Patient-Safety-Learning

This is the second in a series of investigations exploring why medications intended to be provided to patients were not provided. Patients who need medications can suffer harm if these are not provided. This investigation explored the systems and processes in place to support staff when a patient who is usually taking an anticoagulant undergoes a procedure. An anticoagulant is a medication that reduces the ability of a patient’s blood to clot. The investigation also explored the role played by electronic prescribing and medication administration (ePMA) systems and electronic patient record (EPR) systems in supporting care in this area. The investigation explored a patient safety event involving a man aged 87 who was admitted to hospital. He usually took an anticoagulant medication (apixaban) to reduce the risk of having a stroke. A stroke is a serious medical condition that occurs when the blood supply to part of a person’s brain is lost. The patient was taken to hospital with shortness of breath and nose bleeds. He was transferred from the emergency department to a medical ward while waiting for a procedure. The medical team paused the patient’s regular apixaban, initially because of his nose bleeds. The apixaban continued to be paused while the patient was waiting for his procedure. However, delays to the procedure taking place meant that apixaban was not given for a total of 10 days. After the procedure, the apixaban was not restarted as intended. Two days after the procedure the patient had a stroke and later died. Medical staff needed to make informed prescribing decisions, balancing the patient’s risk of developing a blood clot, his everyday risk of bleeding, with the risk of bleeding from the required medical procedure. The investigation explored the range of complex, dynamic and interacting clinical and wider hospital factors that led to the difficulties in managing the patient’s anticoagulation. Findings The patient’s apixaban was appropriately paused in the emergency department. Past clinical information about the patient that would have supported anticoagulant risk assessments was not easily available to staff. Variations in the hospital care processes supported some working practices, but created uncertainty about when the patient’s procedure could happen. This made dynamic clinical decision making challenging. A lack of specialist nursing and/or administrative support limited the ability for respiratory referrals to be followed up by the respiratory team in a timely way. There was no reassessment of the ongoing decision to pause the patient’s apixaban when the procedure did not happen as expected. It was clear to staff that the patient’s apixaban was paused on the ePMA system, but the system did not prompt staff to re-review the paused apixaban. An assessment of the risks and benefits of pausing the patient’s apixaban was not documented which prevented a shared understanding of the decision for other staff involved in the patient’s care. Workforce challenges created conditions on the acute general medical ward that limited the resources available to follow up on the patient's medication status and delayed discussions around the patient’s transfer to the respiratory ward. A mismatch between demand and capacity within the respiratory service prevented the patient being transferred to the respiratory ward or receiving regular specialty respiratory input while he was being cared for on the acute general medical ward. Some local clinical guidance available to staff on the management of patients’ anticoagulant medication was overdue for a review and did not reflect updated national guidance. Local clinical guidance was sometimes hard to access using the Trust’s computer systems and some staff were unaware of relevant guidance that was in place. There were no cues in the post-procedure documentation to prompt staff to consider restarting the patient’s anticoagulation medication. Phased implementation of the Trust’s EPR system meant that sometimes staff were duplicating entries across paper and electronic record systems. Local level learning prompts for acute hospitals HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. The following prompts are provided by HSSIB to help acute hospitals to improve the safety of patients who are taking anticoagulation medication who need to have a procedure. These prompts may also be useful in other settings. Anticoagulant prescribing How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed? How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication? Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused? Does your organisation have a process for ensuring that guidelines that cross-refer to other relevant guidelines are reviewed together to ensure they provide consistent advice? How do you ensure that all members of the multidisciplinary team with relevant expertise are included in clinical guideline reviews? Does your organisation have processes in place to ensure that when new evidence on newer anticoagulants becomes available it is considered for inclusion in local guidance as soon as possible? How does your organisation support staff to find and readily access anticoagulation related guidelines? Care processes supporting inpatients on anticoagulants Do your organisation’s bed management meetings include a review of patients who have been waiting more than 24 hours for transfer to a specialty ward? Does your organisation have effective processes in place to ensure inpatients accepted by a speciality, but awaiting a specialty bed, receive a specialty review on a regular basis? Does your organisation have a process in place for the prioritisation of inpatient transfer to specialty services? Does your organisation have a process in place for the prioritisation of inpatients who need investigations (including imaging) and procedures? Do your organisation’s post procedure processes include a prompt to review anticoagulation? EPR/ePMA systems supporting anticoagulation Does your organisation ensure it is easy for staff to access information in patients’ records relevant to decision making about anticoagulant medication? Does your ePMA system identify patients with paused time-critical medication that may warrant a review? How does your organisation consider factors relating to equipment which may affect the successful implementation of EPR/ePMA systems?

Sublingual nitroglycerin (Nitrostat) is a nitrate vasodilator used to treat episodes of chest pain in patients who have coronary artery disease. The tablets are supplied in small, amber bottles that are tightly capped to keep out light, moisture, and air. The loss of potency from environmental exposure often prevents repackaging of the tablets from a multidose bottle into single doses. Therefore, without single doses pre-packaged ahead of time and proper safeguards to warn against the multidose bottle, an overdose of up to 25 times the intended dose can occur. This study examines reports to the Pennsylvania Patient Safety Reporting System (PA-PSRS) describing unintended dispensing and administration of whole bottle contents. These incidents have resulted in patients needing to be resuscitated and transfer to a higher level of care.

Sara Riggare has had Parkinson's disease for nearly forty years. In this BMJ blog, she highlights the importance of trust and dialogue when making treatment decisions. Sara describes a recent interaction with a doctor to illustrate why listening to patients' concerns and answering their questions is vital to building mutual trust.

The Patient Experience Agency is an Australian consultancy that aims to change the approach of healthcare providers towards delivering exceptional patient experiences. They want to see a healthcare sector in Australia that works in partnership with its patients, embraces a team-based, data-driven approach, constantly monitors experiences and outcomes and uses patient insights to continuously improve.

In this BMJ Leader article, Stephen Swensen outlines the concept of 'The Kind Organisation'—an organisation that prioritises the workforce’s mental, physical, social and spiritual wellbeing. He argues that when organisations help their people do better, patients get better experience and outcomes, and the organisation's financial results improve. The article describes how an integrated systems approach that cultivates staff agency, coherence, belonging and positivity is needed for the best work environment. It outlines nine validated actions that improve staff well-being are presented.

This study investigated burnout and sources of stress related to the Covid-19 pandemic among a group of healthcare risk managers and patient safety practitioners. An online survey asked the open question, "Since the start of the Covid-19 pandemic, what work or non-work-related issues have been causing you the most stress?" The results showed that burnout and pandemic-related stress were very common in the healthcare risk management and patient safety workforce. Stressors included: the impacts of social distancing. changing duties and workload. real and potential impacts of the virus (for example, fear of infection for self or others). financial concerns (personal and organisational). untrustworthy and constantly changing guidance. feeling abused by persons in power. positive comments about the experience of working during the pandemic.

Patient-reported measures provide a comprehensive, real-life understanding of patients’ care, essentially “telling the story” that data sources often miss. While conventional metrics offer only snapshots of safety events, patient-reported experiences (PREs) and patient-reported outcome (PROs) capture the lived experience of patients, shedding light on patterns and opportunities for improvement that might otherwise go unnoticed. This blog looks at an innovative project which aims to redefine how patient feedback shapes patient safety and diagnostic excellence. Project PIVOT is organised by Patients for Patient Safety US, an emerging coalition of patients, patient groups and other key stakeholders committed to safer care.

In this BMJ article, Mala Rao, director at the Ethnicity and Health Unit and Imperial College London, and Victor Adebowale, Chair of NHS Confederation, share their perspectives on whether racism has improved in the NHS and UK medicine since 2020.

ASSIST ME is a model for staff support following patient safety incidents in healthcare, developed by the National Open Disclosure Programme of the Irish Health Services Executive. This booklet aims to provide practical information and guidance for health and social care managers and staff about: understanding the potential impact of patient safety incidents on staff. recognising and managing the associated signs and symptoms. supporting staff following patient safety incidents. providing information on the support services available to staff.

In this Health Services Journal article, Alastair McLellan looks at the financial planning challenges facing Daniel Elkeles as he takes up the position of Chair of NHS England. The article suggest that NHS Providers should prioritise making the challenges facing trusts clear to the Government and NHS England. It also suggests the need for a patient approach to ensure that all parties understand the implications of financial agreements that are made.

This guidance sheet developed by Alberta Health Services in Canada offers advice for people supporting healthcare staff who have been involved in serious adverse events. It also describes the impact these incidents can have on 'second victims'—staff involved in errors and patient safety incidents who may develop serious mental health impacts as a result of the experience.

The immediate release of test results to patients via patient portals is required. However, pathology reports contain complex medical terminology, are not written for patients and are often read by patients before discussion with a healthcare professional. Whether patients can extract relevant diagnostic knowledge from these reports is unclear. To address this challenge, US researchers have designed patient-centred pathology report (PCPR) formats, which present the most important clinical data from the pathology report in plain language. Pathologists can generate PCPRs as a supplement to their standard report using a template in a few minutes. However, no previous study has directly compared PCPRs with standard report formats in current use. This study compared diagnosis knowledge and worry among adults presented with different formats of prostate biopsy reports.

This blog tells the story of Sarah,* whose baby was stillborn due to negligent maternity care. Sarah also suffered from severe, permanent injuries in labour which led to her decision to leave the UK. Sarah was admitted to a leading London maternity unit, but staff failed to recognise that she was in active labour. Lack of appropriate care and monitoring led to her baby dying in the womb. Once her baby's death had been confirmed, Sarah was then left to deliver without support for seven hours, which left her with permanent injuries. The article describes the findings of the trust's internal investigation and the negligence claim Sarah and her partner are pursuing. *not her real name

The use of digital health portals, including websites, apps and online consultations, has expanded. The pandemic and increasing public acceptance of digital tools has driven this change. However, this has also led to inconsistency in definitions, language and terminologies used within them, and there is also a significant variation in their functionality. This research by the Professional Record Standards Body (PSRB) and the Patient Information Forum (PIF) aimed to understand the current use of portals and the barriers to increasing engagement for people with long-term conditions to manage their own care better using existing tools and new innovations in the future. Key findings and recommendations User feedback is generally positive about digital health portals. However, there are some barriers to access and use of such portals, including lack of public awareness, lack of proper integration in care pathways, and digital inclusion. Evidence showing the effectiveness of portals in the UK is lacking. However, UK commissioners and suppliers are beginning to see efficiency benefits from appointment portals. These include reducing missed appointments and the cost of printing and postage. Clinicians do not see the benefits of portals. Work plans are not adjusted to accommodate the split of face-to-face and digital work. Digital work is perceived as extra workload rather than a change in model.

Governments worldwide have sought to reform the delivery of public services by mimicking private sector governance models that grant top directors greater autonomy, give them responsibility for meeting key government targets and reward performance with respect to these targets. This paper examines a central plank of this approach–that directors can impact the organisations they run–in the context of English public hospitals, complex organisations with multi-million turnover. The authors find little evidence of top directors’ impact on hospital performance, though estimated differences in pay suggest that the directors are perceived to be differentiated by the market. The results question the effectiveness of blindly mimicking the private sector to bring about improvements in public sector performance.

In this blog, Sarah Clark, Research Communications Manager at THIS Institute, looks at the ongoing challenge of trying to improve access to GP services for patients. She reflects on analysis by THIS Institute and the Health Foundation which identified what we called a “zombie solution”—where some options are revisited time and time again even though they never seem to make a real difference for patients. She looks at the issue and how to move beyond this pattern.

There are many definitions of therapeutic empathy, which sometimes contradict each other. This leads to variation in how the concept is practiced, taught, and researched. This study analysed therapeutic empathy definitions, finding six common components: exploring understanding shared understanding feeling therapeutic action maintaining boundaries.

Doctors in the US report fear of liability risk and the need to practice “defensive medicine.” In 2024, the American Law Institute revised the legal standard for assessing medical negligence. Understanding the implications of this change is crucial for balancing patient safety, doctor autonomy and the legal system’s role in health care. This JAMA article examines the new standard of care, seeing it as a shift away from strict reliance on medical custom as it invites courts to incorporate evidence-based medicine into malpractice law. Although states may adopt the recommendations from the American Law Institute at different times and to varying degrees, the restatement offers healthcare professionals and the organisations in which they practice an opportunity to reconsider how medical negligence will be assessed, and to focus more directly on promoting patient safety and improving care delivery. Nonetheless, doctors should recognise that, at least for now, many courts will continue to rely significantly on prevailing practice in assessing medical liability.

Patient-Reported Indicator Surveys initiative (PaRIS) was set up by the Organisation for Economic Co-operation and Development (OECD) to allow countries to work together on developing, standardising and implementing a new generation of indicators that measure the outcomes and experiences of healthcare that matter most to people. The PaRIS survey aims to fill a critical gap in primary healthcare by asking about aspects like quality of life, physical functioning, psychological well-being and experiences of healthcare. This website explains how PaRIS works and provides access to research outputs.

The Self-Care Forum and Imperial College London's Self-Care Academic Research Unit (SCARU) collaborated on a major research project to study people’s perspectives on self-care. The ‘Living Self-Care Survey’ collected data from 3,255 UK residents including 227 health & care professionals. This infographic shows five key messages from the research.

This study aimed to develop a systematic method to identify and classify different types of communication failures leading to patient safety events. The authors developed a taxonomy code sheet for identifying communication errors and provide a framework tool to classify the communication error types.

Understanding the effects of Covid-19 infection and vaccination during pregnancy can help inform clinical guidance and overcome concerns about vaccine safety. This study examined relationships between Covid-19 infection during pregnancy, Covid-19 vaccination during pregnancy and early child developmental concerns in children aged 13–15 months in Scotland. The study found that Covid-19 infections during pregnancy do not appear to be linked to early childhood developmental concerns and vaccinations during pregnancy appear to be safe from the perspective of early childhood developmental concerns. As some developmental concerns do not become apparent until children are older than 13–15 months, the authors recommended that future research continue to monitor outcomes as children grow and develop. You will need to sign up for a free Lancet account to view this article.

This report was produced by retired judge Sir Anthony Hooper, who was invited to carry out an independent review of how the General Medical Council (GMC) engages with whistleblowers who have raised concerns in the public interest. The report examines: Patient safety, the duty to raise concerns and the duty of candour Reprisals against those who raise concerns Legal framework of the GMC Recommendations on the handling of referrals in circumstances where the doctor has raised concerns The handling of cases involving those who have reported concerns to the GMC Recommendations Organisations referring a doctor’s fitness to practise to the GMC should be encouraged to answer a written question the effect of which is to ascertain whether the doctor being referred has raised concerns about patient safety or the integrity of the system. Organisations referring a doctor’s fitness to practise to the GMC should be encouraged to have the document containing the allegation signed by a registered doctor and to contain a statement by the doctor to the effect that: “I believe that the facts stated in this document are true”. If the written document containing the allegation is not signed by a registered doctor and/or does not contain a statement to the effect that “I believe that the facts stated in this document are true”, organisations should be encouraged to explain why this has not been done. If a doctor being referred to the GMC has raised concerns about patient safety or the integrity of the system with the organisation making the referral, then the necessary steps should be taken to obtain from the organisation material which is relevant to an understanding of the context in which the referral is made. Investigators assessing the credibility of an allegation made by an organisation against a doctor who has raised a concern should take into account, in assessing the merits of the allegation, any failure on the part of an organisation to investigate the concern raised and/or have proper procedures in place to encourage and handle the raising of concerns. In those cases where an allegation is made by an organisation against a doctor who has raised concerns, the Registrar should, where it is appropriate to do so, exercise his powers under rule 4(4) to conduct an examination into that allegation, including taking the steps outlined in my earlier recommendations and asking the doctor for his or her comments on the allegation and the circumstances in which the allegation came to be made. Those who investigate allegations made against doctors who have raised concerns must be fully trained to understand “whistleblowing”, particularly in the context of the GMC and the NHS. The GMC, together with healthcare regulators, professional organisations, unions and defence bodies, set up a simple, confidential and voluntary online system, run by an organisation independent of the regulators. The system would enable healthcare professionals to record electronically the fact that they have raised a concern with their employers, what steps they have taken to deal with the concerns, including details of when and with whom the concerns were raised. The date and time at which the healthcare professional made the entries would be recorded. Access to the record would be restricted to the professional or another person with his or her consent.