Patient Safety - Health Committee Contents

Annex 1: Terms of reference of the inquiry

1. What the risks to patient safety are and to what extent they are avoidable, including:

  • Role of human error and poor clinical judgement
  • Systems failures
  • How far clinical practice can be risk-free; the definition of "avoidable" risk; whether the "precautionary principle" can be applied to healthcare
  • The role of public perceptions of risk in determining NHS policy

2. What the current effectiveness is of the following in ensuring patient safety:

a)  local and regional NHS bodies, and other organisations providing NHS services (including primary and community care, and mental health services)

  • How far the Boards of NHS bodies have established a safety culture

b)  systems for incident reporting, risk management and safety improvement

  • Whether adequate measurement and assessment is undertaken and acted upon
  • The impact of the changing public-private mix in provision

c)  national policy

  • The appropriateness of the objectives set out in national policy statements, including Safety First and High Quality Care for All, and what progress has been made in meeting them
  • Whether past spending on patient safety has been sufficient and cost effective, and what future spending should be
  • The appropriateness of national targets

d)  the National Patient Safety Agency and other bodies, including:

  • Healthcare Commission / Care Quality Commission
  • NHS Litigation Authority

e)  education for health professionals

3. What the NHS should do next regarding patient safety

  • Whether the measures taken to improve patient safety are supported by adequate evidence regarding their clinical effectiveness and cost effectiveness
  • How to determine best practice and ensure it is spread throughout the whole NHS
  • How to ensure that learning is implemented
  • What should be measured and assessed; and what data should be published
  • What incentives there should be to improve patient safety
  • How patients and the public can be involved in ensuring that services are safe

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Prepared 3 July 2009