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Patient Safety Learning

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  1. Event
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    The Healthcare Safety Investigation Branch (HSIB) would like to invite you to their Healthcare Safety Investigations’ Online Seminar & Learning Event to mark World Patient Safety Day on 17 September 2020. The event is open to anyone interested in our investigations process and who wants to understand how to conduct professional healthcare investigations in their own organisation. Please register via this Zoom link
  2. News Article
    An 'expanded workforce' will be delivering flu and a potential COVID-19 vaccine, under proposals unveiled by the Government today. The three-week consultation also focuses on a proposal of mass vaccinations against COVID-19 using a yet-to-be-licensed vaccine, if one becomes available this year. The Department of Health and Social Care (DHSC) is hoping new legislation could come into effect by October, ahead of the winter season. The consultation proposes to amend the Human Medicine Regulations 2012 to "expand the workforce legally allowed to administer vaccines under NHS and local authority occupational health schemes, so that additional healthcare professionals in the occupational health workforce will be able to administer vaccines". It said this would include 'midwives, nursing associates, operating department practitioners, paramedics, physiotherapists and pharmacists'. The consultation said: "This will help ensure we have the workforce needed to deliver a mass COVID-19 vaccination programme, in addition to delivery of an upscaled influenza programme, in the autumn." The consultation also said that "there is a possibility that both the flu vaccine and the COVID-19 vaccine will be delivered at the same time, and we need to make sure that in this scenario there is sufficient workforce to allow for this". Read full story Source: Pulse, 28 August 2020
  3. News Article
    Hundreds of NHS patients have received personal, specialised care thanks to a new service set up during the coronavirus pandemic. Stroke Connect, a partnership with the NHS and the Stroke Association provides stroke survivors with support and advice in the early days following hospital discharge, without having to leave the house. Experts have said that the new offer is providing a ‘lifeline’ during the pandemic and has helped more than 500 people to rebuild their lives after having a stroke since it launched last month. Patients are contacted for an initial call within a few days of discharge from hospital, from a trained ‘Stroke Association Connector’, an expert in supporting people after stroke. The connector provides reassurance, support with immediate concerns and links the stroke survivor to support they can access in the long-term as part of their recovery journey as well as signposting them to other sources of support. A further call is offered within the month to check in on the stroke survivor’s progress and identify any further support needed. The new service complements existing rehabilitation services and ‘life after stroke’ care, which has continued throughout the pandemic. Read full story Source: NHS England, 31 August 2020
  4. News Article
    A London acute trust has told its staff they may not be paid for time at home self-isolating if it transpires they were not wearing a mask near someone with coronavirus. Staff at Chelsea and Westminster Hospital Foundation Trust were told that if they have to stay at home self-isolating because they were not wearing a mask, that time would have to be taken as annual or unpaid leave. Chief executive Lesley Watts told all staff in an email today, seen by HSJ, that a worker had tested positive for COVID-19, and that four staff members had spent more than 15 minutes with them “without appropriate [personal protective equipment]” and must all now isolate themselves at home for 14 days. The trust considers it “a serious conduct issue not to wear a mask where you are putting colleagues or our patients at risk – this will be dealt with under our formal processes going forward”, Ms Watts said in the email. “If you are sent home to isolate for two weeks because you have not worn a mask, I am now informing you that you will be required to take this as annual or unpaid leave. The four staff members “would not be having to go home to isolate if the use of face masks and social distancing had been in place appropriately”. A Chelsea and Wesminster Hospital spokesman told HSJ: “The guidance around PPE has changed a number of times over the course of the pandemic and we felt it was important to be clear on the trust’s position and to reiterate how seriously we take staff and patient safety." Read full story (paywalled) Source: HSJ, 28 August 2020
  5. News Article
    Trusts underperforming on leadership diversity should not be rated “good” or “outstanding” by the Care Quality Commission (CQC), the NHS Confederation chair has told HSJ. Victor Adebowale said he did not understand how organisations can achieve the top CQC ratings if they do not demonstrate sufficient diversity at senior levels. Lord Adebowale was speaking to HSJ alongside Marie Gabriel, following Ms Gabriel being appointed last month to chair the new NHS Race and Health Observatory, which is being hosted by the confederation. The influential peer’s comments also follow the new People Plan tightened criteria around equality, diversity and inclusion in the “well-led” aspect of the care quality regulator’s inspections. He said: “I struggle to see [how] any NHS trust that performs badly, [on] racial equality and leadership, can be considered to be good and outstanding. I don’t get it. “It seems to me there is enough regulation to take into account the requirement to lead all the people, all the time. But, obviously, if you’re not, then you shouldn’t be [getting] slaps on the back, and [be rated] outstanding or good in anything else.” Read full story (paywalled) Source: HSJ, 28 August 2020
  6. Content Article
    Allotey et al. determined the clinical manifestations, risk factors, and maternal and perinatal outcomes in pregnant and recently pregnant women with suspected or confirmed COVID-19. The authors found that pregnant and recently pregnant women are less likely to manifest COVID-19 related symptoms of fever and myalgia than non-pregnant women of reproductive age and are potentially more likely to need intensive care treatment for COVID-19. Pre-existing comorbidities, high maternal age, and high body mass index seem to be risk factors for severe COVID-19. Preterm birth rates are high in pregnant women with covid-19 than in pregnant women without the disease.
  7. Content Article
    This video from NHS Resolution looks at the criteria that need to be met in order for patient consent to be legally valid. Advice is provided on how to ensure practitioners obtain legally valid consent.
  8. Content Article
    Making Healthcare Safer III report is the third in a series of reports from the Agency for Healthcare Research and Quality (AHRQ), which reviews research supporting patient safety practices in place to reduce patient harms. This supplement from Shoemaker-Hunt et al. presents the reviews for eight of the patient safety practices from the Making Healthcare Safer III report: The use of rapid response teams to reduce failure-to-rescue events. The use of patient monitoring systems to improve sepsis recognition and outcomes. Environmental cleaning and decontamination to prevent Clostridioides difficile infection in healthcare settings. Chlorhexidine bathing strategies for multidrug-resistant organisms Using deprescribing practices and STOPP criteria to reduce harm and preventable adverse drug events in older adults The effect of opioid stewardship interventions on key outcomes System-level patient safety practices that aim to reduce medication errors associated with infusion pumps Improving team performance and patient safety on the job through team training and performance support tools.
  9. News Article
    Any new and effective Covid vaccine will be given emergency approval for use in the UK and an expanded workforce will be trained to give the injections to immunise as much of the population as possible quickly, the government has said. A change in the law will allow the UK regulator, the Medicines and Healthcare Products Regulatory Agency (MHRA), to grant temporary approval for a vaccine from October, before it has been given a licence by the European authorities, which would be the normal procedure. The UK will be out of the EU from January and will approve drugs and vaccines without Brussels’ involvement. Ministers say there will be no shortcut on safety or effectiveness, and that any vaccine will be approved for the UK only if it meets the highest standards. The deputy chief medical officer for England, Prof Jonathan Van-Tam, said: “We are making progress in developing COVID-19 vaccines, which we hope will be important in saving lives, protecting healthcare workers and returning to normal in future. “If we develop effective vaccines, it’s important we make them available to patients as quickly as possible but only once strict safety standards have been met. The proposals consulted on today suggest ways to improve access and ensure as many people are protected from Covid-19 and flu as possible without sacrificing the absolute need to ensure that any vaccine used is both safe and effective.” The MHRA has the power to grant an unlicensed medicine or a vaccine temporary authorisation where a product is proven safe and effective and in the best interest of the patient on the basis of available evidence. Read full story Source: The Guardian, 28 August 2020
  10. News Article
    Guidance to protect at-risk healthcare workers in Wales from coronavirus infection has been relaxed, the BBC has learned. A risk assessment tool initially recommended high-risk workers should not work in the parts of a hospital where infection was most likely. But it now says their personal protective equipment (PPE) should be reviewed or duties changed. The Welsh government says this reflects latest data and low infection rates. However, healthcare professionals say the change to the all-Wales COVID-19 workforce risk assessment tool was made without consultation, and are concerned it was done to prevent hospitals from losing frontline staff ahead of a potential second wave of the virus. Mr Amol Pandit, a urologist who helped to design the tool, has written to the Welsh government four times seeking clarity on the basis for the changes, and why no one was made aware of them before the tool was rolled out. "The changes could have been made in order to keep as many healthcare workers on the frontline as possible, which is why I sent a specific list of questions to the Welsh government, so that I could have assurances that it wasn't done for that reason, but for clinical, evidence-based reasons," Mr Pandit said. Mr Pandit believes healthcare workers who fall into the high-risk category and work in environments where aerosol-generating procedures are performed - considered to carry a high risk of transmission of the virus - may not be fully protected by the current version of the tool if PPE supplies fall short and additional safeguarding measures aren't put into place. "The government needs to be absolutely sure that there is adequate PPE and that it is going to be available to everybody - we have to trust them on that," he said Read full story Source: BBC News, 27 August 2020
  11. Content Article
    Based on extensive interviews with the leaders of seven trusts in the NHS providing good or outstanding care to people with a learning disability and people with autism, and broader ongoing engagement with trusts providing these services, this report from NHS Providers sets out in detail the common themes behind high-quality care, offering detailed case studies of how these services have succeeded.
  12. Event
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    A FREE and LIVE virtual event made up of five educational webinars, Tuesday 8th - Thursday 10th September 2020. Co-produced by BD and Health Plus Care. Looking at the blood culture pathway is relevant to all of us right now. The crossover in symptoms between coronavirus and sepsis, means early diagnosis is even more urgent. We are all moving away from the mentality of 'just in time' to 'just in case'. Our speakers have been handpicked for their expertise in diagnostics, in clinical settings, and as known advocates for patient safety. They will examine what methods and best practices are available, as well as reflecting on the current mood and change in priorities within healthcare. This is against a backdrop of UKI guidelines, the UK’s diagnostic strategy and what the future of blood cultures could look like. You will have the chance to hear real life UK customer stories, and our final session will end with a panel discussion chaired by Ed Jones, former Chief of Staff to the UK Foreign Secretary, Jeremy Hunt MP. The panel features Lord O’Shaughnessy, and Dr Ron Daniels, and will tackle the issues around blood cultures and testing in the current COVID-19 climate. Further information and registration
  13. Event
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    From debrief to safe story sharing. The word “debrief” is throughout our language in healthcare settings, yet it is considered controversial and potentially unsafe if in the wrong hand. However we know in the providing the critical care that our ICU workforce needs, the chance to make sense of experience and share stories is important. This webinar explores the different methodologies for doing this safely in your unit. This webinar from the Intensive Care Society will consist of presentations and then a panel discussion with questions from the audience. Further information and registration
  14. Event
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    10:00 a.m (CEST time) – Roundtable discussion. Patient Safety culture in practice: how patient safety leaders can practically develop or sustain a culture of safety The speakers will discuss: Using a systems approach across patient care journeys. Empowering healthcare workers to recognise, adopt and promote safety initiatives. Leveraging technology to optimise safety for both patients and healthcare workers and will feature a spotlight on how to sustain patient safety culture in a time of crisis with lessons learned responding to the current coronavirus pandemic. Webinar moderated by Prof. Dr. Kris Vanhaecht Speakers: Prof. Dr. Kris Vanhaecht Prof. Cordula Wagner Dr. María Cruz Martín Delgado Mr. Edward Jones 11:30 a.m (CEST time) – Prioritising safety: the critical link between the safety of healthcare workers and patients "Speak up for healthcare worker safety", the call to action for this year's WHO World Patient Safety Day, is especially relevant given the effects of the COVID-19 pandemic on healthcare workers in health systems across the globe. This discussion will emphasise the critical link between the safety of caregivers and patients and the renewed urgency to make fundamental and lasting improvements. Webinar presented by Prof. Dr. Kris Vanhaecht Further information and registration
  15. Event
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    The coronavirus pandemic has proven to be a turning point for the healthcare system and has placed patient safety at the forefront of discussions. As the system recovers, it is vital to address existing patient safety issues that have been exposed and magnified, alongside new challenges that need to be tackled to enable the sustainable transformation of health and social care. HSJ's inaugural Patient Safety Virtual Congress will provide a thought-provoking and timely opportunity for delegates and partners to assess the impact of COVID-19 through a patient safety lens, tackle pressing issues and areas of improvement, and identify innovation opportunities that can be harnessed to shape the future system. Further information
  16. Event
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    The Flight Safety Foundation goal with this Seminar is to promote further globally the practical implementation of the concepts of system safety thinking, resilience and Safety II. There will be two sessions, one for each day, that will consist of briefings and a Q&A panel afterwards. The following themes are suggested for briefings and discussions for the Seminar 1.The limits of only learning from unwanted events. 2. Individuals’ natural versus organisations’ consciously pursued resilience. 3. How the ancient evolutionary individual instincts for psychological safety affect individual and team learning and how these can be positively managed? 4. The slow- and fast-moving sands of operations and environment change over time and their significance for safety. 5. How to pay as much attention to why work usually goes well as to why it occasionally goes wrong? 6. Understanding performance adjustments of individuals to get the job done. 7. The blessings and perils of performance variability. 8. Learning from data versus learning from observing. 9. Learning from differences in operations versus learning from monitoring for excrescences. 10. Can risk- and resilience-based concepts work together? 11. Does just culture matter for learning from success? 12. How to document explicitly, maintain current and use the information about success factors and safety barriers and shall this be a part of organisational SMS? Further information
  17. News Article
    COVID-19 death tolls at individual care homes are being kept secret by regulators in part to protect providers’ commercial interests before a possible second coronavirus surge, the Guardian can reveal. England’s Care Quality Commission (CQC) and the Care Inspectorate in Scotland are refusing to make public which homes or providers recorded the most fatalities amid fears it could undermine the UK’s care system, which relies on private operators. In response to freedom of information requests, the regulators said they were worried that the supply of beds and standards of care could be threatened if customers left badly affected operators. The CQC and Care Inspectorate share home-by-home data with their respective governments – but both refused to make it public. Residents’ families attacked the policy, with one bereaved daughter describing it as “ridiculous” and another relative saying deaths data could indicate a home’s preparedness for future outbreaks. “Commercial interest when people’s lives are at stake shouldn’t even be a factor,” said Shirin Koohyar, who lost her father in April after he tested positive for Covid at a west London care home. “The patient is the important one here, not the corporation.” Read full story Source: The Guardian, 27 August 2020
  18. News Article
    England’s test-and-trace system has been hit with fresh problems after there were delays in contacting nearly 2,000 people infected with coronavirus, and one in seven home tests failed to produce a result. An internet outage meant nearly 3,000 more people than usual were transferred to the contact-tracing system after testing positive for COVID-19 in the week ending 19 August. Two-thirds of these people had been tested days or weeks earlier, meaning there was a delay in reaching them and their close contacts when they should have been self-isolating. The proportion of home tests kits failing to produce a result that week rose sharply, from 4% to 15% of the total, equating to more than 18,000 tests. The Department of Health and Social Care figures also show that test and trace failed for a ninth week running to reach its target of contacting 80% of close contacts of people who test positive for COVID-19. Matt Hancock, the health secretary, acknowledged on Thursday that the programme was “not quite there” in reaching that target. He told LBC radio: “One of the challenges is we want to get NHS test and trace up to over 80% of contacts, getting them to self-isolate – we’re at just over 75%, so we’re nearly there but not quite there.” Read full story Source: The Guardian, 27 August 2020
  19. News Article
    Women are forced to wait more than five times longer than men for a heart failure diagnosis, a new study has found. Researchers discovered women are 96 per cent more likely to get an incorrect diagnosis of heart failure than men – attributing sharp disparities to such problems being wrongly viewed as “a man’s disease”. The study, conducted by leading heart failure charity the Pumping Marvellous Foundation, found men said they waited an average of just over three and a half weeks to get a formal diagnosis after their first GP visit, but women waited just over 20 weeks instead. Researchers warned such delays were linked to “poorer quality of life, financial losses, mental health issues and avoidable deaths” – adding that health professionals do not give heart failure the same attention and gravity as cancer and other diseases. "One of them [GP] actually said, your symptoms are probably not to do with your heart because you’re young and you’re female. Even though my father had a heart condition," says Sarah, who was diagnosed at the age of 42. Read full story Source: The Independent, 27 August 2020
  20. Content Article
    This document outlines the purpose of Patient Safety Specialists, the key requirements of the role, and how we expect them to work in their own organisation, as well as with local, regional and national partners.
  21. News Article
    A home care worker who did not wear protective equipment may have infected a client with a fatal case of coronavirus during weeks of contradictory government guidance on whether the kit was needed or not, an official investigation has found. The government’s confusion about how much protection care workers visiting homes needed is detailed in a report into the death of an unnamed person by the Healthcare Safety Investigation Branch (HSIB), which conducts independent investigations of patient safety concerns in NHS-funded care in England. It was responding to a complaint raised by a member of the public in April. The report shows that Public Health England published two contradictory documents that month. One advised care workers making home visits to wear PPE and the other did not mention the need. The contradiction was not cleared up for six weeks. The government’s guidance had been a shambles that had placed workers and their vulnerable clients at risk, the policy director at the United Kingdom Homecare Association, Colin Angel, said on Wednesday. The association also accused the government of sidelining its expertise and publishing new guidance with little notice, sometimes late on Friday nights, meaning that it was not always noticed by the people it was intended for.
  22. Content Article
    The Healthcare Safety Investigation Branch (HSIB) reiterates the importance of clear personal protective equipment (PPE) guidelines to reduce the risk of COVID-19 transmission when delivering care in people’s homes.
  23. News Article
    The Care Quality Commission (CQC) has taken immediate enforcement action at East Kent Hospitals University Foundation Trust citing “serious concerns” over patient safety. The regulator confirmed it was taking action today after inspectors visited on 12 August following concerns being raised about the standard of care and risk to patients. The CQC confirmed the action had been taken, but it said it could not comment further due to legal restrictions and the trust’s right to appeal the decision. HSJ understands the enforcement action was taken due to concerns over infection prevention control and the number of patients who have contracted COVID-19 in hospital. It is believed to be the first such action against a trust. Read full story (paywalled) Source: HSJ, 27 August 2020
  24. News Article
    Hospitals are not equipped to deal with the surge in screenings and tests as the health service restarts care – leaving patients facing delays in diagnosis and treatment for conditions including cancer, according to medical leaders. As the NHS tries to recover from the worst of the coronavirus crisis, more than a million laboratory samples from cancer screening services are expected in pathology labs, while as many as 850,000 delayed CT and MRI scans need to be carried out. But 97% of labs do not have enough pathologists to carry out the work – with staff already working unpaid hours to tackle the existing backlog – while the number of radiology posts nationally would need to be increased by a third to deal with the rise, experts say. Precautions to protect against the spread of coronavirus also limits the number of scans that can be carried out. The royal colleges of pathologists and radiologists warned that cancers would go undiagnosed and treatments for all patients across the NHS could be further delayed as a result. Read full story Source: The Independent, 27 August 2020
  25. News Article
    Obesity may double the risk of falling seriously ill with Covid-19 and increase the chances of dying by almost 50 per cent, according to researchers, who also warned any future vaccine may be less effective for the clinically overweight. Health issues caused by obesity include a number of pre-existing conditions known to exacerbate a Covid-19 infection – including heart disease, diabetes and high blood pressure. Now a global assessment of health data gathered since the start of the the pandemic by researchers at the University of North Carolina has found people with a Body Mass Index (BMI) of more than 30 were 113 per cent more likely to be hospitalised. Those admitted to hospital were found to be 74% more likely to be admitted to an intensive care unit, while the risk of death among obese patients increased by 48%. Read full story Source: The Independent, 26 August 2020
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