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Patient Safety Learning

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  1. Content Article
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    The Nursing Times awards are free to attend and will give you the chance to highlight and reward innovation in workforce planning and management that will contribute to sustaining a workforce fit for the future. The summit will take place over two days, connecting nurses responsible for the recruitment, retention and development of the workforce to meet with solution providers and workforce experts. Book tickets
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    Normally each year the Academy of Fabulous Stuff has a FabAwards Show, shares to the website are shortlisted and voted on and at the awards show the winner announced. This is no ordinary year. Given the amazing work that NHS/Health and Social care staff are doing during the pandemic, now is NOT the time to judge peoples work and vote for winners. Right NOW is a time to say thank You. This is a fabulous free event for everyone working in health and social care. Further information
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    The institution of medicine has always excluded women. From ancient beliefs that the womb wandered through the body causing 'humours' to 19th century Freudian hysteria, female bodies have been marked as unruly, defective, and lesser. We are still feeling the effects of these beliefs today. In 2008, a study of over 16,000 images in anatomy textbooks found that the white, heterosexual male was presented as the ‘universal model’ of a human being. We see this play out in medical research, when it isn't considered necessary to include women's experiences: approximately 70% of people who experience chronic pain are women, and yet 80% of pain study participants are men or male rats. We also see these beliefs inform clinical decisions. When experiencing pain, women are more likely to be given sedatives than painkillers, in a nod to the stereotype that women are more emotional and are therefore probably exaggerating the nature of their pain. This phenomenon is known as the gender pain gap, which describes the disparities in medical care that men and women receive purely due to their gender. But while awareness has risen over the last few years, how close are we to really closing the gender pain gap? Join The Femedic and Hysterical Women in discussion with Dr Omon Imohi, Dr Hannah Short, and research charity Wellbeing of Women as we consider how far medicine has come and how far we still have to go. Register
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  6. News Article
    The death of a premature baby in 2001 led to a "20-year cover-up" of mistakes by health workers, an independent inquiry has found. Elizabeth Dixon, from Hampshire, died due to a blocked breathing tube shortly before her first birthday. The government, which ordered the inquiry in 2017, said the mistakes in her care were "shocking and harrowing". The inquiry report by Dr Bill Kirkup said some of those involved had been "persistently dishonest". Elizabeth, known as Lizzie, died from asphyxiation after suffering a blockage in her tracheostomy tube while under the care of a private nursing agency at home. Dr Bill Kirkup, who was appointed by the government to review the case, said her "profound disability and death could have been avoided". He said: "There were failures of care by every organisation that looked after her, none of which was admitted at the time, nor properly investigated then or later." "Instead, a cover-up began on the day that she died, propped up by denial and deception." Read full story Source: BBC News, 26 November 2020 Patient Safety Learning's statement on the Dixon Inquiry report
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    Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The investigation chaired by Dr Bill Kirkup looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS. Recommendations Hypertension (high blood pressure) in infants is a problem that is under-recognised and inconsistently managed, leading to significant complications. Its profile should be raised with clinicians; there should be a single standard set of charts showing the acceptable range at different ages and gestations; and a single protocol to reduce blood pressure safely. Blood pressure should be incorporated into a single early warning score to alert clinicians to deterioration in children in hospital. Community care for patients with complex conditions or conditions requiring complex care must be properly planned, taking into account and specifying safety, effectiveness and patient experience. The presence of mental or physical disability must not be used to justify or excuse different standards of care. Commissioning of NHS services from private providers should not take for granted the existence of the same systems of clinical governance as are mandated for NHS providers. These must be specified explicitly. Communication between clinicians, particularly when care is handed over from one team or unit to another, must be clear, include all relevant facts and use unambiguous terms. Terms such as palliative care and terminal care may be misleading and should be avoided or clarified. Training in clinical error, reactions to error and responding with honesty, investigation and learning should become part of the core curriculum for clinicians. Although it is true that curricula are already crowded with essential technical and scientific knowledge, it cannot be the case that no room can be found for training in the third leading cause of death in western health systems. Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error. There should be a clear mechanism to hold individuals to account for giving false information or concealing information relating to public services, and for failing to assist investigations. The Public Authority (Accountability) Bill drawn up in the aftermath of the Hillsborough Independent Panel and Inquests sets out a commendable framework to put this in legislation. It should be re-examined. The existing haphazard system of generating clinical expert witnesses is not fit for purpose. It should be reviewed, taking onto account the clear need for transparent, formalised systems and clinical governance. Professional regulatory and criminal justice systems should contain an inbuilt ‘stop’ mechanism to be activated when an investigation reveals evidence of systematic or organisational failures and which will trigger an appropriate investigation into those wider systemic failures. Scrutiny of deaths should be robust enough to pick up instances of untoward death being passed off as expected. Despite changes to systems for child and adult deaths, concern remains that without independent review such cases may continue to occur. The introduction of medical examiners should be reviewed with a view to making them properly independent. Local health service complaints systems are currently subject to change as part of wider reform of public sector complaints. Implementation of a better system of responding to complaints must be done in such a way as to ensure the integration of complaints into NHS clinical governance as a valuable source of information on safety, effectiveness and patient experience. The approaches available to patients and families who have not been treated with openness and transparency are multiple and complex, and it is easy to embark inadvertently on a path that is ill-suited to deliver the answers that are being sought. There should be clear signposting to help families and the many organisations concerned. Ministerial Statement Anne and Graeme Dixon reaction to Dr Bill Kirkup’s report Patient Safety Learning's statement on the Dixon Inquiry report
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    How many times have you been to the drug cupboard/trolley at work and looked at it with despair? How many times have you looked at a written prescription or plan of care and were unable to read the writing? How many times have you gone into the storeroom and spent ages looking for what you want as everything looks the same or it has moved to a different spot? These are what we call error traps. It is as if you have an annoying brother/sister that is trying to catch you out! Sometimes in healthcare, no matter where you work, there are times when it is not easy to do the right thing. Often, we know about these traps and have become used to living with them. We may set up processes that mitigate us making the mistake. This is great, but is this addressing the problem? We have diagnosed the problem, but we haven’t stopped that potential error from happening again. In the world of ergonomics it is the forcing function commonly cited in human factors case studies as recommendations for error-prevention in health and safety contexts. It means forcing users to do something in a certain way in order to proceed on a journey. A great example is how banks have prevented customers from leaving their card in the ATM. The forcing function is that the machine will bleep to prompt the customer to remove the card from the machine before the money is released. This prevents cards being left in the machine. Whereas if there was just a sign saying ‘remember to take your card’ there will always be a risk that people will not read the sign – the sign may fall off or be removed or it will become invisible as people rush about in their daily lives. So how can we solve these error traps in health and social care? We have created an error trap gallery for hub members to share examples of error traps they have come across and also examples of where action has been take and worked. View our error trap gallery and share your examples Reference 1. Steve Highley. An Encounter with an Error Trap. 6 August 2015. https://www.hastam.co.uk/an-encounter-with-an-error-trap/
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    A network of specialist surgical mesh removal centres is to be set up around England, with a launch planned for April 2021. The move implements a recommendation of the review, chaired by the Conservative peer and former health minister Julia Cumberlege, into three treatments which caused avoidable harm. These included the use of transvaginal tape and pelvic mesh to treat pelvic organ prolapse and urinary incontinence. The review, which published its report in July, heard “harrowing” stories about women left with serious complications. The mesh is hard to remove and only a few surgeons in the UK are able to carry out the procedure. Read full story (paywalled) Source: BMJ, 25 November 2020
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    NHS trust chief executives have told HSJ they need more clarity the Pfizer-BioNTech covid vaccine is safe to reassure their worried staff. Trusts were told last week they need to be ready to start vaccinating their staff from early next month. On Tuesday, it was confirmed that they would initially be asked to use the covid vaccine produced by Pfizer and BioNTech, assuming it is granted a licence by the Medicines and Healthcare products Regulatory Agency. Speaking at the HSJ Provider Virtual Summit, St George’s University Hospitals Foundation Trust chief executive Jacqueline Totterdell said there was a lot of “anxiety” around the vaccine among her staff. Leeds Community Healthcare Trust chief Thea Stein added leaders in her city feel “anxious and uncertain”. Ms Totterdell said: “As a responsible officer for 9,000 staff, I also need to be clear that the vaccination is safe. That bit of narrative just needs to come out from the centre, about the reasons why they think it is safe. “I think there is a lot of anxiety, and some of the polls we’ve done around south west London show that as little as 50 per cent of people are willing just to have it without any of that [assurance]." Northumbria Healthcare FT chief executive Sir Jim Mackey, who also spoke at the summit, admitted he was “a bit surprised” by some staff who said they were not going to get the vaccine. The former NHS Improvement chief added: “I think when it actually comes to it, and we get the messaging right about it, not just the responsibility for you but also your responsibility for the people you work with… then the vast majority of people will get it and take confidence in the fact that it’s been developed really quickly and effectively. “These things don’t get signed off if they’re dangerous, so we need to embrace it as the thing that’s going to get us back to normal.” Read full story (paywalled) Source: HSJ, 26 November 2020
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    Ministers are to invest millions in making Britain's maternity wards safer, it was announced on Wednesday after The Independent exposed a series of cases in which mothers and babies had suffered avoidable harm during childbirth. The new money, almost £10m, was announced as part of the spending review unveiled by Rishi Sunak, the chancellor, in the Commons and will deliver new pilots of what the Treasury called “cutting-edge training” to improve practice during childbirth. Significant failings in maternity safety units across the NHS have devastated families and left some babies needing tens of millions of pounds to look after them in later life. In November last year, The Independent joined with the charity Baby Lifeline to call for a new fund to be set up after exposing the single largest maternity scandal in NHS history at Shrewsbury and Telford Hospitals Trust, where dozens of babies have died or been left with brain damage. The new funding will also cover the final year of the independent investigation into the Shrewsbury trust. Read full story Source: The Independent, 26 November 2020
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    Emergency care leaders are warning it will take up to six more months to determine whether pilots of a radical change to accident and emergency are working, even though it is due to go live nationally next week, HSJ has learned. HSJ understands the new “111 First” system — where walk-in patients not in medical emergencies call 111 to “book” urgent care — is set to “go live” across England from next week following pilots in acute trusts which have been run since the summer. From 1 December, people will be able to call NHS 111 from anywhere in the country and have urgent care “booked” for them if needed, it is understood. NHS England has been pursuing the 111 First model to help reduce overcrowding and the risk of nosocomial infections in A&Es. The service is also intended to be able to book them into GP practice appointments. Well-placed sources confirmed most acute trusts have now implemented some form of 111 First and the model is set to be part of their standard operations when the national system “goes live” next week. A national advertising campaign is expected to promote the approach. But the Royal College of Emergency Care Medicine said there was a “vocal minority” of clinicians who are “vehemently against” 111 First as they believe it will increase demand in emergency departments. Read full story (paywalled) Source: HSJ, 25 November 2020
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    While both ME and long Covid, or post-Covid syndrome, are long-term illnesses, they aren’t the same thing. But, there are ways in which our knowledge of ME has helped experts treat long Covid. It’s also helped those with the illness understand what they’re going through. Evan was diagnosed with ME in 2017, and she believes her experience can help her support those living with long Covid. Watch video Source: BBC News, 26 November 2020
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    How are we ensuring that patient and staff safety is being prioritised during the pandemic? Presenters: Helen Hughes, Chief Executive, Patient Safety Learning, Dr Abdulelah Alhawsawi, Director General, Saudi Patient Safety Center, Professor Ted Baker, Chief Inspector of Hospitals, Care Quality Commission It can be argued that staff safety has not been prioritised as it should have been in recent years. The Covid-19 pandemic has reinforced this. It has exposed risks to staff physical and mental wellbeing, with inadequate Personal Protective Equipment (PPE), intensely difficult physical and psychological working conditions, and, tragically, it has resulted in deaths from exposure to Covid-19 as a result of inadequate infection control. The importance of overarching leadership for patient safety in health and social care is a key concept. Ensuring that leaders embed staff safety into safety programmes is essential. Some of the core issues that the panel will be exploring: How are leaders ensuring patient and staff safety during the pandemic? Are we doing enough? How are we prioritising patient access to non Covid care and treatment? Are we doing enough to encourage just and learning cultures and staff speaking up for safety? How are we sharing learning and knowledge on safe treatment and care? How are system and professional regulators ensuring that patient safety is a priority? Register
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    LATEST November newsletter October newsletter September newsletter August newsletter July newsletter June newsletter May newsletter April newsletter March newsletter February newsletter January newsletter
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    NHS Test and Trace chief Baroness Dido Harding will be interviewed by HSJ editor Alastair McLellan at 9am tomorrow as part of HSJ’s virtual provider summit. HSJ’s subscribers working in the NHS or a non-profit organisation can register to attend the summit here. Other speakers will include new Health Education England chief executive Navina Evans and King’s Fund chief executive Richard Murray. The subjects due to be covered include how the NHS will tackle the drive to recover routine care, the service’s workforce challenges and how forthcoming legislation may impact the governance of the service. Full details of the programme can be seen here.
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    Across Britain, intensive care nurses and doctors are being pushed to their limits as they try to save lives from coronavirus. During 12-hour shifts in sweltering conditions, they are faced with technical and emotional challenges that many have never faced as they tackle a virus that has swept across the globe in a matter of days, threatening to kill tens of thousands in the UK. Britain has yet to even hit the peak of infections, but intensive care specialists are already asking how long they can keep working relentlessly. “We are trained for and used to dealing with difficult and emotional scenarios, but this is like a major incident that never ends,” says critical care nurse Karin Gerber. As an advanced nurse practitioner in critical care outreach, the 47-year-old sees patients in hospital who are getting sicker and may need to be admitted to intensive care. She says she has never seen anything “at this intensity”. The Royal London Hospital is at the forefront of the capital’s fight against the virus and has created more than 200 extra beds at its Whitechapel site in east London. They are filled with COVID-19 patients. Simon Richards, senior charge nurse at the Royal London’s critical care unit, tells The Independent: “In 20 years as a nurse this situation is by far the worst I have ever seen and totally unexpected, but the team spirit that people have shown has been amazing. “It’s extremely difficult, we are working so hard. The whole team is being pushed to their limit and you do wonder how long can this be sustained for? I wish we could see light at the end of the tunnel.” Read full story Source: The Independent, 24 November 2020
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    Hospital trusts have been put on notice that the challenging storage requirements of the first covid vaccines are likely to mean the vaccination of their staff will have to form the vanguard of the planned roll-out next month due. HSJ reported last week that healthcare staff would share priority with “care home residents and staff” in the vaccine roll-out. However, a letter sent to trust chief executives by NHS England seeks to clarify the situation by stressing that “different vaccines are likely to be better suited to different settings because the vaccines are likely to have different storage, reconstitution and administration requirements”. “Given what we currently know about the first expected vaccine, the imperative is that NHS trusts are ready to start vaccinating from the beginning of December.” Trusts are one of several components of the vaccination programme that includes primary care-run sites, mass vaccination centres, and “roving” visits to those who need them. Local systems and regional teams will decide “the most appropriate combination of models required to deliver the vaccine to their local populations based on local needs” the letter says. However, during the early stages of the roll-out this is likely to be dictated by the vaccine types that become available. Read full story (paywalled) Source: HSJ, 25 November 2020
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