Patient-Safety-Learning

The health of the UK is declining—improvements in life expectancy have stalled, more people are living with preventable health conditions for longer periods of their lives and record numbers are unable to access the care they need. Health inequalities are widening, with people living in more deprived areas living for longer in poor health and dying earlier than those in less deprived areas. This report by The Health Foundation looks at how the new government can take a prevention-led approach that enables people to stay healthy for longer, prioritises the reduction of health inequalities and that detects and treats health problems early to reduce harm.

This BMJ cohort study aimed to quantify the prevalence, harms and NHS costs in England of problematic oral non-steroidal anti-inflammatory drug (NSAID) prescribing in high risk groups. It found that NSAIDs continue to be a source of avoidable harm and healthcare cost in five high risk populations—older adults with no gastroprotection, people who concurrently took oral anticoagulants, people with heart failure, those with chronic kidney disease and those with a history of peptic ulcer. Harm was common in people with chronic conditions and people taking oral anticoagulants.

This report by The Health Foundation’s REAL Centre (research and economic analysis for the long term) looks at pressure points in the nursing workforce. It aims to examine the supply of nurses to the NHS in England in light of the ongoing shortfall of registered nurses, which represents a major long-term and growing problem for the NHS. Key findings From 2010/11 to 2017/18, the number of full-time equivalent (FTE) nurses in the NHS barely changed, even as NHS hospital and community sector activity levels increased by 26%. Since 2017/18, nurse numbers have increased, with the number of FTE nurses and health visitors in the NHS rising by 4.8% in the year to June 2020. Disparities between service areas continue to widen. The number of FTE nurses working in adult hospital nursing grew by 5.5% in the year to June 2020, while the number working in community nursing grew only by 1.6%, and by 3.8% in mental health. Over the past 10 years, only adult nursing and children’s nursing have seen increases in FTE nurse numbers, while the numbers in community nursing, mental health nursing and learning disability nursing are all lower than they were in June 2010. Vacancy rates are one measure of staff shortages as they highlight posts that the NHS is funding but cannot fill. Across all staff groups, the NHS had 83,591 FTE vacancies in June 2020. Registered nurse FTE vacancies accounted for close to 38,000 (45%) of these. A quarter of all nursing vacancies are in mental health. This is particularly concerning as Covid-19 is likely to lead to further demand for mental health services. The overall skill mix of the NHS nursing workforce continues to become more diluted. The number of FTE nursing support staff increased at over twice the rate of growth in registered nurse numbers in the year to June 2020. The main ‘supply’ of new nurses to the NHS comes from undergraduate university degree courses. In 2020 there was a 23% increase in the number of students accepted onto nursing degree courses in England (relative to 2019) – the highest annual number of acceptances since 2011. The UK ranks below the average of high-income OECD countries in terms of the number of practising nurses and the annual number of new nurse graduates relative to its population. On both counts, the UK reports lower ratios than comparable countries such as Germany, the USA and Australia. To achieve the required increase in the number of new graduate nurses from domestic education, the UK needs to find solutions to the long-term bottleneck that makes expanding the numbers in training challenging. These solutions could include increasing the use of simulation-based clinical experience, or reducing the total clinical hours required to be on a par with undergraduate nursing courses in the USA and Australia. The UK has been highly reliant on recruiting nurses trained outside the UK. About 15% of registered nurses in the UK are trained outside the UK – more than double the OECD average. Our analysis shows that achieving the government’s target of employing 50,000 NHS nurses by the end of the parliament will only be possible with sustained investment and policy action on domestic supply, including a marked improvement in retention of the current nurse workforce. Coordinated, ethical and effective international recruitment will also be required. To meet the 50,000 target the government will need an average of 5,000 international recruits a year up to 2024/25. But the 50,000 target will be insufficient to meet increased demand. As such it represents a political attempt to galvanise a system drifting from one reactive measure to the next. We argue there needs to be a shift in focus, away from a sigle top-down target to a more sustainable, long-term approach. This should start with robust, independent projections of the future demand for and potential supply of nurses.

This article presents an overview of the research evidence on nurse staffing levels in acute hospitals and how it has been applied to policy and practice, focusing primarily on the UK. Drawing on research reviews and examples of specific studies, the authors outline the current state of knowledge, much of which comes from cross-sectional studies. More recently, longitudinal studies allow a causal link between staffing and outcomes to be inferred. The authors argue that there is a lack of specificity on staffing levels, which has prevented research findings being effectively applied to nursing practice—research rarely specifies how many nurses are needed for safe and effective care. The most significant barrier to achieving safe staffing has been an underestimation of the number of registered nurses needed and overestimation of the potential for substitution, resulting in low baseline staffing and a national shortage of registered nurses. Repeatedly, new staffing solutions have been sought rather than tackling the problem of too few registered nurses head-on.

This article published by the Anesthesia Patient Safety Foundation looks at a concerning trend in which anaesthetists have inadvertently administered tranexamic acid (TXA) intrathecally when performing neuraxial blocks. The mortality rate of this medication error is approximately 50%. The article examines a case involving a TXA-bupivacaine mix-up, offering perspectives from a multidisciplinary group of contributors. It also provides recommendations to avoid these catastrophic medication errors happening again.

In this blog, retired doctor Nadeem Moghal looks at the impact Martha's Rule will have on the NHS. He asks whether the new policy will prevent the medical profession looking at much wider issues relating to candour and professionalism, acting as a bypass mechanism for organisations to avoid dealing with deeper cultural problems. He also raises concerns that Martha's Rule will damage the trust between patients and their doctors and that there are not sufficient teams in place to provide the expert second opinions patients and families will request.

In this blog, Judy Walker unpicks the findings of the Irish Safety Culture and After Action Review Experience study (iCAARE) which describes the enablers and barriers to the successful integration of After Action Review (AAR). The paper highlights the gaps between the expectations held by newly trained AAR Conductors and the reality of implementing AAR. The blog highlights the following recommended actions from the paper: Reduce the time lag between equipping staff with the skills to lead AARs and the immediate reinforcement and promotion of AAR following training.  Invest in structures and processes to make access to AAR easy and widely understood.  Ensure there is a pipeline of AAR work to be done for those newly trained.  Provide active and visible leadership for the AAR approach.  Recognise the emotional reaction pattern that participants may have as they start to use AAR, building confidence in individuals and providing support as they move from novice to expert. 

In the spring of 2022 and 2023, Covid-19 vaccine boosters were recommended for those aged over 75 years in England as well as those in an immunosuppression high risk group. This study in the Journal of Infection aimed to assess the impact of vaccination on preventing Covid-19 hospitalisations in this group. The results show that a clear impact of vaccination on preventing Covid-19 hospitalisations.

The rapid growth of interest in and use of large language models (LLMs) across various industries is raising some crucial and profound ethical concerns, especially in the field of healthcare. This Lancet article highlights ethical concerns from the perspectives of users, developers and regulators. It focuses on data privacy and rights of use, data provenance, intellectual property contamination, broad applications and plasticity of LLMs. The authors argue that a comprehensive framework and mitigating strategies will be vital to ensure LLMs are responsibly integrated into medical practice, ensuring alignment with ethical principles and safeguarding against potential societal risks.

This is the interim report of a review led by Dr Penelope Dash into the operational effectiveness and culture of the Care Quality Commission (CQC). The review spoke to 170 senior managers, caregivers and clinicians working in the health and care sector, along with over 40 senior managers and national professional advisors at CQC. All shared considerable concerns about the functioning of the CQC, with a high degree of consistency in the comments made. At the same time, there was widespread recognition of the need for a strong, credible and effective regulator of health and social care services. A more detailed report will be published in autumn 2024. Emerging findings The Penny Dash review found significant failings in the internal workings of CQC which have led to a substantial loss of credibility within the health and social care sectors, a deterioration in the ability of CQC to identify poor performance and support a drive to improved quality—and a direct impact on the capacity and capability of both the social care and the healthcare sectors to deliver much needed improvements in care. The findings are summarised around five topics: Poor operational performance. Significant challenges with the provider portal and regulatory platform. Considerable loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement. Concerns around the Single Assessment Framework (SAF). Lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections (often several years ago) to calculate a current rating. Recommendations The interim report makes five recommendations: Rapidly improve operational performance. Fix the provider portal and regulatory platform. Rebuild expertise within the organisation and relationships with providers in order to resurrect credibility. Review the SAF to make it fit for purpose. Clarify how ratings are calculated and make the results more transparent particularly where multi-year inspections and ratings have been used.

Michelle Heffer first started seeing her GP for very heavy periods as a teenager. After having her first ultrasound in 2020, she was diagnosed with two cysts on her ovaries caused by endometriosis. In this Independent article, she tells journalist Maya Oppenheim about the impact of having to wait over three years for surgery to deal with her endometriosis, during which time her condition worsened. Michelle had to give up her job and was at times unable to leave the house because the pain was so debilitating. The article also looks at a new report by the Royal College of Obstetricians and Gynaecologists (RCOG) has found gynaecology waiting lists in England have grown more quickly than any other elective specialty and are now over twice the size they were before the Covid-19 pandemic.

Non-Executive Directors and Trustees for Freedom to Speak Up play a vital role in supporting Freedom to Speak Up guardians and championing Freedom to Speak Up at board level within their organisations. When starting out as a new Non-Executive or Trustee for Freedom to Speak Up, it is important to understand your role in your organisation and to gather the knowledge that you need to carry it out well.  This video developed by the National Guardian’s Office brings together information to help Non-Executives and Trustees understand their remit, promote their role and set up positive working relationships. This film is a helpful tool for new and existing Freedom to Speak Up Non-Executive Directors and Trustees and will also support Freedom to Speak Up guardians in their role.

This US study in the Journal of Patient Safety aimed to understand how patient safety professionals from healthcare facilities and patient safety organisations develop patient safety interventions. It also looked at the resources used to support intervention development. The authors analysed semi-structured interviews conducted with patient safety professionals at nine healthcare facilities and nine patient safety organisations. Findings were organised in the following categories: patient safety solutions and interventions use of external databases evaluation of patient safety solutions. The findings highlight that patient safety professionals often use similar methods and resources to develop and evaluate patient safety interventions. However, many of these efforts are not coordinated across healthcare organisations and there would be benefit from working collectively in a systematic fashion. Healthcare facilities and patient safety organisations face similar challenges and there are several opportunities for optimisation on a national level that may improve patient safety.