Patient Safety Learning

See tweet below from Dr Jake Suett on sharing information on Long-covid:

A recent thread on Twitter:

Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame?

Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, has written a blog for the hub looking at why this has come about and what needs to be done to improve incident reporting.

Do you have any ideas on how we can improve incident reporting? We'd love to hear from you. Reply to this topic below.

World Patient Safety Day on Thursday 17 September this year focuses on staff safety. In her latest blog, Eve Mitchell writes about the new impact COVID-19 is having on the mental health and wellbeing of healthcare staff: compassion fatigue has resulted in frontline staff now having to absorb the anger of the public, patients, and their carers.

If you have been affected by the issues raised in this blog and want your voice to be heard, please share by replying to the topic below. If you prefer to remain anonymous, please email info@pslhub.org and we will ensure confidentiality.

Patient Safety Learning will use such insights to highlight the staff safety issues and call for action.

In April, Lord Wills posed the following parliamentary question "What steps are the government taking to remind NHS trusts of their responsibilities to whistleblowers".

The impact of COVID-19 has seen an increase in whistleblowing amongst key-workers in hospital and care settings. There is a duty to protect whistleblowers who speak out and challenge their employers. Encouraging the right for staff to speak out without fear of repercussion ensures that proactive measures are taken to protect the lives of NHS and care workers.

Read the parliamentary response here: https://www.appgwhistleblowing.co.uk/post/parliamentary-questions-1?postId=5ee2bf71e6ab0a0017d86925

Prerana Issar, Chief People Officer of NHS England and NHS Improvement recently retweeted a message from NHS England and NHS Improvement that "It's so important (for NHS staff) to feel able to speak up about anything which gets in the way of patient care and their own wellbeing".

But we still have a long way to go and much needs to change before NHS staff can be sure that it is safe for them to speak up, as highlighted in a blog published on the hub today from our topic lead, Hugh Wilkins: The right – and duty – of NHS staff to speak up

What do you think? Are you a staff member who has spoken up? What was your experience? We'd love to hear your thoughts.

Thanks for sharing on the hub Akhil. Great to get these insights and to hear how other countries are tackling the pandemic.

We'd love to hear what other countries are doing to meet the current challenges and the solutions they are putting in place. 

Hi Sereima.

Welcome to the hub ?. You may be interested in a community thread we had on RCA last year which has some useful resources and links: 

Since then we have also added some other resources to the hub which might help you:

NHS Improvement:Rootcauseanalysis - using five whys
NHS Improvement: Quality, service improvement and redesign (QSIR)tools
NEBOSH HSE introduction to incident investigation
ROSPA accident investigation training

And you should take a read of Martin Langham's blog series and presentation slides from Helen Higham.

Hope that helps and we'd love to hear others' suggestions. Please add.

Following the recent Patient Safety Learning webinar, ‘Patient safety: Time for questions? Non Covid-19 care and treatment’, we’ve gained a deeper understanding of the key issues frontline staff and patients are facing and have heard many more great ideas around how to address these issues and improve staff and patient safety.

Due to its success, and the clear need to spend more time addressing the issues raised and identifying further issues, we plan to hold more webinars. 

So that we can determine what issues need to be addressed urgently, can you spare a few minutes to tell us about the issue/s related to patient safety and staff safety you are most concerned about?

Please add your comments below.

Frontline healthcare workers in the US are sharing their creative solutions to the PPE shortage and other innovative ideas on Twitter at #MacGuyverCare

A great way to know which member of staff has contacted the patients family and when - thought of by a Matron at Sussex and Surrey Hospitals Trust.

NHS Blood and Transplant are calling for people to donate plasma to help treat coronavirus. They need people who’ve recovered from coronavirus (COVID-19) to donate blood plasma, as part of a potential clinical trial to help with the national effort against the virus.

The trial, if approved, will tell us how effective convalescent plasma (plasma from people who’ve had coronavirus) is for treating coronavirus patients.

Visit their website to see how you could help:

https://www.nhsbt.nhs.uk/how-you-can-help/convalescent-plasma-clinical-trial/

Useful visual from an intensive care doctor on ventilators:

Breast Cancer Now has created this useful web page: Reporting breast cancer symptoms: how the coronavirus outbreak is affecting clinic appointments

Share your tips and ideas on what you and your organisation are doing in the coronavirus pandemic. Let's share our solutions to the many problems and challenges we are currently facing. Here's one posted on Twitter from the Simulation and Resuscitation Department at Gloucestershire Hospitals.

Adele Doherty, Head of Dementia Voice at Alzheimer's Society, has written a blog highlighting the difficulties and fears for dementia patients and their families and carers during the coronavirus pandemic.

Shared by Carola Martino, MD Risk Manager and  Hospital Disaster Manager, Teaching Hospital of Pisa, and
GRC Team at Clinical Risk Management and Patient Safety Centre, Tuscany Region on the Global Patient Safety Network

Today our memory went back to 2016 when the Ebola epidemic was in final stage after devastating several Western African countries. At that time just isolated cases or secondary infections occurred outside Africa.

At that time what we were seeing in Africa was not a problem that would have interested high resources countries.

At that time, in 2016, we were working with WHO to be appointed WHO Collaborating Center and we were studying carefully all the documents that WHO was producing for supporting countries and healthcare systems in getting ready for an emergency, toolkit for evaluating the preparedness of our systems, checklists for evaluating logistics and medical devices and human resources, plans for community engagement.

Plans for "war" have to be defined, tested, simulated, spread, adapted during "peace" time.

But at that time pandemic or health emergency were problems that did not have anything to do with us.

Our risk manager and Hospital Disaster Manager, Doctor Carola Martino that is now working for managing the emergency and the related risks in the Teaching Hospital of Pisa underlines:” You need to exercise your mind to be able to adapt quickly to manage changes, we need to anticipate in time this exercise because in all these situations, time is the only resource that we will no longer be able to recover. This organizational strategy needs a structured method and lots of training and simulations. So we must take this commitment if we want all this experience not to be lost”

One very practical example of managing in different way during the emergency concerns the PPE management. This critical resource must be managed with a centralized approach, underlines Doctor Carola Martino. Infact, at the very beginning of the emergency there was no a single coordination line, or a centralized control of the PPE nor any national guideline that reflected international indications for the most appropriate use of PPE. It is fundamental in each hospital to have a specific procedure
and a centralized point of distribution to manage PPE in order not to waste basic equipment that is precious and scarce during the emergency. This is a small and practical example of different way of thinking during an emergency situation.

We believe that for the future to come, our communities of experts in the field of risk management,  human factor and ergonomic, quality and safety of care and public health should play all together an important role from the very beginning, from the time of peace. Another challenge at the moment is adapting our reporting and learning systems in new ways of tracing information for detecting system weaknesses and barriers to overcome. We have to respond to the situation and react as soon as possible to be
resilient.

Human factors principles can be a guide to coordinate interactions among different stakeholders of the emergencies, simulation sessions the way to learn how to act together when the scenario become real.

We also believe that when the emergency will arrive to an end a profound reflection will have to be done on what really means global health, on what really means one health. May be this scaring crisis will be the opportunity to think again about this.

Tweet from Hugh Pym:

Why aren't staff being protected more? Read this anonymous blog from a hub member on why she is angry and scared.

A member of the hub has just shared the nightmare she is currently living through with her 25-year-old son who has significant cerebral palsy due to kernicterus and is speech, hearing and motor impaired but is isolated with no help.

What more should be done? Do you have a similar story to share? How can we protect the most vulnerable during this pandemic? Add your comments below.

Are you a patient with an issue not related to the coronavirus, and yet facing new challenges because of it?

Understandably the healthcare system is currently focusing its attention on the deadly effects of the coronavirus, so the need to pay attention to patient safety is now more important than ever. We’re asking for patients, carers, family members and friends to share their stories, highlight weaknesses or safety issues that need to be addressed and share solutions that are working. We’re looking for people to share with us:

• What have you noticed that has been different since the crisis started? (e.g., outpatient appointments, collection of medication, GP appointments, cancellation of operations).
• Whether you have had an elective intervention or appointment postponed? (Do you know the warning signs to call for help? Is there a hotline or urgent clinic for you to contact?).
• Has anything improved since the crisis? (e.g., has the use of digital/virtual interventions (accessing a GP) had a positive effect).

Read a summary of this initiative here.

If you are a member of the hub, just reply to this topic below. If you're not already a member of the hub, it's quick and free to join. Register here.

We will be identifying themes and reporting to healthcare leaders with your insights. We want to help close the gaps that might emerge as everyone focuses on the pandemic.

Is the language used by officials describing the coronavirus pandemic dehumanising those with underlying health conditions and making us feel we no longer matter?

In a blog published in the Guardian, Kathryn Hearn says the UK government’s treatment of the coronavirus outbreak has in effect written off all of us with health issues.

Three blogs originally published in the Guardian highlight the serious concerns doctors are having:

‘We don’t have the masks, goggles – or the staff’

"I'm losing faith in the leadership"

"There is a policy of surrender"