader in patient safety, having recently published the first comprehensive strategy to improve safety, including embracing new technology with a new and more transparent patient safety reporting system, a medication safety programme to provide focused and long-term support, and the introduction of patient safety specialists to work alongside medication safety officers in every NHS organisation, all of which will empower front line staff to make decisions about the best way to improve patient safety rather than relying only on top-down instructions.”

Background: The new National Patient Safety Alerting Committee will oversee all patient safety alerts to ensure they are of the highest standards to mitigate risks. The Care Quality Commission will also review them during inspections.



[1] Cousins D. A failure to learn from our mistakes puts patients at risk. Clin Pharm 2018. doi: 10.1211/CP.2018.20205263

[2] Care Quality Commission. Opening the door to change: NHS safety culture and the need for transformation. December 2018. Available at: (accessed August 2019)

[3] Healthcare Safety Investigation Branch. Inadvertent administration of an oral liquid medicine into a vein. 11 April 2019. Available at: (accessed August 2019)

[4] NHS Improvement. The NHS Patient Safety Strategy. 2 July 2019. Available at: (accessed August 2019)

[5] Reason J. Human error: models and management. West J Med 2000;172(6):393–396. doi: 10.1136/ewjm.172.6.393

[6] O’Dowd A. Hospitals’ disregard of patient safety alerts is risking lives, claims charity. BMJ 2010;340:c984. doi: 10.1136/bmj.c984

Last updated
The Pharmaceutical Journal, PJ, August 2019, Vol 303, No 7928;303(7928):DOI:10.1211/PJ.2019.20206882

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