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Patient Safety Learning

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  1. Event
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    This two day intensive masterclass will provide Root Cause Analysis Training in line with the July 2019 Patient Safety Strategy. This intensive two day masterclass will provide Root Cause Analysis training in line with the 2019 Patient Safety Strategy and subsequent guidance. The course will offer a practical guide to conducting RCA with a focus on systems-based patient safety investigation as proposed within the latest guidance released by NHS England and NHS Improvement. The course provides insights into how RCA is evolving and gives detailed information on what standards RCA investigations are expected to reach following the detailed recent reviews of patient safety work across the NHS and healthcare. For further information and to book your place or email kate@hc-uk.org.uk hub members receive 20% discount code. Email info@pslhub.org
  2. Event
    This course is suitable for anybody who deals with complaints as part of their job role, or anybody who may have to handle a complaint. This includes dedicated complaints teams and customer support teams and managers. A highly interactive and effective workshop to improve confidence and consistency in handling complaints. The masterclass explains how mediation works and how techniques can be used effectively within local complaint resolution to develop a person-centred process (for both patient and healthcare professional). Within these key areas, the course will explore how unconscious bias plays a role in complaints and their resolution. A mediation inspired approach to complaint resolution produces invaluable insight to help reduce recurring complaint situations, develop training and development plans and support the teams on the frontline. Further information and to book or email kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org
  3. Event
    The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. Further information and to book your place visit or email: kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org
  4. Event
    The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. Further information and to book your place visit or email: kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org
  5. Event
    The course will offer a practical guide to Root Cause Analysis with a focus on systems-based patient safety investigation as proposed by the forthcoming National Patient Safety Incident Response Framework which emphasises the requirement for investigations to be led by those with safety investigation training/expertise and with dedicated time and resource to complete the work. This course will include an opportunity for learners to gain a Level 3 qualification (A level equivalent) in RCA skills (2 credits / 20 hours) on successful completion of a short-written assignment. This one-day course is designed to provide delegates with the key skills and knowledge that they will require to conduct Root Cause Analysis effectively. The course content walks learners through the seven-key stages to conducting a high-quality Root Cause Analysis investigation. It pays particular attention to planning and managing investigations, interviewing staff, mapping information, using appropriate analysis tools to establish contributory factors, plus focus on creating fit-for-purpose action plans and final reports. It advocates Root Cause Analysis as a team-based approach and concur with NHS Improvement’s 2018 statement ‘investigations must be led by trained investigators with the support of an appropriately resourced investigation team’. Further information and to book your place visit or email: kate@hc-uk.org.uk hub members receive a 20% discount. Email: info@pslhub.org
  6. Content Article
    In the Patients Association 2020 survey, patients told us about their experiences of living with health and care needs during the COVID-19 pandemic. Their testimony painted a bleak picture in many ways. This follow-up survey finds that many aspects of their experiences are not much better, and some are worse.
  7. Event
    Sarah Miller, Director of Partnerships, Patient Safety Movement Foundation is joined by Ariana Longley, Chief Operating Officer of the PSMF to discuss how you and your loved ones can prepare before going into the hospital. Ariana highlights the importance of knowing possible risks and alternatives to proposed treatments, things you should bring to your hospital visit, and shares the free resources the Patient Safety Movement Foundation has to offer, both general and COVID-19 resources.
  8. News Article
    General practices are “reaching breaking point” because of the “intense” workload pressure facing doctors and staff, the country’s most senior GP leaders have warned. The warning came as new figures from NHS Digital showed that practices in England delivered almost five million more appointments in March 2021 than the month before and nearly three million more than in March 2019. Richard Vautrey, chair of the BMA General Practitioners Committee, said that the figures underlined the huge efforts practices were going to and the workload pressure on staff. He said, “GPs and their teams are consistently telling us they’re busier now than they have ever been, and this data—which does not include a large proportion of the vaccine programme undertaken by practices, nor a vast amount of other daily tasks—backs this up.” Last week the Ivy Grove Surgery in Derbyshire provided an example of the strain facing some practices in a 16 page open letter to its patients about the huge demand it was facing and the resulting risk of staff burnout. The surgery said it would be reducing its use of the video consultation tool eConsult, as it had seen a doubling of demand over recent months, with some patients submitting several requests a day. In a statement the practice told The BMJ, “We are aware of the stir our letter has caused but have also been overwhelmed by the kind feedback from our own patients, and the many encouraging messages of support we have received from GP surgeries all around the country. We therefore know that many of our GP colleagues are experiencing the same issues, but they may be fearful of articulating what is happening." “We feel that open and honest debate about demand and workload in general practice is vital. If this letter goes even a little way towards sparking some much needed discussion then it will have been a good thing.” Read full story Source: BMJ, 4 May 2021
  9. Content Article
    Asthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition. Healthcare Safety Investigation Branch (HSIB) looked at the risks involved in the management of children aged 16 years and under diagnosed with asthma. Diagnosis and the management of asthma, particularly in children and young people, can be complex. It is important to get it right, as otherwise significant harm or death can result. The investigation was launched after HSIB identified an event involving a 5 year old child. The child had numerous planned and unplanned (emergency) attendances at hospital with respiratory symptoms, before suffering a near fatal asthma attack. Prior to the event, the child had no formal diagnosis of asthma and issues had been identified (but not resolved) regarding adherence to treatment.
  10. News Article
    Children with asthma are at risk of avoidable deaths in England because of poor NHS systems and a failure to appreciate the dangers posed by the condition. A new investigation by NHS safety watchdog the Healthcare Safety Investigation Branch (HSIB) has revealed a series of risks to children with asthma, as concerns emerge of the impact of the pandemic on asthma patients more generally. The latest inquiry was sparked by the deaths of three children between 2014 and 2017. All were caused by asthma attacks which were later the subject of warnings by coroners. In each case HSIB said there were missed opportunities to recognise asthma as a life-threatening condition as well as problems with how the children were managed by doctors working in different parts of the NHS. Read full story Source: The Independent, 5 May 2021
  11. News Article
    Women are bearing the overwhelming brunt of the “gargantuan challenges” health and care services are grappling with during the Covid pandemic, health leaders have said. A new study by the NHS Confederation’s Health and Care Women Leaders Network found female health and care workers’s physical and mental health substantially deteriorated due to working during the coronavirus crisis. The survey, which polled more than 1,200 NHS staff in February and March this year after the virus peaked, found issues with mental and physical health had notably worsened since last summer. Researchers found more than 80% of women said the pandemic meant their job had greater detrimental repercussions on their emotional wellbeing. This is a significant rise from 72% of female workers who said the same during equivalent research carried out in June. The report, which polled nurses, doctors, administrative staff, allied health professionals and managers, warned there are “still many mountains to climb” as services strive to cope with the chaos unleashed by the Covid crisis, as well as dealing with the long-term consequences of the pandemic. The study said: ”This includes tackling the growing issue of long Covid, meeting increased demand for mental health services, continuing to deliver the largest vaccination programme the UK has ever seen, and addressing a backlog of treatment that could extend to nearly seven million people by the end of 2021." Read full story Source: The Independent, 5 May 2021
  12. Content Article
    The Patient Safety Movement Foundation has compiled all of their achievements over the past year into their first-ever annual report. Despite the global COVID-19 pandemic, they have stayed loyal to their vision of achieving ZERO preventable patient harm and death across the globe by 2030.
  13. News Article
    When we put people on a pedestal, my experience is that they are less likely to be asked, ‘are you OK?’, writes Samantha Batt-Rawden, a senior registrar in intensive care medicine. Like many she has been touched by the groundswell of support from the public. But there’s a problem with this hero image, she says. "It’s not just that many NHS staff are feeling increasingly uncomfortable with being hailed as heroes for what they see as simply doing their jobs. Of course, we were going to step up to the plate when the COVID-19 pandemic hit. As doctors it was our duty. There was never any question. "But there’s something more than just feeling undeserving of the cape weighing heavily on our shoulders. The worst thing about being seen as a superhero? Very few think to ask if you’re OK. And herein lies the problem. Because healthcare workers are not heroes, we are human. Completely, painstakingly, fallibly human." Read full story Source: The Independent, 2 May 2021
  14. Content Article
    Hospitals across the US are grappling with nurse shortages as the pandemic continues to change the healthcare system as we know it. Two intensive care unit nurses who left their jobs shared their experiences in Becker's Hospital Review.
  15. Event
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    In this #RedRisks Live Event hosted by Sonni Gopal with Diane Chadwick-Jones, the key components of safety leadership and the mechanisms by which it strengthens safety performance, including the statistical proof of effectiveness from across industries, are explored.We know that rules alone don’t drive behaviour, and that even the best trained, most diligent, and well-motivated people can make mistakes due to workplace influences.For an organisation to be successful, leaders work to shape the culture by the priorities that they set and their engagement with the workforce.Drawing upon experience from working with many companies, Diane will cover the principles and steps for implementing safety leadership, and how to build your own skills to improve safety in your company. Focussing on:– What is “safety leadership”?– Why it improves safety performance?– How you can build your skills as a safety leader? Find out more
  16. News Article
    Healthcare workers and patients are being put at risk not only from COVID-19 but other deadly diseases as a result of an increase in sharps injuries due to the pandemic. Sharps injuries are accidents where a needle or other medical sharp instrument penetrates the skin with the potential to transfer blood borne viruses, including HIV or hepatitis B or C, from the patient to healthcare worker and vice versa. Sharps injuries cause increased costs and disruption in the healthcare system, which have all been exacerbated by the pandemic anyway. Sharps injuries also have a major emotional and mental impact on staff who always put patients first and literally have put their lives on the line during COVID-19. The European Biosafety Network has commissioned a survey to be published in June on the impact COVID-19 has had on sharps injuries in Europe. The preliminary findings of the survey by Ipsos MORI, covering more than 300,000 healthcare workers in 80 large public hospitals across Europe, show that the number of sharps injuries has increased by some 276,000 injuries (23%) over the last year: with 98% of respondents saying that the increase was a result of the increased pressure and stress due to COVID-19. Other recent published survey results also show that the number of reported sharps injuries has increased as a result of the pandemic. We need to ensure that other existing legislation and regulations which prevent sharps injuries are both understood and complied with. Read full story Source: The Brussels Times, 28 April 2021
  17. Content Article
    In the United States many areas have returned to a 'new normal,' as the COVID-19 pandemic has come under control. In this blog, Dr Michael Ramsay, Chairman of the Board, Patient Safety Movement Foundation looks at what we learned and where we failed.
  18. Content Article
    The recording of harm and adverse events in psychological trials is essential, yet the types of harm being captured in trials for talking treatments involving children and young people have not been systematically investigated. The aim of this review from Daniel Hayes and Nur Za’bawas was to determine how often harm and adverse events are recorded in talking treatments for children and young people, as well as the metrics that are being collected.
  19. Event
    Since the emergence of the disease, severe Covid infections have been associated with a risk of severe and dangerous coagulopathy. And in recent weeks two vaccines have been linked to a rare increased risk of clotting, in particular cerebral sinus venous thrombosis (CSVT) which requires urgent and specific treatment. This Royal Society of Medicine webinar will tell the story of our understanding of these coagulation disorders, looking at the causes, risks, diagnosis, and treatments. Register
  20. Event
    A high level meeting convened by the World Health Organization Deputy Director General to drive national and local action mainly by high level decision makers, in order to sustain improved hand hygiene behaviour at the point of care. The meeting is organized in the context of the World Hand Hygiene Day 2021. Objectives: Outline the case for the range of hand hygiene investment and improvement efforts to be taken in health care, especially by decision makers at national and facility level. Showcase policy maker and national leads’ views on how to achieve hand hygiene action at the point of care, presenting their country improvement efforts related to the different aspects of the WHO multimodal hand hygiene improvement strategy. Intended for those at national and facility level who can influence hand hygiene investment and programmes (i.e. decision-makers rather than frontline health care workers). Infection prevention and control (IPC), water, sanitation and hygiene (WASH), quality of care and patient safety leads at national level, and WHO and other United Nations agencies representatives and technical leads are invited to join, as well as facility managers, donors, partners and non-governmental organizations (NGOs) (chief executive and director level/technical leads) with an interest in improving hand hygiene in healthcare facilities. Agenda and registration
  21. News Article
    Patients with life-threatening coronary heart disease will be treated five times faster thanks to 3D scans being introduced on the NHS that allow for a diagnosis in just 20 minutes. The revolutionary technology can turn a regular CT scan of the heart into a 3D image, allowing doctors to diagnose them rapidly, NHS England said. It added that about 100,000 people will be eligible to use the HeartFlow technology over the next three years. Patients – who would previously have had to undergo an invasive and time-consuming angiogram in hospital – will now be seen, diagnosed and treated around five times faster. The new technology, introduced from last month, is part of the NHS long-term plan to cut the number of heart attacks and strokes by 150,000. NHS England said more people here will have access to the potentially life-saving technology than anywhere else in Europe, the US or Japan. Matt Whitty, director of innovation and life sciences for NHS England, said HeartFlow had been a “huge success” in clinical trials and would now help “tens of thousands of people a year receive quick diagnosis and treatment and ultimately save lives”. Read full story Source: The Guardian. 4 May 2021
  22. News Article
    On Christmas Day, Gail Jackson’s 16-year-old daughter said she was in so much pain she thought she would die. Liliana had been briefly admitted to hospital with Covid in September. Her symptoms never went away and, as time went on, new ones had emerged. “For months she had a relentless, agonising headache, nausea, tinnitus, fatigue and insomnia, but the worst thing was the agonising nerve pain,” said Jackson. “I couldn’t even touch her without her screaming in pain.” On Christmas morning, Jackson drove to hospital with her daughter vomiting from pain in the passenger seat. When they got to the hospital, however, the A&E doctor said there was no such thing as long Covid in children. “He said she just needed to go home and get on with her life,” Jackson said. “It was jaw-dropping.” It is extremely rare for children and young people to contract severe Covid, but recent research has shown that even mild or asymptomatic infection can lead to long Covid in children. A study at UCL is investigating long Covid in 11- to 17-year-olds who were not hospitalised with the disease. The National Institute for Health and Care Excellence (NICE) has recommended more research to produce guidance on how children and young people are affected and how they can be treated. However, there is no case definition of long Covid in children and young people in the way there is in adults. Read full story Source: The Independent, 3 May 2021
  23. News Article
    The critical finding at the inquest into Laura Booth’s death raises alarming concerns about the failing system of investigation into the deaths of people with learning disabilities. Initially, Laura’s death was said to be expected and was attributed to natural causes on the basis of a death certificate signed by a hospital doctor. Without the determination of Laura’s family and the intervention of the media, this inquest would never have happened, and the truth about her death from malnutrition and neglect would not have been uncovered. The concerns about how many other avoidable deaths have not been scrutinised because there is no one to speak up on behalf of those who died or because families are obstructed in their search for answers by the prevailing assumption that people will die early. The premature deaths of people with learning disabilities (on average 30 years before their non-disabled peers) demand robust scrutiny particularly as when inquests do take place, they so often reveal basic failings in healthcare. The way in which the Booth family were so nearly failed by the coronial system is a sharp reminder of how urgently reform of these processes is needed. Read full story Source: The Guardian, 2 May 2021
  24. News Article
    Thousands of UK doctors are planning to quit the NHS after the Covid pandemic because they are exhausted by their workloads and worried about their mental health, a survey has revealed. Almost one in three may retire early while a quarter are considering taking a career break and a fifth are weighing up quitting the health service to do something else. Long hours, high demand for care, the impact of the pandemic and unpleasant working environments are taking their toll on medics, the British Medical Association findings show. Dr Chaand Nagpaul, the leader of the BMA, said the high numbers of disillusioned doctors could worsen the NHS’s staffing problems and leave patients waiting longer for treatment. “It’s deeply worrying that more and more doctors are considering leaving the NHS because of the pressures of the pandemic – talented, experienced professionals who the NHS needs more than ever to pull this country out of a once-in-a-generation health crisis,” Nagpaul said. Read full story Source: The Guardian, 2 May 2021
  25. News Article
    Pregnant women are facing a postcode lottery over whether they can bring a partner to maternity appointments. Health boards were given flexibility in November to allow pregnant woman in low Covid rate areas to take their partners to maternity appointments. But many parts of Wales with the lowest rates are still forcing pregnant women to attend some appointments alone. There are calls, as lockdown eases, for partners Wales-wide to be allowed to all appointments and during labour. Emma Fear, 30, was not able to take her partner with her to hospital when she experienced bleeding during pregnancy in June last year and was told, alone, that she was losing her baby. She then had to repeat the news to her partner, who was waiting outside in the car. "At the time, he could have come and sat outside a pub with me, but he couldn't come with me when I'd had severe bleeding and knew I had probably lost my baby." Read full story Source: BBC News, 2 May 2021
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