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How JAG supports the new NHS patient safety agenda
18 July 2019

Dr Siwan Thomas-Gibson, JAG chair


The new NHS patient safety strategy sets out a positive future that aims to be the ‘golden thread’ running through healthcare and highlights what the NHS will do to continuously improve patient safety.

Having worked as a gastroenterologist for 23 years and with a keen interest in patient safety, I have always been struck by the difficulty we have in learning from errors and near-misses within and across organisations. We all have experiences that significantly influence our careers; an endoscopic complication as a registrar has stayed with me, shaping how I approach my practise, how I teach and how I manage teams. The NHS is complex, however, how can it be that an incident can happen to one patient in one department, then the same incident can reoccur in another patient in another organisation without us sharing what we have learned to prevent further patients coming from harm?

Several years ago, I was inspired to read ‘Black Box Thinking’ by Matthew Syed. This highlighted how common it is to make an error but how important it is to get things right for our patients and speak up. Sadly, this is not always easy to do and the culture of the NHS needs to support this in order for there to be change.

And so, when I read the new NHS Improvement patient safety strategy earlier this month, it resonated with the work we have been doing in JAG. The strategy focuses on bringing patients, staff and partners together to improve patient safety. This important document encapsulates all we are trying to achieve in endoscopy. It aims to create a learning, not blame, culture. There is a commitment towards improving shared learning across the NHS, not just within individual services or organisations, and using digital methods to help to share best practice and have access to data to drive developments.

The strategy highlights three key aims for the NHS to work on:
Insight - looks at culture, leadership and data. An important aspect is the plan to not only investigate those deemed ‘serious incidents’ but to review those incidents with a lower score, to reduce the chance of recurrence in other areas
Involvement - highlights the critical role of patients as partners in safety and the development of a patient safety syllabus to allow for specific training 
Improvement - focuses on scaling great work already taking place to improve safety in different areas across the NHS.


So, how can JAG contribute to this important patient safety strategy?

A key priority for JAG is our Improving Safety and Reducing Error in Endoscopy (ISREE) workstream. We launched our framework for this new project last year and we have made commitments in various areas to ensure we are continually working to improve safety for our patients. 

Here are a few specific pieces of work that we’re working towards as part of our ISREE workplan in 2019:

Development of simulation courses focusing on human factors and non-technical skills and e-learning modules to complement these
Including a measure on the next version of the Global Rating Scale to have an allocated safety lead for endoscopy 
Promoting a patient safety culture through developing a “lesson of the month” from endoscopy team members.

This is just the beginning and we know there’s so much more to do. Through our committees we will work to influence change and provide support and guidance to endoscopy clinical leaders and executives around patient safety and ensure it remains a priority area. We know many units are already doing innovative work in this area. We want to hear from you to share your knowledge and skills. If you’re interested in getting involved, please get in touch.  

Keep updated on our ISREE work by following us on Twitter @JAG_Endoscopy #ISREE and watch out for more news stories as the work progresses.

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