Patient-Safety-Learning

The NHS England National Patient Safety Team has produced two podcasts to provide an overview of the background and development of the new National Maternity Early Warning Score (MEWS) tool. In the first podcast, Professor Marian Knight, University of Oxford; Professor Peter Watkinson, Oxford University Hospitals NHS Foundation Trust; and Tony Kelly, National Clinical Advisor, Maternity & Neonatal Safety Improvement Programme NHS England, discuss the development of a new national Maternity Early Warning Score (MEWS) tool. In the second podcast, Tony Kelly, Hannah Rutter, Senior Improvement Manager at MatNeoSIP NHS England, Louise Page, Consultant Obstetrician and Gynaecologist, West Middlesex University Hospital and Chelsea and Westminster Hospital NHS Foundation Trust, Anita Banerjee, Consultant Obstetric Physician, Guys and St Thomas’s NHS Foundation Trust and Katherine Edwards, Director of Patient Safety and Clinical Improvement, Oxford Academic Health Science Network discuss the the benefits of implementing the new national MEWS tool.

This annual report sets out how NHS Resolution's dispute resolution strategy has continued to drive down litigation against the NHS in England in 2021-22. 77% of claims made by patients were resolved in 2021/22 without court proceedings, continuing the year-on-year reduction for the last five years, and in line with the organisation's strategy to keep patients and healthcare staff out of court. NHS Resolution achieved this reduction through a range of dispute resolution approaches and continued cooperation across the legal market. It emphasises that the reduction in litigation has not been at the expense of a rigorous approach to investigation.

The National Infusion and Vascular Access Society (NIVAS) is a multidisciplinary organisation made up of healthcare professionals with a special interest in vascular access and IV therapy.  This white paper by NIVAS lays out evidence that having a nursing-led vascular access team in every hospital in the UK will improve patient safety, reduce workload pressures for other staff, and save the NHS money. Vascular access involves the use of devices such as catheters to deliver or remove fluids, blood or medication from a patient’s bloodstream. The paper examines the arguments advocating for Vascular Access Services Team (VAST) across the NHS, acknowledging the current pressures of restarting the NHS following the pandemic and the roadmap to reduce the elective waiting lists. It also outlines how integrating a standardised model of VAST into the healthcare systems of the NHS will benefit patients, the new Integrated Care Systems (ICS) and the wider objectives of the NHS.

The Covid-19 pandemic presented the need for fast decision-making in a rapidly shifting global context. This article in BMJ Evidence Based Medicine looks at the limitations of traditional evidence-based medicine (EBM) approaches when investigating questions in the context of complex, shifting environments. The authors argue that it is time to take a more varied approach to defining what counts as ‘high-quality’ evidence. They introduce some conceptual tools and quality frameworks from various fields involving what is known as mechanistic research, including complexity science, engineering and the social sciences. The article proposes that the tools and frameworks of mechanistic evidence, sometimes known as ‘EBM+’ when combined with traditional EBM, may help develop the interdisciplinary evidence base needed to take us out of this protracted pandemic.

People with a learning disability and autistic people should have the right support in place to live an ordinary life and fulfil their aspirations, in their own home. This action plan from the Department of Health and Social Care (DHSC) aims to strengthen community support for people with a learning disability and autistic people, and reduce reliance on mental health inpatient care. This action plan outlines the government's policy to achieve this by: strengthening community support. reducing the overall reliance on specialist inpatient care in mental health hospitals. improving the experiences of people with a learning disability and autistic people across public services such as health, social care, education, employment, housing and justice. It brings together the commitments that have been made by different organisations to realise these aims, and aims to drive long-term change for people with a learning disability and autistic people.

This open letter from the Pharmacists' Defence Association (PDA) raises concerns about unnecessary full or part-day closures of community pharmacies throughout the UK by some large multiple pharmacy operators. The letter states that these operators are telling patients and the government that they have been unable to find pharmacists, citing an alleged national pharmacist shortage. However, the PDA's members report that this is not the case, and the letter draws attention to closures being planned four weeks in advance, and to locum pharmacists having agreed rates of pay reduced at the last minute. The PDA highlights the risk to patient safety caused by these closures, and calls for more regulatory action to be taken by the government and other regulators. The letter is addressed to: Government Health Secretaries of England, Northern Ireland, Scotland and Wales Chief Executives of the National Health Service in England, Northern Ireland, Scotland and Wales NHS Chief Pharmaceutical Officers for England, Northern Ireland, Scotland and Wales Chief Executive of General Pharmaceutical Council and Pharmaceutical Society of Northern Ireland.

In this McKinsey & Co blog, the authors examine how organisations can achieve cohesion among decentralised business units and transform their culture. Drawing on McKinsey's experience supporting organisations through change, they look at how setting a common cultural goal and minimum standards for how each business unit will achieve this goal, can result in lasting performance improvements. They examine the following facets of cultural change: How you’re changing: Organizational oversight What you’re changing: Mindsets and behaviours Who is responsible at the business unit level?

This report by the Tony Blair Institute for Global Change looks at how the NHS needs to adapt to meet the demands of the current population. It asks the questions, should we and could we go much further in fundamentally changing the design of how the NHS is run, highlighting two key societal changes that make change necessary: increases in our knowledge of how to stay healthy, and huge technological advances such as artificial intelligence.

In July 2021, the UK Government lifted all Covid protections, meaning people were no longer legally obliged to take infection control measures such as wearing face masks in designated places. Twelve months on, the UK is facing high levels of infection and hospitalisations from Covid-19. In this opinion piece for The BMJ, members of Independent SAGE—a group of scientists working together to provide independent scientific advice about Covid-19 to the UK government and public—propose a series of measures to help people make informed decisions that will reduce the risk of illness and disruption to them, their families and their communities. The authors accuse the government of ignoring published scientific advice from their own advisory group, SPI-B, and call for action to give people the information they need to make responsible personal choices as part of the plan to 'live with Covid'.

Nursing workforce shortages are an issue of international concern, with the gap between demand for services and the limited numbers of nurses widening. Recruiting nurses internationally is one solution that is helping to bridge this gap in some health systems. This systematic review in the International Journal of Nursing Studies Advances aimed to explore the lived experiences of international nurses working and living in different countries globally. The authors identified factors that can help nurses from other countries to adapt culturally to the UK health system, and that may support retention of international staff. The authors found that in order to improve the long term retention of international nurses, cultural integration and language barriers should be sensitively managed to enable effective acculturation. Culturally sensitive leadership should also be promoted to ensure zero tolerance of inappropriate racist and discriminatory behaviours.

On his last day in office as Chief Investigator at the Healthcare Safety Investigation Branch (HSIB), Keith Conradi sent this letter to the Secretary of State for Health and Social Care, outlining his concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB. In his letter, Keith highlights a lack of interest in HSIB investigations and activity from leaders in both NHS England and DHSC, and describes how this attitude permeates both organisations. He also draws attention to a lack of priority and support for patient safety at a structural level, and calls on government and healthcare leaders to take a new approach and introduce a regulated safety management system with appropriate accountability. Patient Safety Learning has written a blog reflecting on Keith Conradi's letter, highlighting the ways in which his concerns align with those consistently raised by Patient Safety Learning.

The National Audit of Care at the End of Life (NACEL) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). It was carried out by the NHS Benchmarking Network in collaboration with The Patients Association and aims to assess the quality of care that patients receiving end of life care and their families experience, as well as staff perceptions of their confidence and ability to deliver end of life care. The audit included: an Organisational Level Audit covering Trust/Health Board and hospital/submission level questions for 2020/21. a Case Note Review which reviewed 20 consecutive deaths between 12th April 2021 and 25th April 2021 and 20 consecutive deaths between 1st May 2021 and 14th May 2021 for acute providers and up to 40 consecutive deaths in April and May 2021 for community providers. a Quality Survey completed online, or by telephone, by the bereaved person. a Staff Reported Measure, completed online. Key findings Recognising the possibility of imminent death The possibility that the patient may die within the next few hours/days was recognised in 87% of cases audited, compared to 88% in 2019. The median time from recognition of dying to death was recorded as 44 hours (41 hours in 2019). Communication with the dying person Results on all key metrics regarding the recording of conversations with the dying person remain similar to 2019, pre-pandemic levels However, from the Quality Survey, the proportion strongly disagreeing or disagreeing with the statement ‘staff communicated sensitively with the dying person’ increased from 7% (2019) to 11% (2021). Communication with families and others There was little change in 2021 when compared to 2019, with continued high compliance on recording of conversations about the possibility that the person might die and on the individualised plan of care. As in 2019, discussions on hydration and nutrition with families and others were documented, or a reason why not recorded, in only around half of cases. Involvement in decision making Findings from the Case Note Review in 2021 suggest continued strong compliance on involvement in decision making, with similar results to those reported when this theme was last tested in 2018. However, from the Quality Survey, in 2021, 23% of people felt they would like to be more involved in the person’s care compared to 19% in 2019. Individualised plan of care Third round findings from the Case Note Review showed similar results for the existence of an individualised plan of care, 73% of cases compared to 71% in 2019, suggesting this is an ongoing area for improvement. Documented evidence of an assessment of wider needs such as emotional/psychological, spiritual/religious/cultural and social/practical shows a reduction since 2019, which may be a result of continuing pressures of the Covid-19 pandemic on services during 2021. Needs of families and others The needs of the family were identified as an improvement area in both round one and round two of the audit. Comparison with 2019 findings suggests performance has deteriorated, which may reflect the impact of the pandemic on the ability of visitors to access wards and the capacity of staff to assess and address the needs of families and others. Families’ and others’ experience of care The overall rating of care and support to the person who died, and the overall rating of care and support provided to families and others, are lower than in 2019. Governance Governance was last measured in 2018 and Trusts/Health Boards (HB) continue to show high compliance with the existence of key policies related to care at the end of life in 2021. Workforce/specialist palliative care The results show an improvement in access to specialist palliative care, in particular, face-to-face access 8 hours a day, 7 days a week was available in 60% of hospitals/sites compared to 36% in 2019. The increased provision may reflect a response to the pandemic and it is not yet clear whether the change will be permanent. Staff confidence Staff completing the survey expressed confidence in recognition of dying, communication, responding to the needs of the dying person and those important to them, involving people in decision making, accessing specialist palliative care and managing pain and physical symptoms, with less than 6% stating they strongly disagreed or disagreed with positive statements of confidence in these areas. Staff support Training was identified as a potential area for improvement with only 49% of respondents stating they had completed training specific to end of life care within the last three years. Although staff felt support was available from the specialist palliative care team, only 66% felt managerial support was available to help provide care at the end of life. Care and culture Although 83% felt able to raise a concern about end of life care, this should be closer to 100%. Only 80% answered positively that they felt they work in a culture the prioritises care, compassion, respect and dignity, which is also a concern.

Some patients are unable to tolerate imaging procedures such as MRIs due to pain or anxiety. In these cases, a variety of medications are routinely used prior to imaging to allow the procedure to be carried out successfully. Varying levels of sedation before imaging can be appropriate given the need for patients to remain still during the imaging process, but the minimal amount of sedation should be used to mitigate unwanted side effects and reduce the risk of adverse events. This article examines two cases that highlight the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required and when monitoring is limited or inadequate.

In this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.

This study in the journal Infection Control & Hospital Epidemiology aimed to determine the extent to which asymptomatic individuals infected with Covid-19 transmitted the disease to other patients and staff on a hospital ward. The authors found that a comprehensive symptoms and signs assessment, in combination with adequate follow-up, allows for a more precise determination of Covid-19 symptoms. The results of the study revealed that asymptomatic infection was quite uncommon amongst adults in this setting.

This is the annual report of the National Diabetes Inpatient Audit–Harms (NaDIA-Harms) programme, which aims to monitor and reduce instances of key life-threatening diabetes specific inpatient events. The programme covers hypoglycaemic rescue, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) and diabetic foot ulcer. Overall 4,605 inpatient harms were submitted to the NaDIA-Harms audit between May 2018 and October 2020; the majority of which related to hypoglycaemic rescue (69%). This report also covers: the number of submissions of each inpatient harm. the impact of the Covid-19 pandemic on inpatient harms. patient profiles of people that experience each inpatient harm. These include demographics, diabetes characteristics, treatment targets, care processes, admission characteristics and comorbidities.

There has been an increase in the use of video group consultations (VGCs) by general practice staff, particularly since the beginning of the Covid-19 pandemic, when in-person care was restricted. This qualitative study in the British Journal of General Practice aimed to examine the factors affecting how VGCs are designed and implemented in general practice. Through semi-structured interviews with practice staff and patients, the authors found that: in the first year of the pandemic, VGCs focused on supporting those with long-term conditions or other shared health and social needs. most patients welcomed clinical and peer input, and the opportunity to access their practice remotely during lockdown. not everyone agreed to engage in group-based care or was able to access IT equipment. significant work was needed for practices to deliver VGCs, such as setting up the digital infrastructure, gaining team buy-in, developing new patient-facing online facilitation roles, managing background operational processes, protecting online confidentiality, and ensuring professional indemnity cover. national training was seen as instrumental in capacity building for VGC implementation.

Cancer screening involves testing for early signs of cancer in people without symptoms. It can help spot cancers at an early stage, when treatment is more likely to be successful, or in some cases prevent cancer from developing the first place. The screening test for bowel cancer is the faecal immunochemical test, or FIT, that looks for tiny traces of blood in your poo. These tests are sent to everyone in the eligible population every two years. In this blog Jacob Smith from Cancer Research UK looks at the importance of increasing bowel cancer screening in socioeconomically deprived communities, where there is a higher incidence of bowel cancer and death from bowel cancer. This is partly due to lower levels of participation in screening. The blog highlights the results of a recent study carried out by the University of Sheffield to determine which interventions may be successful in reducing health inequalities related to bowel cancer screening. Modelling found that re-inviting non-participants to take part in screening each year was a highly effective intervention, and it is estimated that this approach would prevent over 11,000 bowel cancer deaths over the lifetime of the current English population aged 50-74.

This report by the All Party Parliamentary Group (APPG) on Muslim Women and the Muslim Women's Network UK aimed to investigate the maternity experiences of Muslim women in the UK, particularly from Black, Asian and other minority ethnic backgrounds. It aimed to better understand the factors that influence the standard of maternity care Muslim women receive, and to determine whether this may be contributing to poorer outcomes for them and their babies. 1,022 women completed surveys and 37 women were interviewed for the research. The study focused on the care given throughout pregnancy in the antenatal, intrapartum and postnatal periods. Experiences of sub-standard care were analysed to find out: whether they were associated with the women’s intersecting identities such as ethnicity, religion and class. whether attitudes were due to unconscious bias (for example, negative stereotypes or assumptions) or conscious action (for example, microaggressions). what role (if any) organisational policies and practices played. Particular attention was paid to how near misses occurred as this information could help to save lives of mothers and babies. To show what good practice looks like, positive experiences were also highlighted.

People with diabetes are increasingly using medical devices to help manage their condition, including devices for monitoring glucose and delivering insulin. However, healthcare professionals are finding that they cannot always access up to date information about a person with diabetes and the data from their medical devices. This makes it harder to provide the best advice and support. The Professional Record Standards Body (PRSB) was commissioned by NHS England and NHS Improvement to produce two standards for sharing diabetes information between people and professionals across all care settings, including self management data from digital apps and medical devices (for example, continuous glucose monitors). The Diabetes Information Record Standard which defines the information needed to support a person’s diabetes management. It includes information that could be recorded by health and care professionals or the person themselves that is relevant to the diabetes care of the person and should be shared between different care providers. The Diabetes Self-Management Standard which defines information that could be recorded by the person (or their carer) at home (either using digital apps or medical devices) and shared with health and care professionals.

In this presentation Paula Goss, the founding member of Rectopexy Mesh Victims and Support, shares her experience of having a mesh implant. She describes the absence of informed consent during the procedure and the pain and complications she experienced following her surgery. This was shared at a Bristol Biomedical Research Centre workshop aimed at improving shared decision making for surgical innovation.

An increasing number of healthcare artificial intelligence (AI) applications are in development or already in use, but the safety impact of using AI in healthcare is largely unknown. This qualitative study in the journal Safety Science aimed to explore how different stakeholders (patients, hospital staff, technology developers and regulators) think about safety and the safety assurance of healthcare AI. Through a series of interviews, the authors assessed stakeholder perceptions of an AI-based infusion pump in the intensive care unit. Participants expressed perceptions about: the potential impact of healthcare AI requirements for human-AI interaction safety assurance practices and regulatory frameworks for AI and the gaps that exist how incidents involving AI should be managed. The authors concluded that there is currently a technology-centric focus on AI safety, and a wider systems approach is needed. They also identified a need for greater awareness of existing standards and best practice among technology developers.

This guide developed by the AHSN Network, the University of Plymouth and the pharma company Boehringer Ingelheim sets out four key principles to involve and engage patients and the public in digital health innovation: Engage – map out your strategy and motivations, identify a representative cohort and develop inclusive engagement practices. Acknowledge, value & support – show you value patients’ and the public’s contribution to ongoing and transparent communication, any necessary training and potential financial reimbursement. Communicate – tailored external communication and open feedback channels are crucial to maintaining engagement and accountability by all parties. Trust and transparency – In order to gain patients’ trust, organisations conducting PPIE should be trustworthy and transparent about potential risks.