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Patient Safety Learning

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  1. News Article
    The Royal College of Obstetricians and Gynaecologists ( (RCOG) has today launched a Race Equality Taskforce to better understand and tackle racial disparities in women’s healthcare and racism within the obstetric and gynaecology workforce. Addressing health inequalities is a key priority area for RCOG President Dr Edward Morris, who is co-chairing the Taskforce alongside Dr Ranee Thakar, Vice President of the RCOG, and Dr Christine Ekechi, Consultant Obstetrician & Gynaecologist and RCOG Spokesperson for Racial Equality. Statistics show, for example, that black women are five times more likely to die in pregnancy, childbirth or in the six-month postpartum period compared with White women and the risk for Asian women is twice as high. During the pandemic, 55% of pregnant women admitted to hospital with coronavirus were from a Black, Asian or other minority ethnic background despite the fact 13% of the UK population identify themselves as BAME. It is also clear that there is a significant gap in understanding the factors that result in a higher risk of morbidity and mortality for Black, Asian and other ethnic minority women in the UK. The Taskforce will collaborate with groups across healthcare and government as well as individual women to address these concerning trends and will ensure that the work of the RCOG is reflective of its anti-racist agenda. Read full story Source: RCOG, 15 July 2020
  2. News Article
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
  3. News Article
    The initial data on a trial of the coronavirus vaccine being developed by Oxford University will be released in the coming week, The Lancet medical journal has announced amid reports its findings have been promising. The development of a vaccine to fight against the virus has been touted as pivotal in returning the world to life as it was before the pandemic by protecting vulnerable people and building up immunity among populations. Now Oxford University’s contribution - one of the world’s leading candidates for a viable vaccine – is understood to have made promising results in initial testing. Read full story Source: The Independent, 16 July 2020
  4. News Article
    Every child in Scotland will need additional mental health support as a consequence of measures taken to tackle the coronavirus crisis, according to the country’s children and young people’s commissioner. Speaking exclusively to the Guardian as he publishes Scotland’s comprehensive assessment of the impact of the pandemic on children’s rights – the first such review undertaken anywhere in the world – Bruce Adamson said the pandemic had sent a “very negative” message about how decision-makers value young people’s voices. He said Scotland has been viewed as a children’s rights champion but that efforts to involve young people in the dramatic changes being made to their education and support “went out the window as soon as lockdown came along”. There have been escalating concerns across the UK about children’s mental health after support structures were stripped away at the start of lockdown. Earlier this week, the Guardian revealed that five children with special educational needs have killed themselves in the space of five months in Kent, amidst warnings over the impact of school closures on pupils. Read full story Source: The Guardian, 16 July 2020
  5. Content Article
    SBAR can be used in any setting to communicate more effectively. It can be particularly effective in reducing the barrier to effective communication across different disciplines and between different levels of staff. When people use SBAR, they conclude by making specific recommendations that help to ensure the reason for the communication is clear. This is particularly important in situations where people may be uncomfortable about making a recommendation, eg those who are inexperienced or who need to communicate with someone who is more senior than them in an organisation. The use of SBAR provides clarity to communication and prevents the unreliable process of ‘hinting and hoping’ that the other person/target audience understands.
  6. Content Article
    Why use this tool? Use a measurement plan in order to clearly set out your family of around 3-8 measures that you will be using to track progress in your improvement project. The template will prompt you to think through your measures thoroughly, and when complete it will be an essential communication and reference document for your project team. This will help ensure consistency of measurement over time and between team members, so minimising the potential for adding in variation to your data that could make it harder to see what’s actually happening.
  7. Content Article
    Why use this tool? To allow a team to explore the possible reasons, root causes and possible solutions for a problem To visually represent the reasons, root causes and possible solutions for a problem To help identify change ideas and develop an improvement plan To enable team to focus on content of the problem, not on the history or differing personal interests.
  8. Content Article
    Why use this tool? To capture and visually represent all the steps in an existing process. To show everyone in a team how a process works in practice now, rather than what they think is happening, To help identify change ideas for improvement. To visually represent a new process. To assist team building as it should involve all team members in accurately capturing current process and the design of any new process.
  9. Content Article
    An Improvement Team would use the tool as a framework for applying the five fundamental principles of improvement: Knowing why there is a need to improve. Being able to interpret if improvement is happening through measurement. Developing an effective change theory which will result in improvement. Testing a change before moving to implementation. Knowing when and how to implement a change.
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