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Patient Safety Learning

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  1. Content Article
    The Professional Standards Authority (PSA) performance reviews look at a regulators’ performance against PSA's Standards of Good Regulation, which describe the outcomes regulators are expected to achieve. They cover the key areas of the regulators’ work, together with the more general expectations about the way in which regulators are expected to act. Here is the review of the Health and Care Professions Council performance review.
  2. Content Article
    During COVID-19, clinical teams faced disruption, having to respond to challenging circumstances and high uncertainty, whilst providing quality care to patients. We know that staff psychological wellbeing affects team effectiveness and patient experience and resilience is fostered by connections between (not just within) individuals. New collaborations between clinical, service improvement and psychology teams recognised the value of introducing the psychologically-informed ‘Start Well>End Well’ team procedure into routine team processes. This evidence-based approach consists of 1) an enhanced safety briefing, 2) peer-to-peer debrief guidance and signposting for trauma-focused support, and 3) team check-out. Initially launched as a general procedure across all wards with variable uptake, a more tailored co-design and coaching approach was then piloted on 2 neurology wards over 3 PDSA cycles. Formative evaluation (focus groups and written feedback) demonstrated staff felt “cared for” whilst achieving “positive impact” through improved ways of working within new teams.
  3. Content Article
    In response to the COVID-19 pandemic, the Department for Health and Social Care (The Department) began an unprecedented programme of Personal Protective Equipment (PPE) procurement buying items such as gowns, gloves and masks. It eventually purchased 37.9 billion items at a cost of just over £13 billion. Two years on from that initial procurement activity the Department is still having to manage many of the contracts that it signed. It has now received nearly all of the PPE that it ordered but it is in dispute with many suppliers over the quality of the PPE that has been supplied and is also looking at whether fraud was committed on certain contracts. Much of the PPE still resides in storage locations, both around the UK and in China, and the Department is looking at options for how it might now dispose of some of the stock that it deems to be excess. Responsibility for management of the PPE programme has now largely been transferred back to Supply Chain Co-ordination Limited, the NHS’s main procurement partner prior to the pandemic. This report makes a series of recommendations.
  4. Content Article
    The Invited Reviews service was formed in 1998 and offers consultancy services to healthcare organisations on which they may require independent and external advice. Reviews provide an opportunity to healthcare organisations to deal with issues and concerns at an early stage. Medical directors (MDs) or chief executive officers (CEOs) of healthcare organisations can request an invited review when they feel the practice of clinical medicine is compromised and there are potential concerns over patient safety. The Royal College of Physicians (RCP) Invited Reviews service has gained a wealth of experience dealing with demanding situations involving individuals, teams, departments and services. This is their learning from invited reviews report. It brings together their experiences across multiple specialities, identifying common themes and crystallising some of our generic findings, which will prove useful to all in clinical leadership roles.
  5. Content Article
    The Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
  6. News Article
    Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system. The reviews take place after unintended incidents of harm and ensure improvements are made. The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness. It found the process was not "sufficiently robust". In the RQIA report, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an understanding of what factors, both systems and people, have led to a patient or service user coming to harm". It added: "The reality is that similar situations, where events leading to harm have been inadequately investigated and examples of recognised good practice have not been followed, have been and are likely to be repeated in current practice." It identified failures in the SAI procedure, including failures to: Answer patient and family questions. Determine where safety breaches have occurred. Achieve a systemic understanding of those safety breaches. Design recommendations and action plans to reduce the opportunity for the same or similar safety breaches in future. Read full story Source: BBC News, 7 July 2022
  7. News Article
    Louisiana is fighting to become a leader in the race to criminalise doctors who allegedly provide abortions, since the US supreme court ended federal abortion protections. In doing so, the state may also become an example of how abortion bans could worsen maternal health in America, as criminal penalties across the US redefine where and how doctors are willing to practice. In turn, that is likely to worsen a leading reason some states are more dangerous places to give birth – lack of hospitals, birthing centres and obstetricians. “It should be no surprise that in a lot of the states where there’s a [trigger ban], there’s a strong correlation [with maternity care deserts],” said Stacey Stewart, president and chief executive of the March of Dimes, an organization that advocates for maternal and infant health and is strictly neutral on abortion. Many of the same states hostile to abortion have also pursued intersecting policies that can worsen health overall for residents, such as refusal to expand a public health health insurance program for the poor, called Medicaid. Now, the severe criminal penalties and extraordinary civil liability doctors are exposed to under such anti-abortion statutes could become fundamental to how and where healthcare providers decide to practice. Read full story Source: The Guardian, 8 July 2022
  8. News Article
    Emma Hardy MP has secured a Westminster debate on gynaecological wait times. Gynaecology waiting lists across the UK have now reached a combined figure of more than 610,000 – a 69% increase on pre-pandemic levels. New analysis by the Royal College of Obstetricians and Gynaecologists (RCOG) shows that in England, gynaecology waiting lists have grown the most by percentage increase of all elective specialties. Emma is co-chair of the All Party Parliamentary Groups (APPGs) for Surgical Mesh and Endometriosis - both come under the heading of ‘gynaecological conditions’ and both are being impacted by increased waiting times. Through her involvement with these APPGs, Emma has heard the testimony of so many women whose lives have been impacted by conditions that can be so painful and debilitating that they impact on every aspect of family, social and work life. Emma will ask the minister to launch an investigation into possible gender bias in the prioritisation of gynaecology services and ensure that elective recovery will address the unequal growth of gynaecology waiting lists compared to other specialties. Emma said: "It is completely unacceptable that 610,000 women are waiting for gynaecological care across the UK. The reality is that many of these women will be in excruciating pain awaiting treatment, unable to go about their day-to-day lives." Read full story Source: Hull Daily Mail, 5 July 2022
  9. News Article
    An ‘outstanding’ rated mental health trust has been criticised by the Care Quality Commission (CQC) for ‘unsafe’ levels of staffing and inadequate monitoring of vulnerable patients. The CQC said an inpatient ward for adults with learning disabilities and autism run by Cumbria Northumberland Tyne and Wear Foundation Trust “wasn’t delivering safe care”, and some staff were “feeling unsafe due to continued short staffing”, following an unannounced inspection in February. The inspection into Rose Lodge, a 10-bed unit in South Tyneside, took place after the CQC received concerns about the service. Inspectors highlighted a high use of agency staff, with some shifts “falling below safe staffing levels”, which meant regular monitoring of patients with significant physical health issues “was not always taking place”. They said the trust had “implemented a robust action plan” following the inspection. The CQC did not issue a rating. The trust’s overall rating for wards for people with a learning disability remains as “good”, and its overall rating remains “outstanding”. Read full story (paywalled) Source: HSJ, 8 July 2022
  10. News Article
    Some hospital leaders in England say they are "living with risk" every day, with buildings in urgent need of repair. According to NHS trust bosses, delays to funding allocations have stalled vital upgrade projects. Structural safety concerns caused the critical care unit at one trust to be temporarily closed and planned operations were stopped. The government said it was working closely with trusts on building plans. One trust has installed props and steel beams in the maternity unit, making life very difficult for staff and mothers, according to hospital managers. The hospital leaders said the current political situation - with the government looking for a new leader - complicates matters. "This kind of political paralysis and instability is deeply unhelpful for the NHS when we've got a whole range of critical decisions that need to be made not only in capital investments but also NHS pay," said NHS Providers chief executive Saffron Corder. Read full story Source: BBC News, 8 July 2022
  11. News Article
    A world-famous hospital has a culture where some staff may put research interests above patient safety, according to an external investigation. A report published yesterday cited some employees at Great Ormond Street Hospital for Children Foundation Trust as saying “they feel that the hospital sometimes put too much emphasis on pushing the boundaries of science” and “are concerned [this] may lead to a culture where some prioritise innovation over safety in their practice”. The trust’s medical director Sanjiv Sharma commissioned the report into the effectiveness of its safety procedures, from consultancy Verita, in 2020, after families of several patients who died at the hospital raised concerns in the media about how it responded to safety incidents. The report said: “We believe that it is sometimes culturally difficult within Great Ormond Street to accept that things can go wrong and to respond appropriately. We were told that some see the organisation as ‘bullet-proof’ in the face of criticism." “There is also a view outside the trust that some clinicians at Great Ormond Street can find it difficult to accept that something had gone wrong. Some believe that this reflex is deeply ingrained. This is potentially indicative of a culture of defensiveness. Acknowledging this trait is the first step on the road to changing it.” Dr Sharma said in a statement yesterday that GOSH had already taken steps to improve its culture and systems, appointing patient safety educators and patient safety leads in each directorate. Read full story (paywalled) Source: HSJ, 7 July 2022
  12. News Article
    The NHS will have to cut investment in cancer care if ministers award frontline staff a pay rise above 3% but refuse to provide extra money to cover it, health service bosses have warned. The NHS England chief executive, Amanda Pritchard, and Julian Kelly, its chief financial officer, made clear their belief that soaring inflation means the service’s 1.3 million staff deserve a pay award of more than the 3% the government has already given the organisation funding to cover. But they warned that any increase above that would force it to cut services, including primary care and the planned new nationwide network of centres intended to diagnose killer diseases early – unless the Treasury covers the cost of the higher amount. If ministers do award staff more, then the 3% originally planned “we would then be looking at having to … cut back on investment in our major areas, when our major areas are primary care, cancer care, or indeed at the margin … some big capital investments. In fact we were just talking about the diagnostic centres [intended to spot cancer and other illnesses sooner]", said Kelly. “[A] pay settlement higher than 3% and no extra money would entail some really difficult decisions.” It is “not realistic” to expect the NHS to absorb any extra costs, he added. Read full story Source: The Guardian, 7 July 2022
  13. Content Article
    Previous research has shown that visitors can decrease the risk of patient harm; however, the potential to increase the risk of patient harm has been understudied. Sanchez et al. queried the Pennsylvania Patient Safety Reporting System database to identify event reports that described visitor behaviours contributing to either a decreased or increased risk of patient harm. The study provides insight into which visitor behaviours are contributing to a decreased risk of patient harm and adds to the literature by identifying behaviours that can increase the risk of patient harm, across multiple event types. 
  14. News Article
    The chief executive of a hospital has said the building is not in a condition "we should expect any of our nearest and dearest to receive care" in. Kettering General Hospital chief executive Simon Weldon described the site as "a big hotchpotch of things, some things that are new, about 10 years old, to things that are 100 years old, and everything in between". He added: "Those are not conditions a modern hospital should be proud of, those are not conditions we should ask any staff to work in, they are not the conditions we should expect any of our nearest and dearest to receive care." The initial £46m the hospital was award in 2019 was to replace the temporary "power plant". Mr Weldon said he would submit a business case to get money "to fix the vital infrastructure work that will keep this site safe". But he said the hospital really needed to be rebuilt, and that "fixing the hospital would be bad value for taxpayers". Read full story Source: BBC News, 7 July 2022
  15. News Article
    The UK must urgently procure stocks of a drug that can boost vulnerable people’s protection against Covid, experts have urged in a letter to The Times. Evusheld, made by AstraZeneca, was licensed by the UK regulator the Medicines and Healthcare products Regulatory Agency in March. Some people with immune system problems, such as blood cancer patients or organ transplant patients do not get sufficient protection from vaccinations and many are continuing to shield. Campaigners believe that offering Evusheld to those people could allow them to resume normal life. Evusheld is being used in countries including the United States and Israel but the UK government has yet to ask AstraZeneca for supplies. In a letter published in The Times, Gemma Peters, chief executive of Blood Cancer UK, and Lord Mendelsohn, co-chairman of the All-Party Parliamentary Group on Vulnerable Groups to Pandemics, say that this represents a failure of a promise made at the start of the pandemic that the government would “do everything in its power to protect the vulnerable”. They write: “People who are immunocompromised are still dying from Covid at much higher rates than the rest of the population. They cannot afford to wait. They deserve better.” Read full story (paywalled) Source: The Times, 6 July 2022
  16. News Article
    Steve Barclay has been named as the new health secretary following the resignation of Sajid Javid, who stepped down after saying he had lost faith in Boris Johnson's leadership. He starts as secretary of state at a time when the NHS and social care in England are under serious pressure. Amanda Pritchard, the head of NHS England, has warned that the next two years could be even tougher for the health service than the two years since the start of the pandemic. NHS Providers, which represents hospitals and other NHS trusts, described the problems Mr Barclay faces on his first day in the job as "big and pressing". At the very top of that list is a record backlog for planned operations. Read full story Source: BBC News, 6 July 2022
  17. News Article
    The controversial ‘SIM’ mental healthcare model sometimes ‘blurred’ the role of police with healthcare staff, according to results of local reviews seen by HSJ. Following a whirlwind of concerns last summer, national clinical director Professor Tim Kendall wrote to mental health trust medical directors urging them to review use of the controversial Serenity Integrated Mentoring (SIM) programme. Pressure to investigate the model, which has been used by at least 22 NHS trusts in recent years, came from patient groups and clinicians alike. One year on and results of local reviews, obtained under the Freedom of Information Act, have revealed a varying picture of SIM’s use across English mental health trusts. Professor Kendall’s letters, seen by HSJ, asked trusts to investigate five key areas of concern. These included: a lack of patient reported outcomes; adherence to National Institute for Health and Care Excellence guidelines on self-harm and personality disorders; the principle of police involvement in case management; the legal basis for sharing patient records; and human rights/equalities implications. Read full story (paywalled) Source: HSJ, 7 July 2022
  18. News Article
    An acute trust has had to stand down a new service which led to a ‘marked improvement’ in ambulance handover times, due to a lack of permanent funding to support it. In recent months, York and Scarborough Teaching Hospitals Foundation Trust has deployed additional staff to receive and care for patients arriving by ambulance, meaning ambulance crews could be released more quickly. A report to the trust board last month said of the scheme: “Data shows a marked improvement in ambulance release times when deployed.” However, it would cost £1m per year to fully implement the service and the report said commissioners had confirmed there is “no external funding to support this cost”. There have been mounting concerns in recent months over the handover delays experienced by paramedics when taking patients to hospital, which have severely affected their response times for new incidents. In a statement, the trust said it was discussing with system partners how the service, which was introduced on a “short-term basis”, could be supported in future. It was delivered by independent ambulance and healthcare provider CIPHER Medical and used at peak times such as bank holiday weekends. Read full story (paywalled) Source: HSJ, 6 July 2022
  19. Content Article
    In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents.
  20. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
  21. Content Article
    One of the reasons why patient safety may be put at risk during healthcare interventions is a lack of staff adherence to patient safety guidelines. There could be a relationship between staff’s adherence to patient safety guidelines and their perceived level of reward for their work and/or motivation. This study from Asmoro et al. examined the relationship between reward and adherence to patient safety guidelines, and between motivation and adherence to patient safety guidelines, among nurses working in emergency departments (EDs) in Indonesia. They found that ensuring ED nurses are motivated for their work by offering rewards – such as a decent salary, a supportive workplace environment and career progression opportunities – is important to enhance their adherence to patient safety guidelines.
  22. Content Article
    The COVID-19 pandemic has made it more difficult to maintain high quality in medical education. As online formats are often considered unsuitable, interactive workshops and seminars have particularly often been postponed or cancelled. To meet the challenge, Angelina Müller and her colleagues converted an existing interactive undergraduate elective on safety culture into an online event. In this article, they describe the conceptualisation and evaluation of the elective.
  23. Content Article
    This is the report of the Health and Social Care Select Committee endorsing the appointment of Dr Henrietta Hughes as the first Patient Safety Commissioner for England. The publication of this report follows a formal meeting (oral evidence session) of the Committee which took place Tuesday 5 July 2022.
  24. Content Article
    Psychological safety is a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes. More than 20 years of research demonstrates that organisations with higher levels of psychological safety perform better on almost any metric or key performance indicator (KPI) in comparison to organisations that have low psychological safety. However, achieving psychological safety is a challenge in the complex, ever-evolving health and care systems in which we operate. In this guide, Professor Amy C. Edmondson shares insights that emerged from exploring the experience of differing Integrated Care Systems; a range of case studies, and a wealth of tools and resources. This guide is not a 'how to' for how to create psychological safety; it is more of a reflection on the opportunities and challenges in our health and care system, and how you might seek to work with them.
  25. News Article
    A two-day old baby died just days after his mother begged doctors to assess her ahead of a c-section despite her pregnancy being deemed high risk. Davi Heer-Do Naschimento was born via emergency caesarean section during the early hours of 29 September 2021, after doctors at Royal London Hospital failed to communicate crucial details during handover meetings. An inquest at Poplar Coroners Court heard that his parents, Ruth Heer and Tiago Do Naschimento, had asked numerous times for assistance and were not seen by the obstetrics team the day before her planned caesarean. Tragically, after becoming "feverish" during the night, she was rushed into theatre with Devi sadly dying two days later. Speaking on behalf of the family, Francesca Kohler said that there had been “multiple occasions” throughout the day when Ms Heer and her partner had called for assistance and had raised concerns, but were not attended. She had also not been seen by the obstetrics team and had not been spoken to about the upcoming caesarean section. Read full story Source: My London, 4 July 2022
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