The hub's top patient safety picks of 2024

Summary

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. Since launching in 2019, the hub now has over 19,000 knowledge resources, 6900 member from 95 countries and over 1 million unique users.

In this blog, the hub's Editor, Samantha Warne, reflects on the top 10 most popular pieces of content on the hub in 2024. It showcases the breadth of original content shared on the hub from patients, frontline staff and leaders in patient safety.

Content

1 Covid-19 : A risk assessment too far? A blog by David Osborn

In a series of blogs for the hub, David Osborn, a health and safety practitioner has explored the way Government departments have handled healthcare worker safety during the Covid-19 pandemic. In this blog from September, David reflects on the misuse and abuse of ’risk assessment’, the very cornerstone of workplace health and safety. David explains how this left hundreds of thousands of healthcare workers at risk of catching Covid-19 as they provided close-quarter care to infectious patients. As the narrative unfolds, David introduces new information evidenced by emails and other correspondence obtained through Freedom of Information (FOI) requests.

2 A simple guide to the Patient Safety Incident Response Framework (PSIRF)

NHS organisations in England are changing the way they investigate patient safety incidents with the introduction of the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. Our discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides information about what PSIRF is and why it’s been introduced.

3 Patient Safety Incident Response Plan (PSIRP) finder

As part of PSIRF, every NHS trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. We will continue to add links to plans as they become available.

4 Application of SEIPS and AcciMap to a patient safety incident

At the first Patient Safety Education Network meeting of the year, Chris Elston, a patient safety education lead, shared with the group a patient safety incident that happened at this trust. In this blog he describes how he used Safety Engineering Initiative for Patient Safety (SEIPS) and Accident Mapping (AcciMap) to learn from it. 

5 Electronic patient record systems: Putting patient safety at the heart of implementation

Electronic patient record (EPR) systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare. However, it has become increasingly evident that introducing EPR systems comes with serious patient safety risks. In the report 'Electronic patient record systems: Putting patient safety at the heart of implementation', Patient Safety Learning looks at this in depth. Drawing on a recent roundtable event, it considers how patient safety can, and must, be put firmly at the heart of the design, development and rollout of EPR systems. This blog gives a summary of the report and the 10 principles it sets out for safe EPR system implementations.

6 My experience of an outpatient hysteroscopy procedure

Studies indicate that some women do not find hysteroscopy procedures painful. However, it is now widely recognised that many women experience severely painful and traumatic hysteroscopies. At Patient Safety Learning, we have worked with patients, campaigners, clinicians and researchers to understand the barriers to safe care and call for improvements. We believe that no woman should have to endure extreme pain or trauma when accessing essential healthcare.  We invited women to share their hysteroscopy experiences with us, and this blog is one of many stories shared on the hub. We’d like to thank all the patients for to sharing their experiences to help raise awareness of the patient safety issues surrounding outpatient hysteroscopy care.

7 Patient Safety: Emerging Applications of Safety Science

There are few resources and books for professionals within the patient safety sector that use case studies to model the practical application of theories of patient safety incident investigation. Exploring these theories, this book, published earlier this year, brings together contributors from a variety of academic and healthcare professions, alongside those with lived experience, to help you understand some of the emerging theories of safety science and their practical application.

8 A silent safety scandal: A nurse’s first-hand account of a corridor nursing shift

Corridor nursing has featured heavily in the media this year as it is increasingly being used in the NHS as demand for emergency care grows and A&E departments struggle with patient numbers. In this anonymous account, a nurse shares their experience of corridor nursing, highlighting that corridor settings lack essential infrastructure and pose many safety risks for patients. They also outline the practical difficulties providing corridor care causes for staff, as well as the potential for moral injury. Using the System Engineering Initiative for Patient Safety (SEIPS) framework, they describe the work system, the processes and how that influences the outcomes.

9 The hospital told me to GO HOME, but my daughter was critically sick. A bereaved mother’s 11 patient safety lessons

It was a beautiful sunny summer’s day. Twenty-five year old Gaia Young had been out for a gentle bike ride to do some shopping, came home and had an ice cream in the garden in north London that afternoon. Just hours later she was dead. Gaia, the only daughter of Dorit Young, died of an unexplained brain condition after an emergency admission to a London teaching hospital on a Saturday night in July 2021. This is Dorit's story, as a bereaved mother, about lessons she has learnt following the unexpected death of her previously well daughter Gaia. Dorit has written 11 patient safety lessons in the hope this helps other families be more assertive if they have a critically sick relative in hospital.

10 World Patient Safety Day 2024

The theme of this year's World Patient Safety Day was 'Improving diagnosis for patient safety'. In this blog for World Patient Safety Day, Patient Safety Learning sets out the scale of avoidable harm in health and care and highlights the need for a transformation in our approach to patient safety. We reflect on the theme of this year’s event and our World Patient Safety Day blogs shared on the hub, drawing out some key areas, including rapid and timely diagnosis; improving investigations into diagnostic error and the importance of listening to patients.

Share your experiences on the hub

the hub is a platform for everyone with a professional or personal interest in patient safety to share and learn from one another. Have you implemented a new initiative in your organisation? Have you improved patient safety where you work? Or are you a patient and would like to share your experience to improve patient safety? 

We would love to hear from you and share on the hub your stories. This can be done anonymously if you prefer.

If you are a member, you can share directly on the hub or please contact [email protected] to discuss further.