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Patient Safety Learning's response to the AHSN Network Strategy for Patient Safety

In June 2019, the Academic Health Science Network (AHSN), established by NHS England in 2013 and re-licensed from April 2018 to operate as the key innovation arm of the NHS, invited comment on its proposed patient safety strategy. The strategy aims to demonstrate the added value that AHSNs and Patient Safety Collaboratives can bring to patient safety by working much more collaboratively.

Chief Executive of Patient Safety Learning, Helen Hughes, has responded to the strategy. Helen comments: "We see the potential of the AHSNs: the capability and expertise, the desire to make a real difference and a belief in collaboration. We want to see this potential realised, and Patient Safety Learning wants to help."

See Helen's response in full

AHSN will launch its strategy at NHS Expo in September.

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NHS health information available through Amazon's Alexa

The NHS has teamed up with Amazon to allow elderly people, blind people and other patients who cannot easily search for health advice on the internet to access the information through the AI-powered voice assistant Alexa. The health service hopes patients asking Alexa for health advice will ease pressure on the NHS, with Amazon’s algorithm using information from the NHS website to provide answers to health questions. Matt Hancock, Health Secretary, said the move will help patients, especially the elderly, blind and those who are unable to access the internet in other ways, take more control of their healthcare and help reduce the burden on the NHS.

However, despite welcoming the move, the Royal College of GPs warned that independent research must be carried out to ensure the advice given is safe. Professor Helen Stokes-Lampard, Chairwoman of the Royal College of GPs, said: “This idea is certainly interesting and it has the potential to help some patients work out what kind of care they need before considering whether to seek face-to-face medical help... However, it is vital that independent research is done to ensure that the advice given is safe, otherwise it could prevent people seeking proper medical help and create even more pressure on our overstretched GP service.”

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Source: The Independent, 10 July 2019

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Caring GPs do more to prolong life than medication, study shows

Researchers at the University of Cambridge discovered that patients who had been diagnosed with Type 2 diabetes were up to 50 per cent less likely to die within a decade if their doctor showed empathy. In healthcare, empathy is defined as understanding the patient’s perspective, shared decision making between patient and doctor, and consideration how the illness may impact other areas of their life. But with financial and time pressures plaguing the NHS, doctors increasingly complain they do not have enough time to carry out the softer side of medicine. Now research, published in the Annals of Family Medicine, shows that showing care for a patient can be far more effective at prolonging life than giving drugs to lower cholesterol or blood pressure and so should be prioritised.

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Source: The Telegraph, 8 July 2019

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NHS operations cancelled as consultants work to rule in pensions standoff

Hospitals are having to cancel operations and cancer scans are going unread for weeks because consultant doctors have suddenly begun working to rule in a standoff over NHS pensions. Doctors say the dispute is escalating so quickly that it will send NHS services “into meltdown” and is so serious that it poses “an existential threat” to the health service’s survival.

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Source: The Guardian, 8 July 2019

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NHS casualty bungles cost £400m

Accident and emergency has become the top source of negligence claims by patients. Delays, misdiagnosis and poor treatment in accident and emergency (A&E) departments are now the top cause of NHS negligence claims, overtaking orthopaedic surgery for the first time. Bungled operations on backs, bones, joints, ligaments, nerves and muscles usually lead to the most claims, but a 41-page NHS strategy document for the next 12 months reveals that emergency units have become the main source of litigation against the service.

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Source: The Times, 7 July 2019

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Hancock hopes NHSX will "transform technology use" across healthcare

Matt Hancock, Secretary of State for Health and Social Care, has said he hopes NHSX will "provide the leadership to transform the use of digital technology" across the health service. Speaking exclusively to Digital Health News at the launch of NHSX in London on 3 July, Matt Hancock added that he ultimately hopes NHSX “will save clinician’s time and patient’s lives”.

NHSX, which will oversee technology across health and social care, was confirmed by Digital Health News in February 2019 and brings together teams from the Department of Health and Social Care, NHS England and NHS Improvement.

Source: Digital Health News, 4 July 2019

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Bereaved families could be forced to turn to ambulance-chasing claims firms, in fight for justice

Plans to cap legal costs for NHS mistakes that lead to deaths of newborns could leave the bereaved at the mercy of 'ambulance-chasing' claims firms, a former Lord Chancellor has warned. Health officials have drawn up plans to limit spending in cases where damages are worth less than £25,000. This covers around eight in ten medical negligence claims, including the deaths of newborns, and stillbirths - where Britain’s record is among the worst in the developed world. Ministers have said the changes will stop “unscrupulous law firms” receiving excessive legal costs that dwarf the damages received by victims. However, Lord Falconer, Lord Chancellor under Tony Blair, raised fears that the measures could see established law firms leave the market  and be replaced by unregulated claim management companies. 

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Source: The Telegraph, 6 July 2019

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New guidance calls on NHS to embed a learning and just culture to support staff, patients and carers

Challenging the NHS’ workplace culture is key to improving patient safety says NHS Resolution in their latest guidance: Being fair: supporting a just and learning culture for staff and patients following incidents in the NHS. The paper draws on NHS Resolution’s unique dataset to explore best practice in response to incidents resulting from claims from across the system. The guidance aims to help the NHS to create an environment to better support staff when things go wrong and to encourage learning from incidents.

 

 

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'Crumbling hospitals’ are putting patient safety and care at risk

Hospitals throughout the NHS are in such a poor state of repair that patient safety and care is being put at risk, according to an investigation by the Labour Party. A freedom of information requests sent to every hospital trust in England highlighted problems such as sewage and water leaking on to hospital wards, broken lifts and ceilings collapsing. The incidents have affected patient care, often leading to the cancellation of appointments and leaving people waiting longer for vital treatment. It is speculated that these issues are not just confined to secondary care.

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Source: Nursing Notes, 5 July 2019

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Sepsis: How good are hospitals at treating 'hidden killer'?

Patients' lives are being put at risk because of delays giving them treatment for sepsis, experts are warning. Hospitals are meant to put patients on an antibiotic drip within an hour when sepsis is suspected, but research by BBC News suggests a quarter of patients in England wait longer. However, NHS England said there were signs performance was improving and that hospitals were getting better at spotting those at risk sooner. 

Dr Ron Daniels, of the UK Sepsis Trust, said the "concerning" figures showed patients were being put at risk. In some hospitals, over half of patients face delays. Dr Daniels said the one-hour window was "essential to increase the chances of surviving". "There is no reason really why it should take longer," he added.

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Source: BBC News, 4 July 2019

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'One in a million’ matron is crowned RCN Nurse of the Year

Royal College of Nursing (RCN) member Tara Matare has won the coveted title of RCN Nurse of the Year 2019. She scooped the leadership category at the RCNi Nurse Awards before being crowned the overall winner. Tara has tackled short staffing, improved workplace culture and enhanced patient care at her ophthalmology unit at Whipps Cross Hospital in London. Over a 14-year mission to overhaul the unit, there have been a steady stream of challenges, including fighting ophthalmology’s corner to ensure it wasn’t overlooked in favour of higher-profile inpatient services and tackling an ingrained culture of bullying.  

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Source: Royal College of Nursing, 4 July 2019

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NHSX: giving patients and staff the technology they need

NHSX has just completed a major review of NHS tech spending. They have agreed to reducing the burden on clinicians and staff, so they can focus on patients; giving people the tools to access information and services directly; ensuring clinical information can be safely accessed, wherever it is needed; aiding the improvement of patient safety across the NHS; and improving NHS productivity with digital technology.

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Tackling bullying in the NHS

The Social Partnership Forum (SPF)’s collective call to action tasks employers and trade unions in all NHS organisations to work in partnership to create positive workplace cultures and tackle bullying. To support this work, the SPF is publicising the views of NHS leaders and experts on this topic and signposting information, tools and resources and case studies which can help partnership initiatives.

Creating positive workplace cultures and tackling bullying in the NHS - a collective call to action

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Rude surgeons may have worse patient outcomes

Traditionally, as a group, surgeons are not well known for their bedside manner. While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession. However, a study published in JAMA Surgery challenges these ideas. The study, which looked at interactions between surgeons and their teams, found that patients of surgeons who behaved unprofessionally around their colleagues tended to have more complications after surgery. Surgeons who model unprofessional behavior can undermine the performance of their teams, the authors write, potentially threatening patients' safety.

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Source: NPR, 19 June 2019

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Can we change the culture around breaks in the NHS?

The culture of working without breaks is dangerous to doctors’ and patients’ wellbeing and only a cultural shift can change things, argues Heidi Edmundson. 

Heidi, Consultant for Emergency Medicine at Whittington Health NHS Trust, discusses in BMJ Opinion how it has become impossible to ignore the huge cost of burnout to both individual doctors and the medical workforce. Breaks are no longer being viewed as a luxury, but as an integral part of physician wellbeing, patient safety, and workforce sustainability. However exceptional reporting and the costs associated with recruitment and retention issues mean that they are becoming a financial issue as well. Heidi ran her own departmental “public health” campaign entitled “take a break” to see if she could change this culture. 

"I started this project with a desire to try and change culture and I have come to realize that changing the culture around taking breaks is really just the tip of the iceberg. What we really need is a huge cultural shift in our attitudes and behaviours towards staff wellness. This will require imagination, innovation, and investment at all levels."

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Source: BMJ Opinion, 28 June 2019

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Blame culture forcing Northern Ireland doctors to consider quitting

Doctors in Northern Ireland feel increasingly "vulnerable" to criminal proceedings in the workplace, forcing them to consider abandoning the profession, senior medic, Dr Tom Black, warns. Dr Black, chairperson of the British Medical Association Northern Ireland, says that consultants in Northern Ireland are operating in a "hostile working culture" as a result of the situation. He explains that medics are increasingly fearful of the professional repercussions if they make a medical error amid pressured case loads: "Doctors feel vulnerable to criminal and regulatory proceedings, and this creates a hostile training environment for our medical students, young doctors... This blame and sanction culture creates disrespect and mistrust. This has a price - it encourages risk avoidance behaviours in professionals, inefficient and ineffective management, increased cost for the system and deteriorating services for patients."

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Source: Belfast Telegraph, 25 June 2019

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NHS patients will be able to log anonymous complaints via smartphones under safety plans

Patients will be able to anonymously log concerns about their NHS treatment, via a phone app, as part of efforts to boost safety. The new strategy will see the creation of a centralised portal, allowing patients, their families and staff to record problems with medical devices, errors in medicines administration, or difficulties in spotting a patient’s condition deteriorating. Officials said that swift recording of such information would enable them to alert the rest of the NHS more quickly to risks of serious harm, and prevent tragedies being repeated.

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Source: The Telegraph, 29 June 2019

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The NHS Patient Safety Strategy

NHS Improvement and NHS England have published their NHS Patient Safety Strategy. The publication out today describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems. The strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety. 

 

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Launch of Patient Safety Learning’s 'the hub'

After many months of development and several user workshops, we are delighted and proud to present the hub at Patient Safety Congress 2019.

the hub is one of the actions proposed by Patient Safety Learning's A Blueprint for Action. The report identifies six foundations of safe care: shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture, and proposes a range of actions to address these foundations. the hub is Patient Safety Learning's share online learning platform, which encourages and facilitates knowledge sharing, collaboration and conversation in patient safety across the whole of health and social care. It is a platform for health and social professionals, patients and their families to share and learn from one another.

the hub is free for everyone to use. Have a browse and you will find the latest news, research, resources and events in patient safety, and lively conversations and debates. Members can share content, comment on posts and start conversations in our communities. Please use the hub, share content and let us know what you think and how we can continue to develop it.

We would like to take the opportunity to thank everyone who has contributed this far in the development of the hub. Your thoughts, ideas and critique have been invaluable. the hub is still in development and we continue to seek out user testing and feedback. Please contact us at feedback@pslhub.org with your ideas or if you would like to be a part of our user testing group.  

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The Care Quality Commission’s annual in-patient survey reveals an increase in patient safety risks

PRESS RELEASE - 1 July 2019

Patient Safety Learning identifies that reduced performance in two aspects of patient experience may increase the safety risks patients face as in-patients.

The Care Quality Commission’s (CQC) recently published 2018 annual in-patient survey shows that improvement in two areas of patient experience has stalled while a range of issues that matter to patients have worsened. The charity, Patient Safety Learning, has identified that deteriorating performance in two of these issues is likely to make patient safety risks worse.

Fewer patients informed properly when discharged home
The CQC’s sixteenth annual survey of people who stayed as an in-patient in hospital was published on 20 June 2019. It shows that most people had confidence in the doctors and nurses treating them, and felt that staff answered their questions clearly.

However, the survey reports that 40% of patients were discharged from hospital without written information about how to look after themselves following treatment. This is up 2% from 2017. Of patients who had been given medication to take home, 44% were not told of possible side effects for which they should watch.

Fewer patients report being involved in their own care
Only 54% of patients report that they are involved as much as they want to be in decisions about their care and treatment, down from 56% in 2017. The number of patients reporting that their views had been sought on the quality of care they received was down by a quarter compared with 2017, from 20% to 15%.

An increasing challenge to safety
Giving patients written information about how to look after themselves on discharge is clearly a patient safety issue. If this practice is reducing, then the inherent risk to patients must be increasing.

Patient Safety Learning’s recent report, A Blueprint for Action, cited a wide range of evidence that communication with patients – listening to them and acting on what is heard – has a demonstrable effect on improving patient safety. The evidence from the CQC survey indicates, however, that such practice is reducing, not increasing, with corresponding implications for patient safety.

Patient Safety Learning Chief Executive, Helen Hughes, said, “Effective communication and engagement with patients is essential for safe care. The CQC’s survey is a valuable tool for assessing this. It is concerning that their report evidences that communication with patients is reducing in ways that have the potential to increase the risk to patient safety. Patient safety is a core part of the purpose of healthcare and action is needed to share good practice across the wider health system.”   /ENDS

Note to editors

Patient Safety Learning is a charity. We help transform safety in health and social care, creating a world where patients are free from harm.

We identify the critical factors that affect patient safety and analyse the systemic reasons they fail. We use what we learn to envision safer care. We recommend how to get there. Then we act to help make it happen. 

Patient Safety Learning’s latest report, A Blueprint for Action, can be downloaded here: www.patientsafetylearning.org/resources/blueprint.

For more information, contact

Margot Knight, Marketing and Communications Manager, Patient Safety Learning
E: margot@patientsafetylearning.org

Or

Helen Hughes, Chief Executive, Patient Safety Learning
T: +44 (0) 7793 550855
E: helen@patientsafetylearning.org

Patient Safety Learning
SB 220
China Works
100 Black Prince Road
London SE1 7SJ

www.patientsafetylearning.org

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Global white paper urges leaders to invest in safe nurse staffing

The Nursing Times has just broken a story about the importance of safe nurse staffing levels, which has been underlined in an international white paper that calls on countries around the world to take action to ensure they have enough nurses.

The paper – launched at the International Council of Nurses’ annual conference – states evidence for a clear link between nurse staffing levels, patient safety and the quality of care is now “overwhelming and compelling”.

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Confidence and trust in hospital staff high but no improvement in inpatient experience

Findings from the Care Quality Commission's (CQC’s) latest annual survey of people who stayed as an inpatient in hospital show that most people had confidence in the doctors and nurses treating them and felt that staff answered their questions clearly. However, just over a third (40%) of patients surveyed left hospital without written information telling them how to look after themselves after discharge (up from 38% in 2017), and of those who were given medication to take home, 44% were not told about the possible side effects to watch out for. 

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