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Content ArticleNHS chairs and non-executive directors play a key role in driving forward transformational change across the health and care sectors. As a vital leadership group they hold executive teams to account and in doing so build patient, public and stakeholder confidence in the NHS. The NHS North West Leadership Academy (NHS NWLA) have curated a range of development support and useful resources tailored to support those in non-executive roles. This webpage contains information on: system leadership modules NHS NWLA Executive Coaching leadership masterclasses the Non-executive Leaders Network the Next Director scheme. It also contains links to the following reports and resources: Non-executive directors and integrated care systems: What good looks like Strengthening NHS board diversity Healthcare Leadership Model (HLM) self-assessment and 360 feedback System leadership behaviours framework and conversation cards Healthy leadership framework.
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Content Article
NHS Providers board development programme
Patient-Safety-Learning posted an article in Boards
NHS Providers offers a board development programme that aims to improve the effectiveness of NHS boards and organisations through practical, interactive training and development delivered by expert trainers with extensive senior-level sector experience. This webpage contains information about the board development programme including: core training modules. in-house training. induction programmes. bespoke development programmes. -
Content ArticleIn this blog, US family doctor Lisa Baron highlights the role that social media has played in exposing how patients, particularly women, are dismissed and gaslighted by healthcare professionals, resulting in delayed diagnosis, deterioration and trauma. She talks about her own experience of having her symptoms and concerns dismissed by her GP, which led to a two-year delay in being diagnosed with coeliac disease, rheumatoid arthritis and Sjogren's syndrome. She goes on to talk about her experience of Long Covid and how her symptoms were dismissed and not taken seriously in spite of the life-limiting nature of her condition. She raises concerns that Long Covid patients are turning to unqualified practitioners offering untested, ineffective and expensive treatments as they are not being taken seriously by mainstream healthcare systems.
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Content Article Comment
Understanding Covid-19 as a vascular disease and its implications for exercise
Patient-Safety-Learning commented on an article in Blogs
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Glad you enjoyed the article Chris, if you would like to share any of your own perspectives from the US, we'd love to hear them.- Posted
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Content ArticleSelf-binding directives instruct clinicians to overrule treatment refusal during future severe episodes of illness. These directives are promoted as having the potential to increase autonomy for individuals with severe episodic mental illness. Although lived experience is central to their creation, the views of service users on self-binding directives have not been seriously investigated. This study in The Lancet Psychiatry aimed to explore whether reasons for endorsement, ambivalence or rejection given by service users with bipolar disorder can address concerns regarding self-binding directives, decision-making capacity and human rights.
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Content ArticleThis article in Nurse Leader examines mounting evidence for nurse and patient safety associated with registered nurse (RN) fatigue. What changes driven by strong evidence are nursing leaders enacting to reduce the impact of RN fatigue on patient and nurse safety?
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Content ArticleStorytelling gives a voice to patients and staff as well as providing an opportunity for others to understand the importance of patient safety from the perspectives of those that access services or work within them. This toolkit was developed by the National Quality and Patient Safety Directorate in Ireland which works in partnership with health services, patient representatives and other partners to improve patient safety and quality of care. It provides a step by step guide to creating patient and staff stories.
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Content ArticleIn this episode of The Human Risk podcast, host Christian Hunt speaks to Dr Gordon Caldwell, a retired NHS Consultant and Clinical Lead about the impact of medical bureaucracy. In 2019, Gordon had a photograph taken of himself lying next to a long line of forms, to highlight the amount of paperwork healthcare professionals need to fill in. Gordon is a campaigner against bureaucracy, and he wanted to make the point that time spent filling in forms is time spent not looking after patients. In the podcast, Christian and Gordon discuss: the genesis of the photograph and why Gordon felt motivated to take it the reasons why there is so much bureaucracy within the NHS the impact this has on patient care what Gordon sees as ways to improve it. See also: The Spectator: The NHS is drowning in paperwork Pictured: Doctor shows army of ‘pointless’ forms burying NHS hospitals
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Content ArticleThis article explains the emerging role of simulation in improving quality and safety. It is part of the Cambridge University Press 'Elements of Improving Quality and Safety in Healthcare' series. The article covers: Healthcare Simulation as an Improvement Technique Definition and Description of Healthcare Simulation How Simulation Became Integrated into Approaches to Improve Quality and Safety Simulation in Action Exploring Working Environments and the Practices and Behaviours of Those in Them Improving Clinical Performance and Outcomes Testing Planned Interventions and Infrastructural Changes Helping Healthcare Professionals to Learn about and Embed a Culture of Improvement Critiques of Simulation Is Simulation an Effective Technique for Improvement? How Should We Integrate Simulation into Healthcare Improvement? Can We Build a Business Case for Simulation?
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Content Article
A bitter pill: Primodos (Sky News, 3 January 2023)
Patient-Safety-Learning posted an article in Medication
This Sky News investigation looks at one of the pharmaceutical industry's biggest scandals—the hormone pregnancy test Primodos which was prescribed to pregnant mothers in the UK between 1958 and 1978. Primodos was found to lead to birth defects, miscarriages and stillbirth, and regulatory failings led to avoidable harm to thousands of babies. -
Content ArticleIncomplete or inaccurate recording of ethnicity will undermine attempts to address health inequalities and improve access, experience and outcomes for Black, Asian and minority ethnic communities. This report by the Race Equality Foundation and the Office for National Statistics (ONS) looks at different aspects of the recording of ethnicity in healthcare. The authors interviewed people from a range of communities across England, as well as healthcare workers from different areas and settings to understand both sides of the process of collecting ethnicity data.
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Content ArticleFor years, it has been known that pulse oximeters may present racial biases, with studies dating back as far as the late 1980s suggesting a flaw in how the device measures oxygen in people with darker skin tones. This article looks at how the Covid-19 pandemic finally brought the problem to the forefront of medicine. Ashraf Fawzy, Assistant Professor of Medicine at the Johns Hopkins University School of Medicine, talks about how he and other doctors noticed a trend in pulse oximeter readings not matching up to patient symptoms, and how they went on to research the issue, publishing their results in a study in May 2022. Their study found that Black and Hispanic patients were 29% and 23% less likely than white patients, respectively, to have pulse oximeters recognise their eligibility for more aggressive Covid-19 treatment. The resulting delay in care for patients with darker skin tones is likely to have a significant impact on patient outcomes.
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Content ArticleBased on data from 22,132 patients who had emergency bowel surgery in England and Wales between December 2020 and November 2021, this report from the National Emergency Laparotomy Audit (NELA) found that improvements in in-hospital mortality have levelled off. As such, it calls for hospitals to continue to engage with NELA data collection and, in particular, to make use of real-time data and resources available to drive clinical and service quality improvement.
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Content ArticleThis report by The Queen's Nursing Institute presents the findings of a survey of community nurses (also known as district nurses) conducted in 2022 to look at how digital technologies are used in community nursing. The survey found that: 43.1% respondents reported problems with lack of compatibility between different computer systems, compared to 32.7% in 2017 87% respondents reported issues with mobile connectivity, compared to 85% in 2017 53%.respondents reported problems with device battery life, compared to 29.5% in 2017 The report concludes that overall, the community nursing workforce has a high level of digital literacy and that poor user experience frequently appears to be around design and function rather than a lack of literacy or enthusiasm for technology. The workforce also has an appetite for high functioning technology and can see the potential of new applications, for example, in managing wound care or long-term conditions.
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Content ArticleThis guidance from the Office of Rail and Road outlines how to manage the risk of fatigue that may arise from a working pattern. It defines 'fatigue factors', highlighting that the more a working pattern features these fatigue factors, the greater the likely need to assess, avoid and control potential fatigue risks.
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Content ArticleNHS trusts have often reported emergency department doctors having low levels of satisfaction and high rates of burnout, leading to a high turnover. In 2017, Brighton and Sussex University Hospitals (BSUH) and Western Sussex Hospitals merged to form University Hospitals Sussex NHS Foundation Trust. The Trust found that the organisation of shifts at Royal Sussex County Hospital (RSCH) and Princess Royal Hospital (PRH) and lack of flexibility were adding to the strain already felt by doctors working in the high pressure emergency department. To combat the pressure consultants and other doctors were under, the Trust implemented a system to help improve rota design and flexible working. The hope was that the system would help the trust retain and recruit staff, whilst saving locum costs and improving patient care.
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Content ArticleIn recorded interview, Roger Kline, research fellow at Middlesex University, and Anton Emmanuel, Head of Workforce Race Equality Standard (WRES), discuss 'No more tick boxes', progress on WRES and the need to address race equality as an organisational improvement metric.
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Content ArticleNurses work long hours and play a critical role in keeping patients healthy. Many nurses feel that fatigue “comes with the territory” of such a high-stress, high-impact job. But what’s really at risk when a nurse is fatigued? This blog by US insurance company Nurses Service Organization (NSO) looks at the impact of nurse fatigue on patient and staff safety. It suggests several strategies to address the issue: Designing schedules and organising work to reduce nurse fatigue Developing a fatigue management plan Educating staff on sleep hygiene and the effects of fatigue on nurse health and patient safety Providing opportunities for staff to express concerns about fatigue and taking action to address those concerns Making sure extended shifts have adequate staff support and rest periods
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Content ArticleThis blog by Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson, looks at safety and regulatory issues associated with Essure, a permanent contraceptive implant. Essure anchors inside the fallopian tubes and reacts with the tissues, causing them to become inflamed and scarred. The resulting scar tissue then blocks the tubes off, intending to prevent fertilisation. The devices are about 4cm long and contain a stainless steel, nickel and titanium inner coil and an expanding outer coil containing iron, chromium and tin. Essure has been shown to cause allergic reactions, lifelong inflammatory reactions and internal injuries. The authors examine how Essure came to be approved for use in the USA, the UK and the rest of Europe, highlighting regulatory failings and conflicts of interest with the medical tech industry. They also highlight how pressure from women harmed by Essure resulted in its use being banned in several countries. The blog then describes ongoing efforts to access UK data on reports of adverse events due to Essure that are held by the Medicines and Healthcare Regulations Agency (MHRA). Freedom of Information requests for this data have been denied.
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Content ArticleThe National Institute for Clinical Excellence (NICE) updated their guidance for continuous glucose monitoring (CGM) in 2022, recommending that CGM be available to all people living with type 1 diabetes. This review in the journal Diabetes, Obesity and Metabolism aimed to compare regulatory standards for CGM in the UK and Europe, with those applied in the USA by the Food and Drug Administration (FDA) and in Australia by the Australian Therapeutic Goods Administration (TGA). It describes the processes in place and highlights that the criteria applied in the UK for assessing accuracy do not translate into real-life performance. The authors offer a framework to evaluate CGM accuracy studies critically and conclude that FDA- and TGA-approved indications match the available clinical data, whereas CE marking indications applied in the EU can have discrepancies. They argue that the UK can bolster regulation, but that this need to be balanced to ensure that innovation and timely access to technology for people with type 1 diabetes are not hindered.
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Content ArticleThis Patient Safety Advisory from the Pennsylvania Patient Safety Authority provides an overview of the issues associated with healthcare worker fatigue. It outlines fatigue risk mitigation practices that are being used in healthcare and other industries, including comprehensive fatigue risk management programs.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.- Posted
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Content ArticleSentinel Event Alerts from the Joint Commission identify specific types of sentinel event (a patient safety event that results in death, permanent harm or severe temporary harm), describe their common underlying causes and suggest steps to prevent them occurring in the future. This Sentinel Event Alert looks at the well-documented link between health care worker fatigue and adverse events. It looks at: The impact of fatigue Contributing factors to fatigue and risks to patients Actions suggested by The Joint Commission for healthcare organisations
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Content ArticleFatigue has increasingly been viewed by society as a safety hazard. This has lead to increased regulation of fatigue by governments. The most common control process has been compliance with prescriptive hours of service (HOS) rule sets. Despite the frequent use of prescriptive rule sets, there is an emerging consensus that they are an ineffective hazard control, based on poor scientific defensibility and lack of operational flexibility. In exploring potential alternatives, we propose a shift from prescriptive HOS limitations toward a broader Safety management system (SMS) approach. Rather than limiting HOS, this approach provides multiple layers of defence, whereby fatigue-related incidents are the final layer of many in an error trajectory. This review presents a conceptual basis for managing the first two levels of an error trajectory for fatigue.
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Content ArticleEating disorders are often seen as an illness that affects young women, but research estimates that one in four people with eating disorders are male. As a result, boys and men with eating disorders most often live in silence with the double stigma of having a mental health condition that is not recognised in their gender. In this BBC documentary, former England cricketer and TV presenter Andrew "Freddie" Flintoff goes on a personal journey into the eating disorder he has kept secret for over 20 years–bulimia. He discusses his own experience and meets specialists and young men with eating disorders across the UK.
