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Content ArticleA National Patient Safety Alert has been issued on the elimination of bottles of liquefied phenol 80%. The alert has been issued by the NHS England and NHS Improvement National Patient Safety Team, British Orthopaedic Society, The Association of Coloproctology Great Britain and Ireland, and Royal College of Podiatry.
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Content ArticleSafety voice is theorised as an important factor for mitigating accidents, but behavioural research during actual hazards has been scant. Research indicates power distance and poor listening to safety concerns (safety listening) suppresses safety voice. Yet, despite fruitful hypotheses and training programmes, data is based on imagined and simulated scenarios and it remains unclear to what extent speaking-up poses a genuine problem for safety management, how negative responses shape the behaviour, or how this can be explained by power distance. Moreover, this means it remains unclear how the concept of safety voice is relevant for understanding accidents. To address this, 172 Cockpit Voice Recorder transcripts of historic aviation accidents were identified, integrated into a novel dataset , coded in terms of safety voice and safety listening and triangulated with Hofstede’s power distance. Results revealed that flight crew spoke-up in all but two accidents, provided the first direct evidence that power distance and safety listening explain variation in safety voice during accidents, and indicated partial effectiveness of CRM training programmes because safety voice and safety listening changed over the course of history, but only for low power distance environments. Thus, findings imply that accidents cannot be assumed to emerge from a lack of safety voice, or that the behaviour is sufficient for avoiding harm, and indicate a need for improving interventions across environments. Findings underscore that the literature should be grounded in real accidents and make safety voice more effective through improving ‘safety listening’.
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Content Article
NHS Health at Work Network
Patient Safety Learning posted an article in Occupational health and safety
NHS Health at Work is the network of occupational health teams dedicated to ensuring that the NHS has a healthy, motivated workforce that is able to provide the best possible patient care. The NHS is the largest employer in the UK and aims to provide an exemplary occupational health service that is improving the health and well being of over 1.3 million NHS staff. NHS Health at Work influences and advises Government and other bodies about occupational health in the NHS. It also provides a gateway for businesses in the broader community who are seeking occupational health advice and support. -
Content ArticlePeople increasingly provide feedback about healthcare services online. These practices have been lauded for enhancing patient power, choice and control, encouraging greater transparency and accountability, and contributing to healthcare service improvement. Online feedback has also been critiqued for being unrepresentative, spreading inaccurate information, undermining care relations, and jeopardising professional autonomy. Through a thematic analysis of 37 qualitative interviews, this paper explores the relationship between online feedback and care improvement as articulated by healthcare service users (patients and family members) who provided feedback across different online platforms and social media in the UK.
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Content ArticleWaiting lists across the country have risen due to COVID-19 and, as we continue in our recovery from the pandemic, hospitals are focusing on initiatives to reduce the backlog of appointments. Read how Barking, Havering and Redbridge University Hospital are holding 'Bones R Us' super clinics to ensure patients get the care they need.
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Content ArticleYou may not have heard about them; what they do is rarely in their job description. You may not even be aware of what they do; they tend to act as enablers rather than taking credit or seeking the spotlight. But they are here— working on sustainable change, across challenging silos, in complex social landscapes, amid changing circumstances. We call them systems conveners. For many people, being a systems convener is only something that exists in retrospect. They may never have set out to convene people across a social landscape but have found themselves taking this on as a way to make a difference they care to make. Even if they set out with the intention to use a convening approach to make a difference, they may not have an adequate language to describe what they do. The purpose of this book from Etienne and Beverly Wenger-Trayner is to shine some light on systems convening—to emphasise the importance of this work and provide a language to articulate what it entails. The authors also want to describe the experience of people who do it. Systems convening is not an abstract type of work that can be done with detachment. It takes personal commitment and passion. It involves the heart as well as the head. To bring this to life, they have included portraits and quotes from people they interviewed.
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Content ArticlePeople who identify as LGBTQ+ experience disproportionately worse health outcomes and have poorer experiences when accessing health services. In this King's Fund podcast, Helen McKenna sits down with Dr Michael Brady, National Advisor for LGBT Health at NHS England, and Michelle Ross, Co-Founder and Director of Holistic Wellbeing services at cliniQ to explore the health inequalities LGBTQ+ people face and what needs to happen to make sure health services are inclusive.
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Content ArticleThe Defective Medicines Report Centre (DMRC) is part of the Medicines and Healthcare products Regulatory Agency (MHRA). The role of the DMRC is to minimise the hazard to patients arising from the distribution of defective medicines by providing an emergency assessment and communication system between manufacturers, distributors, wholesalers, pharmacies, regulatory authorities and users. This guide is for patients, healthcare professionals, manufacturers and distributors for reporting, investigating and recalling suspected Defective Medicinal Products.
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Content ArticleNo two countries are alike when it comes to organising and delivering healthcare for their people, creating an opportunity to learn about alternative approaches. Schneider et al. compared the performance of 11 high-income countries healthcare systems.
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EventuntilThis seminar is an opportunity for colleagues in public health, early years, social care and the third sector to take stock and consider how Integrated Child and Family Health Services can be redesigned and commissioned to provide early intervention and preventative services. It is also an opportune time to consider what Integrated Child and Family Health services could mean for children and families to lead to better support and outcomes. The event will: Highlight how ICSs can develop truly integrated Child and Family Health Services that improve outcomes and reduce inequalities for children and families. Share exemplars from Integrated Child and Family Health models of innovation and excellence. Inspire system leaders to think and work differently. Register
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Content ArticleThe use of digital health services has risen over the course of the COVID-19 pandemic. The digital divide and the resulting impact on people’s experiences of the pandemic have disproportionately affected certain groups of society. Age UK analysis suggested that only 24% of those aged 75+ were using the internet more during the pandemic, and 9% were using it less. And although the population has become better connected since the start of the pandemic, still 6% of homes (around 1.5 million households) in the UK lack home internet access. People in the poorest households are four times more likely to not use the internet at home than those in the wealthiest households. Disability, impairment, and health conditions also correlate with lower levels of digital access and use. In this article, Emma Stone, Director of design, research and communications at the Good Things Foundation, discusses the implications of digital health services on inequalities.
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Content ArticleDuring the rapid rise in COVID-19 illnesses and deaths globally, and notwithstanding recommended precautions, questions are voiced about routes of transmission for this pandemic disease. Inhaling small airborne droplets is probable as a third route of infection, in addition to more widely recognised transmission via larger respiratory droplets and direct contact with infected people or contaminated surfaces. While uncertainties remain regarding the relative contributions of the different transmission pathways, Morawska et al. argue that existing evidence is sufficiently strong to warrant engineering controls targeting airborne transmission as part of an overall strategy to limit infection risk indoors. Appropriate building engineering controls include sufficient and effective ventilation, possibly enhanced by particle filtration and air disinfection, avoiding air recirculation and avoiding overcrowding. Often, such measures can be easily implemented and without much cost, but if only they are recognised as significant in contributing to infection control goals. The authors believe that the use of engineering controls in public buildings, including hospitals, shops, offices, schools, kindergartens, libraries, restaurants, cruise ships, elevators, conference rooms or public transport, in parallel with effective application of other controls (including isolation and quarantine, social distancing and hand hygiene), would be an additional important measure globally to reduce the likelihood of transmission and thereby protect healthcare workers, patients and the general public.
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Content ArticleThis document provides the principles, concepts, terms and definitions for health software and health IT systems, key properties of safety, effectiveness and security, across the full life cycle, from concept to decommissioning. It also identifies the transition points in the life cycle where transfers of responsibility occur, and the types of multi-lateral communication that are necessary at these transition points. This document also establishes a coherent concepts and terminology for other standards that address specific aspects of the safety, effectiveness, and security (including privacy) of health software and health IT systems.
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Content ArticleInternational Standards and Recommended Practices for aircraft accident and incident investigation.
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Content ArticleHaugen et al. studied the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. They found that the National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture.
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Content ArticleRecently, NHS England and NHS Improvement published planning guidance for the year ahead, outlining six priorities for the NHS as it emerges from the pandemic. The guidance strikes a balance between prioritising covid response and recovery efforts and advancing the broader service transformation objectives of the NHS Long Term Plan. With NHS surgical waiting lists now standing at a record 4.6 million, it is not surprising that accelerating the restoration of elective care is one of the priorities. The elective backlog challenge is not a new one for the NHS, but addressing it has acquired a new urgency and scope. Clearing the backlog sustainably and equitably will require the NHS, as the guidance states, “to do things differently.” In this BMJ article, Jugdeep Dhesi and Lisa Plotkin what they think "doing things differently" must include.
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Content ArticleResearchers have developed an artificial intelligence (AI) tool for rapidly detecting COVID-19 in people arriving at a hospital’s emergency department. The tool can accurately rule out infection within an hour of a patient arriving at hospital, significantly faster than the PCR (polymerase chain reaction) test that has a turnaround time of typically 24 hours.
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Community PostThe Royal College of Midwives have now updated their guidance to members on the importance of staying hydrated on shift and the potential implications of not doing so. Guidance Press release
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Content ArticleThe Royal College of Midwives is calling for "common sense" from NHS trusts and boards on staff access to water and other drinks. The college is concerned that the health and wellbeing of midwives could be in jeopardy as a result of having limited opportunities to stay hydrated on long, hot shifts. .In new guidance to its members, the RCM sets out the importance of staying hydrated on shift and the potential implications of not doing so. These included an impact on decision making, memory, attention span, mood and tiredness. The document also debunks myths suggesting that having fluid bottles on units is a cross infection risk.
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Content ArticleThe aim of this study from Mahadevan et al. was to understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. They observed 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. The study found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. The authors propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.
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Content Article
Humanising the 'machinery' of care (March 2019)
Patient Safety Learning posted an article in Good practice
Charlie Jones and Martin Seager outline ways in which healthcare staff can be more open to spontaneity and connection, and explain why it matters. -
Event
The NHS maternity scandal: Inside a crisis
Patient Safety Learning posted an event in Community Calendar
At a time when the NHS is struggling unprecedently, having been battling a pandemic for 18 months, one of the most concerning areas is the state of maternity services at trusts around the country. It has been uncovered following recent investigations by the Independent newspaper's health correspondent Shaun Lintern that the scale of the problem is putting the lives of both mothers and babies at risk on a daily basis. To explore the apparent crisis existing within our hospitals Shaun will be hosting a live panel discussion with maternity experts who have experience of the situation from within the NHS as well as elsewhere. The speakers will help explain what has gone so wrong, what impact it has had and what lasting effects there might be, as well as what the future holds and if the scandal has at least ensured improvements are now in place and our maternity services are becoming safer for all who use them. The panel will include Donna Ockenden, the chair of Shrewsbury inquiry and Senior Midwifery Adviser, Gynaecologists president Edward Morris and James Titcombe, OBE and ambassador for charity Baby Lifeline; Associate Editor, Journal of Patient Safety and Risk Management and campaigner who helped expose poor care at University Hospitals Morecambe Bay Trust following the death of his son Joshua. Register -
Content ArticleResearch in women's health deserves more attention, and not only for conditions related to reproduction. Clinical and pre-clinical studies alike tend to focus on men: for example, only one-third of people participating in clinical trials relating to cardiovascular disease are women, and an analysis of neuroscience studies published in six journals in 2014 found that 40% of them used only male animals. Although progress can be made when women’s health challenges are brought to the fore, women’s health advocates caution that the field is often still viewed too narrowly. The study of health and disease in women should not be limited to conditions that affect only women. Conditions such as type 2 diabetes, Alzheimer’s disease and heart disease affect men and women differently. Such diseases must be studied in both men and women, with the recognition that diagnosis, prognosis and treatment might need to be different between the sexes.
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Content Article
University of Plymouth: Telerehab Toolkit
Patient Safety Learning posted an article in Telemedicine
The Telerehab Toolkit is a patient and practitioner guide to remote appointments for people with movement impairment and disability. -
Content Article
Thought piece on the Ockenden Report by Susan Stanford
Patient Safety Learning posted an article in Maternity
People with an interest in patient safety read the interim Ockenden report with despair. It was immediately and starkly apparent that it repeated many of the common themes which have emerged in other patient safety investigations. Many of the recommendations in the Ockenden report were already covered by national guidance, Susan Stanford asks why the guidance wasn’t followed and whether it might not be being followed elsewhere.
