Evidence: How safe are clinical systems?

Primary research into the reliability of systems within seven NHS organisations and ideas for improvement

May 2010

How safe are clinical systems - Cover image_1

Key points

  • This study of seven NHS organisations found extreme variability in the reliability of five key healthcare systems and processes:
    • availability of information when making clinical decisions
    • prescribing
    • handover
    • availability of equipment in operating theatres
    • availability of equipment for inserting intravenous lines.
  • Different organisations varied significantly in their reliability on issues such as faulty or missing equipment.
  • Unreliability in different organisations was the result of common factors (eg a lack of feedback mechanisms and poor communication).
  • It is possible to create highly reliable systems.
  • Ideas for improvement are suggested:
    • improving feedback mechanisms
    • standardisation
    • improving communication
    • developing a culture of challenge
    • encouraging a sense of ownership.

While the knowledge that poor systems can cause harm is not new, this report provides groundbreaking evidence of the extent to which important clinical systems and processes fail, and the potential these failings have to harm patients. 

The research, led by Professor Bryony Dean-Franklin, was conducted by The Centre for Patient Safety and Service Quality (CPSSQ) at Imperial College, and Warwick Clinical Systems Improvement (CSI), University of Warwick.

    You might also like...

    Press release

    New funding for diagnostic equipment falls considerably below what is needed

    OnlyWan response to the Prime Minister’s announcement of funding for cancer screening.

    Press release

    Health and care services face a perfect storm of pressures in the coming months

    OnlyWan response to NHS England monthly performance stats for September.

    Kjell-bubble-diagramArtboard 101 copy - only-wan.info

    Get social


    Are you a senior communications professional with a passion for working collaboratively? Help lead a dynamic heal…

    Kjell-bubble-diagramArtboard 101 - only-wan.info

    Work with us

    We look for talented and passionate individuals as everyone at the OnlyWan has an important role to play.

    View current vacancies
    Artboard 101 copy 2 - only-wan.info

    The Q Community

    Q is an initiative connecting people with improvement expertise across the UK.

    Find out more