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Content ArticleThis standard operating procedure (SOP) for Leicester Royal Infirmary Children's Hospital outlines the process to be followed at times of increased pressure on services caused by increased acuity or activity in the pathway for non-elective care.
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Content ArticleIn this blog, Gurpreet Kaur, who had to use a wheelchair for five years due to the severity of her endometriosis, talks about her firsthand experience of gender bias in pain management. She recalls sexist and inappropriate comments made to her by male healthcare professionals, describing how they belittled her pain and treated her as a 'hysterical woman'. She also highlights that research clearly demonstrates that women of color are more disproportionately affected by dismissals of their pain.
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Content ArticleIn the UK, regulation prevents prescription-only medications being advertised directly to consumers, but not medical tests. This opinion piece in the BMJ raises concerns about the growing availability and popularity of consumer blood testing. The authors found that dozens of companies are offering health screening for a range of conditions and deficiencies through blood testing kits for use at home. They are often advertised to people with symptoms such as tiredness, low energy, irritability, sleep problems and weight issues. The authors highlight that reading blood test results requires context and training, and results can give people a false sense of security or panic depending on whether they are perceived to be in 'normal' range. They call for guidance on mixing NHS and private care to be updated and recommend that the Care Quality Commission (CQC) should be empowered to appraise private screening and the apps that recommend it.
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Content ArticleThe third leading cause of death in the US is its own healthcare system—medical errors lead to as many as 440,000 preventable deaths every year. To Err Is Human is an in-depth documentary about this silent epidemic and those working quietly behind the scenes to create a new age of patient safety. Through interviews with leaders in healthcare, footage of real-world efforts leading to safer care, and one family’s compelling journey from being victims of medical error to empowerment, the film provides a unique look at the US healthcare system’s ongoing fight against preventable harm.
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Content ArticleThis report by the Care Quality Commission (CQC) looks what people with a learning disability and autistic people experience when they need physical health care and treatment in hospital. People with a learning disability face huge inequalities when accessing and receiving health care, and initiatives to try and improve people’s experiences have not brought about improvement at the speed or scale needed. The consequences of this are serious, as when people do not get care and support that meets their individual needs, it can lead to avoidable harm and premature death. Equity for people with a learning disability and autistic people is therefore a critical patient safety issue.
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EventuntilSarah Whitehead, External Relations and Public Affairs Manager, Novo Nordisk and Sarah Louis, patient partnership, talk about The Patient Association's biosimilars project. A speaker from Nutricia, and Carolyn Wheatley, patient participant, will speak about the nutrition checklist. Dr Aman Gupta, Medical Affairs Manager at Pfizer and Fran Husson, patient participant, will speak about their work in antimicrobial resistance. Register for this event.
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Content ArticleMedical records include any information about your physical or mental health recorded by a healthcare professional. This includes hospital staff, GPs, dentists and opticians. This page on The Patients Association website explains how to get copies of your medical records in England and Wales. It provides information on: How to get your GP records Using the NHS App to access records A guide to formally requesting medical records Requesting the records of someone who has died Seeing a child’s medical records Requesting the records of a vulnerable adult More information on medical records Complaints
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Content ArticleREACH is a system that helps patients, carers and family members to escalate their concerns with staff about worrying changes in a patient's condition. It stands for Recognise, Engage, Act, Call, Help is on its way. REACH was developed by the New South Wales Government Clinical Excellence Commission in collaboration with local health districts and consumers. It builds on the surf life‐saving analogy for recognition and appropriate care of deteriorating patients by encouraging patients, carers and their families to 'put their hands in the air' to signal they need help.
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Content Article
BD - Voices of safety videos
Patient-Safety-Learning posted an article in Patient stories
This series of videos produced by pharmaceutical company BD features patients, caregivers and healthcare professionals telling their stories about patient safety. Each video highlights an experience of avoidable harm, with topics including sepsis, antimicrobial resistance, medication errors and healthcare associated infections. -
Content ArticleThis webpage outlines the role of Medical Examiner Officers (MEOs), who provide the continuity and oversight that the medical examiner service requires to have the maximum benefit. It includes information on training, induction and recruitment, as well as a model job description for an MEO.
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Content ArticleLocum GP Manjula Arora was given a month’s suspension by the Medical Practitioners Tribunal Service (MTPS) in May 2022 after a complaint to the General Medical Council (GMC) that centred on whether or not she had been promised a laptop by her employer. The ruling was overturned and the GMC conducted a review of the case that found that a legal test around dishonesty was incorrectly applied. The two co-chairs of the GMC review highlight some of its recommendations in this opinion piece in the BMJ. They argue that while the NHS is very diverse, it is not very inclusive and that structural racism affects the treatment of and opportunities available to staff from different cultural backgrounds. They call for greater compassion and cultural competency in the GMC, and for healthcare services to manage concerns on a local level before referring cases to the GMC.
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Content ArticleThis series of short guides aims to help providers and commissioners better understand the use of patient insight and to use it effectively in delivering local services. These topics are covered in the guides: Seeking feedback in distressing or highly emotional situations Writing an effective questionnaire Building greater insight through qualitative research Helping people with a learning disability to give feedback How and when to commission new insight and feedback Insight – what is already available? The National Patient Reported Outcome Measures (PROMS) programme
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Content Article
Blog - Long Covid: A catalogue of shame (2 November 2022)
Patient-Safety-Learning posted an article in Blogs
In this blog, Roger Kline, Research Fellow at Middlesex University Business School, highlights the lack of support from the Government and NHS that healthcare staff with Long Covid face. He looks at the impact of the Government’s decision to scrap extended sick pay for NHS staff with Long Covid and argues that healthcare workers deserve better support. The blog includes accounts from 31 NHS nurses and midwives with Long Covid; some are having to use annual leave as they cannot work their full hours and some have been threatened with redundancy. Others describe their experiences of phased return to work and applying for the NHS Injury Allowance or ill health early retirement. -
Content ArticleThis editorial in BMJ Quality & Safety examines literature that looks at the negative side effects of quality improvement (QI) approaches and initiatives, arguing that QI can contribute to staff burnout, stress and reduced engagement. The authors make a number of recommendations for avoiding the negative side effects of QI.
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Content ArticleRyan Saunders is a little boy who died in 2007 from an undiagnosed streptococcal infection, which led to Toxic Shock Syndrome. According to the Queensland Clinical Excellence Division, when Ryan’s parents were worried he was getting worse, they did not feel their concerns were acted on in time. This blog outlines Ryan's Rule, a process introduced by the Queensland Department of Health to try and prevent similar events happening in future. Ryan's Rule allows patients and their families and carers to escalate serious concerns about their own or a family member's condition.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, talks about her experience as an early adopter of PSIRF. She describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. She talks about the open way in which investigation reports are compiled and reviewed to ensure everyone involved is happy with the way events are presented.
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Content ArticleOn 19 October 2022, the long-awaited findings of Dr Bill Kirkup’s independent investigation into maternity services at East Kent were published. This blog outlines the response of the charity Birthrights to the investigation. It focuses on how breaches of mothers' human rights contributed to negative experiences of care and affected outcomes. Lack of informed consent, the use of disrespectful and discriminatory language and a failure to listen to mothers' concerns all contributed to many cases of avoidable harm. It argues that there is a desperate need for proper funding and real commitment to improving staff recruitment and retention, coupled with a culture shift in maternity care that embeds human rights at the centre of care.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) explores issues around patient handover to emergency care. Patients who wait in ambulances at an emergency department are at potential risk of coming to harm due to deterioration or not being able to access timely and appropriate treatment. This is the second interim bulletin published as part of this investigation, and findings so far emphasise that an effective response should consider the interactions of the whole system: an end-to-end approach that does not just focus on one area of healthcare and prioritises patient safety. The reference event in this investigation involves a patient who was found unconscious at home and taken to hospital by ambulance. They were then held in the ambulance at the emergency department for 3 hours and 20 minutes and during this time their condition did not improve. The patient was taken directly to the intensive care unit where they remained for nine days before being transferred to a specialist centre for further treatment.
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Content ArticleHow can NHS provider organisations and systems reliably and sustainably improve care? Historically, most improvement interventions have been discrete, small-scale efforts run by individual teams, often without reference to what else is taking place in their trust. However, it is now widely accepted that a patchwork of local interventions is unlikely to deliver sustained improvement or efficiencies on the scale that policymakers and local leaders want. This report by the Health Foundation outlines learning from the evaluation of the NHS partnership with Virginia Mason Institute, which examined how five NHS trusts in England attempted to build a culture of continuous improvement.
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Content ArticleThese reports outline the findings of separate investigations into the deaths of three teenage girls who were detained mental health patients in the care of Tees, Esk & Wear Valleys NHS Foundation Trust (TEWV). The reports uncover many systemic failings at West Lane Hospital in Middlesbrough, the secure mental health unit for children where Christie Harnett and Nadia Sharif, both 17 years old, died and where Emily Moore, 18, was placed prior to her death in Lanchester Road Hospital, Durham. The girls had been friends and spent time together at West Lane, and all three deaths were self-inflicted. The reports highlight a total of 119 care and service delivery problems at West Lane including ineffective management, reduced staffing, lack of leadership, aggressive handling of disciplinary problems, issues with succession of crisis management and failures to respond to concerns from patients and staff. Although West Lane was closed in 2019, it was reopened in May 2021 under the new name of Acklam Road Hospital. Subsequent Care Quality Commission (CQC) inspections and further deaths demonstrate that dangerous cultures and practices are still operating in the Trust's inpatient mental health units. In June, the Care Quality Commission (CQC) announced that they will be bringing criminal charges against TEWV in relation to Christie’s death. This document contains three separate investigation reports relating to Christie Harnett, Nadia Sharif and Emily Moore's individual cases.
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Content ArticleThis article in Time reviews the documentary film 'To Err is Human', which explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
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Content ArticleInflammatory rheumatic disease (IRD), such as rheumatoid arthritis, can cause poor outcomes in pregnancy, and the health of the mother and developing foetus must be balanced when making decisions about medication. This updated guideline from the British Society for Rheumatology contains evidence and best practice for prescribing rheumatology medications during pregnancy and breastfeeding. It includes a table that summarises information about drug compatibility in pregnancy and breastfeeding.
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Content ArticleThe Department for Health and Social Care has launched an investigation into allegations made by 22 former patients of mental health units run by private firm The Huntercombe Group. The group ran at least six children’s mental health hospitals between 2012 and 2022. In this Independent article, young women who were subject to humiliating and sometimes abusive treatment talk about their time as inpatients. Some of the experiences they recount are harrowing: "I would get awoken by staff members restraining me out of bed and dragging me down to the de-escalation room to force-feed me." "Patients were left naked in their rooms under anti-ligature blankets because they wouldn’t buy anti-ligature clothing." "I distinctly remember someone saying ‘if you hit me again, I’ll hit you back ten times harder because there are no cameras in here and you can’t cry to [name of nurse] about it’."
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Content ArticleConversations that leaders have with their team members are the drivers of psychological safety. In this blog, Tanmay Vora looks at how to start conversations that build psychological safety in teams. He includes two infographics which highlight suggested conversation starters for team leaders and team members.
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Content Article
IHI: Quality Improvement essentials toolkit
Patient-Safety-Learning posted an article in Quality Improvement
This toolkit from the Institute for Healthcare Improvement (IHI) includes the tools and templates you need to launch a successful Quality Improvement (QI) project and manage performance improvement. The QI tools include: Cause and effect diagram: Also known as the Ishikawa or fishbone diagram, this tool helps you analyse the root causes contributing to an outcome. Failure modes and effects analysis: Also used in Lean management and Six Sigma, FMEA is a systematic, proactive method for identifying potential risks and their impact. Run charts: These charts help you monitor performance over time. PDSA worksheet: Plan-Do-Study-Act rapid-cycle testing helps teams assess whether a change leads to improvement using a methodical learning process. You will need to create an IHI account in order to download the toolkit. You can then download the complete toolkit with all ten tools, or download individual tools as you need them to guide your continuous improvement work.
