Patient-Safety-Learning

This report by the Neurological Alliance shares the results of the My Neuro Survey, the largest national neurological patient experience survey in the UK, which is carried out every two years. The survey and report aim to inform and support improvement in services for people affected by neurological conditions. Recommendations The NHS should develop a Patient Experience Dashboard. Healthcare providers should routinely collect and analyse patient experience data about their services. Everyone involved in gathering patient experience data and insights should coproduce actionable insights. Everyone involved in gathering patient experience data and insights should build in feedback loops. Everyone involved in gathering patient experience data and insights should ensure support and information is available to those who share their experiences.

Black men face twice the risk of getting prostate cancer and 2.5 times the risk of dying from it than white men. They are also diagnosed younger, in a world where the majority of treatments and diagnostics have been designed based on data from white men, and in which the health of Black men can also be affected by factors such as entrenched racism, barriers in accessing care, economic injustice, nutrition and education. This report by Prostate Cancer Research (PCR) shares data from a survey conducted in March 2024 that asked 2,000 Black adults living in the UK their views on prostate cancer in Black men. The report shares what PCR is doing to tackle inequalities in screening, representation in research, treatment and support, with the aim of improving prostate cancer care for Black men.

This US cohort study looked at whether the shift from face-to-face to virtual mental health service delivery is associated with the risk of suicide-related events. The results suggest that offering virtual mental health care in addition to in-person care may reduce suicide-related events.

This cohort study examined how hospital six early warning scores compare with one another, based on 362,926 patient encounters. The authors compared three proprietary artificial intelligence (AI) early warning scores: Simultaneous Epic Deterioration Index (EDI) Rothman Index (RI) eCARTv5 (eCART) against three publicly available simple aggregated weighted scores: Modified Early Warning Score (MEWS) National Early Warning Score (NEWS) NEWS2 scores. In the study, eCART outperformed the other AI and non-AI scores, identifying more deteriorating patients with fewer false alarms and sufficient time to intervene. NEWS, a non-AI, publicly available early warning score, significantly outperformed EDI. The authors concluded that, given the wide variation in accuracy, additional transparency and oversight of early warning tools may be warranted.

This article in JAMA Internal Medicine looks at the impact of language barriers on healthcare safety and quality in the US. Research shows that language discordance between patients and healthcare professionals worsens health outcomes, especially when there are no available, affordable and adequate interpreter services. The article describes the case of a mother who tried to raise concerns about her newborn baby's breathing and had her concerns dismissed, likely because she was unable to speak English and therefore could not communicate sufficiently with midwives and doctors. The author, Tamara Huson, a doctor in Ohio, describes how she had to convince the NICU unit to take the baby in for observation. On arrival at NICU, the baby's condition quickly deteriorated and she was intubated to save her life. This near miss illustrates the impact of language discordance, and the author argues that statutory requirements for translation service in the US are not being fulfilled by healthcare providers which receive Medicare and Medicaid funding.

Type 1 diabetes with disordered eating (T1DE), or diabulimia as some experts call it, is a serious eating disorder that people with type 1 diabetes can develop where the person reduces or stops taking their insulin as a way of managing their weight. The condition can be life-threatening. Although studies are limited, it’s estimated that eating disorders affect more than a third of patients with type 1 diabetes. This episode of the Healthcare Improvement podcast looks at diabulimia and a new toolkit published by SIGN, part of Healthcare Improvement Scotland, which sets out recommendations to raise awareness and provide guidance on how best to support people living with the diabulimia. Guests in this episode include: Lawrence Smith, who was diagnosed with type 1 diabetes when he was four years old and went on to develop an eating disorder in his teens. Safia Qureshi, Director of Evidence & Digital at Healthcare Improvement Scotland, who talks about the key recommendations in the toolkit. Dr Louise Johnston, Consultant and Clinical Lead on the inpatient unit for eating disorders, NHS Grampian.

UK pharmaceutical industry self-regulatory bodies require member companies who sign up to their code of conduct to publish details of their payments to healthcare professionals and organisations. They are also required to publish the methodologies underlying these payments in the form of methodological notes. This study in Health Policy aimed to analyse UK pharmaceutical companies’ methodological notes. It also looked at their adherence to the Association of the British Pharmaceutical Industry code of conduct and other relevant guidance. The authors conducted a content analysis of methodological notes for the years 2015, 2017 and 2019 and assessed companies’ adherence to self-regulatory bodies’ requirements and recommendations for methodology disclosure. Overall, 90 companies made payment disclosures in all three years, publishing 269 methodological notes. The study found gaps in adherence to self-regulatory requirements. Only three companies provided clear information for all self-regulatory body recommendations and regulations in all of their notes and there was evidence of widespread non-adherence to  requirements. This suggests that there are flaws in the concept of self-regulation and a need for greater enforcement of rules or consideration of a publicly mandated disclosure system.

Although shame is an inevitable human experience, it is often experienced as a negative emotion that drives disconnection, psychological distress, impaired empathy and disengagement. The work of healthcare is infused with risk for shame and this Lancet article looks at the impact it can have on both staff and patients. Healthcare encounters are intimate interactions that can be overshadowed by perceived judgement and negative self-evaluation. Patients may feel ashamed, embarrassed or negatively judged about their bodies, their behaviours or their circumstances. Patient shame can be related to stigmatised experiences such as mental illness, obesity, sexually transmitted infections or substance use. The often well-intentioned “lectures” from doctors that such conditions evoke can increase shame feelings in patients who may already feel insecure or ashamed about their bodies or health conditions. Healthcare professionals can also be subject to the impact of shame as for many, identity and self-esteem are linked to achievement, reputation and belonging in their profession, all of which are, in turn, linked to patient care. They may feel inadequate or negatively judged about their skills, failures and errors, their own mental or physical illness, or their inability to “fix” a patient. The authors argue that engaging healthily with shame presents an opportunity for meaningful transformation in healthcare. Competently acknowledging, recognising and responding to shame will support humane connection, enhance psychological safety, infuse trust and instil the emotionally sensitive healthcare environments that we all need to do the vulnerable work of healing.

Diverse ethnic groups are under-represented in health research, which can mean healthcare treatments and services are less safe, accessible and effective for these groups. This spoken word video aims to increase the number of people with lived experience from diverse ethnic groups who are actively involved in health research, and ultimately improve health treatments and services. The film focuses on why diversity in patient and public involvement (PPI) and in health research matters for people, families and communities. Related reading “Our message about public involvement is don’t be afraid to start.” Interview with Barbara Molony-Oates from the NHS Health Research Authority

This investigation by the Healthcare Service Safety Investigation Body (HSSIB) is one of a series on the theme of patient safety in mental health inpatient settings. This investigation focused specifically on the conditions that contribute to safe and therapeutic care for adults who are staying in mental health wards or units. The demand on mental health inpatient services in England is high and has been increasing. It is reported that the quality of care received by patients admitted to these services varies, meaning patients may not receive the therapeutic care they need. Issues include limited shared decision making and a lack of consideration of recovery-focused goals. Patients may also be placed in situations that create safety risks associated with mental, physical or sexual harm. This investigation examines the impact of workforce challenges on the delivery of safe and therapeutic care to adult patients in acute mental health inpatient settings (settings for people who need urgent care and are experiencing a severe mental health problem). It also looks at the wider workplace conditions and the organisation of care to see how these factors affect care. The investigation’s scope included adults, older-adults and secure (adults who pose a risk to the public) inpatient settings. The investigation's findings and recommendations offer opportunities to make improvements to systems, practices and future plans to support the delivery of therapeutic care, and therefore safety, in mental health inpatient settings. Findings Mental health inpatient workforce Patients in mental health inpatient settings did not always feel safe and staff were not always able to develop therapeutic relationships with patients in support of their care and safety. Best practice standards for care were not embedded across inpatient settings. Some inpatient models of safety continued to focus on restrictive approaches, rather than relational approaches. Approaches were influenced by the ability of the workforce to form therapeutic relationships with patients. Workforce challenges across the multidisciplinary workforce had negatively influenced the ability of staff to develop therapeutic relationships with patients and therefore patient safety had been affected. Workforce challenges included difficulties recruiting staff and retaining experienced staff, and concerns around the knowledge and skills available to support therapeutic relationship formation and trauma-informed care. The mental and physical health care needs of patients cared for in acute inpatient settings may have changed and acuity may now be greater than in the past. Staff were not always equipped with the required knowledge and skills to understand and meet the mental and physical needs of patients. Wards were not always staffed to ensure patients could access the knowledge and skills of a multidisciplinary team. Some patients had no or limited access to professionals such as dietitians or speech and language therapists. Workforce challenges varied across regions. Barriers to region-wide coordinated workforce planning included unclear national expectations, difficulties predicting workforce needs, limited provider engagement, and a lack of available staff. The goals of the NHS Long Term Workforce Plan may be unattainable if barriers to implementation are not recognised and addressed. Barriers found included education capacity to build the workforce and poor working conditions affecting retention. There were conflicting views about how best to educate pre-registration nursing (mental health) students and where responsibility should lie to support their development of mental and physical health care skills. Registered nurses (mental health) may be being promoted to supervisory roles with limited experience. Inexperience influenced the supervision and development of new staff, and leaders may be reluctant to challenge attitudes that undermine the quality of care. Built mental health inpatient environments The built environments (estates and physical environments) of inpatient settings varied. Some environments were not therapeutic, did not contribute to formation of therapeutic relationships, and had created situations where patients and staff could and had been harmed. The short-, medium- and long-term investment requirements for safe and therapeutic built environments across mental health inpatient settings were not always known at regional and national levels. Capital funding for the NHS to maintain, improve and create new built environments was finite and unable to meet the needs of mental health inpatient settings. Hazards in built environments could not always be removed or mitigated, and environments could not be improved to be therapeutic. There were concerns about the long-term ability of some high-secure built environments to maintain patient, staff and public safety. There was no specific process for high-secure services to access the capital funds they required for long-term estate planning. There was limited evidence around how best to design therapeutic built environments to meet potential changes in patients’ needs and acuity. Providers wanted clarity on design standards and on the role of technology to support the safety of patients experiencing mental health problems. Social and organisational factors influencing mental health inpatient care The development of psychologically safe and therapeutic social environments was not always possible because of demands on services, workforce constraints, workforce knowledge and skill development, and cultural influences. Providers of mental health inpatient care were not always able to accommodate patients in single-sex spaces. Best practice standards in relation to ensuring sexual safety were not always embedded. Approaches to accommodating patients who were transgender and non-binary varied in mental health inpatient settings. Staff wanted to meet the needs and preferences of all patients but this was not always possible. Digital systems had contributed to incidents where patients had been harmed. Clinical information was not always easily accessible in electronic patient records or had not been shared across different care providers’ systems. Availability and access to physical healthcare services for mental health inpatients varied. Access was influenced by how providers designed and set up their services, the knowledge and skills of staff, and collaboration between acute and mental health care providers. In some locations, care pathways between different care providers were limited. This reduced continuity of care and made it more difficult to access physical health services, which increased the need for patients to be transferred to acute physical health hospitals. Inequalities continued to exist in the care of patients experiencing mental health problems. Availability and access to services for different patient groups further influenced the ability of inpatient providers to deliver safe and therapeutic care. Some organisational cultures and individual beliefs surrounding people experiencing mental health problems continued to negatively influence attitudes towards their care, including access to physical healthcare. Safety recommendations HSSIB makes the following safety recommendations Mental health inpatient workforce HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes in patients’ needs and the level of care they require, and to support providers to make decisions about workforce requirements that support therapeutic and therefore safe care. HSSIB recommends that NHS England works collaboratively with relevant national bodies and stakeholders including professional regulators, the Department of Health and Social Care, and relevant royal colleges to: Identify and clarify the goals of acute mental health inpatient care and the roles, required skills and ongoing professional development needs of the multidisciplinary workforce team. Review and update the NHS Long Term Workforce Plan with consideration of the concerns around changes in patients’ needs and the need for a multidisciplinary approach to ensure therapeutic care is provided. Develop a strategic implementation plan to address workforce issues in mental health inpatient settings that identifies the social and technical barriers to implementation and sets out actions to address them. This is to develop, enable, support and retain a future multidisciplinary mental health inpatient workforce that is able to deliver therapeutic and safe care to patients. Built mental health inpatient environments HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care to patients, and create a supportive working environment for staff. This is to support the development of a strategic and long-term approach to capital investment and prioritisation for NHS built environments. HSSIB recommends that the Department of Health and Social Care undertakes assessment of the capital requirements of the built environments across high-secure services in England and develops plans to ensure the long-term safety of patients, staff and the public. Social and organisational factors influencing mental health inpatient care HSSIB recommends that NHS England, working with relevant stakeholders, develops guiding principles for providers of mental health inpatient care to support local decision making when accommodating patients, including patients who are transgender and non-binary. This is to ensure a provider’s equality and human rights obligations are considered, and all patients are cared for in environments where they feel safe and that are therapeutic. Safety observations HSSIB makes the following safety observations Providers of mental health inpatient care can improve patient safety by ensuring that where professional judgement is used to help make workforce decisions, this accounts for ward physical environments, changes in patient acuity, and the individual mental and physical health care needs of patients that require support from a multidisciplinary workforce. Those involved in the provision of undergraduate and pre-registration education (educational institutions and placement providers) and preceptorship/induction programmes can improve patient safety by collaboratively ensuring that staff entering mental health related professions are developing the required knowledge and skills, including in trauma-informed care, to care for patients with mental and physical health care needs. Those involved in healthcare research can improve patient safety by seeking to understand the design principles for mental health inpatient settings that underpin safe and therapeutic care. Research should include consideration of sensory environments, the role of technology, and the changing needs of patients. Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients and staff) and experts in human factors and ergonomics. Any design should also consider the changing needs of patients. Providers of mental health inpatient care can support patient safety by evaluating and addressing local barriers to the effective use of technology to support patient care, including through gaining insights from people with lived experience (patients and staff) and ensuring the digital infrastructure is available, usable and reliable. Safety responses HSSIB proposes the following safety responses for integrated care boards HSSIB suggests that integrated care boards work collaboratively with the NHS and independent sector to review their system-level workforce plans to ensure they recognise and mitigate the safety challenges in mental health inpatient settings and agree how variation across a geographical area can be mitigated. HSSIB suggests that integrated care boards: 1) ensure system-level infrastructure strategies clearly reflect the risks across their mental health inpatient built environments, and 2) ensure prioritisation of capital funding is equitable across different healthcare settings in a geographical area. HSSIB suggests that integrated care boards: 1) work with mental health inpatient providers to identify patient needs that require input from other providers and agencies, and 2) facilitate cross-provider working arrangements between mental health, acute and primary care providers to minimise the need for transfers of care unless clinically necessary.

Patients, particularly those with long term conditions, have a pivotal role in managing their own health, but too often they are left to struggle without the tools to do the job, the most basic of which is being able to view their medical record. In this article, members of the BMJ's patient advisory panel look at variations in patient access to health records, and the nature and number of portals that patients have to use to access this information. They examine the benefits of giving patients access to their health information and argue that providing easy to use portals will allow patients to effectively manage their conditions and advocate for their own health.

Hospitals rely on their electronic health record (EHR) systems to help them provide safe, high quality and efficient health care. However, EHR systems have been found to disrupt clinical workflows and may lead to unintended consequences associated with patient safety. This study sought to explore the differences in staff perceptions of the usability and safety of their hospital EHR system by staff position and length of service. The authors found significant differences in results across staff positions and hospital tenure: In comparison to registered nurses, pharmacists had significantly lower scores for EHR system training. Doctors, hospital management and IT staff were significantly more likely to report high frequency of inaccurate EHR information. Compared to staff with 11 or more years of hospital tenure, new staff had significantly lower scores for EHR system training, but higher scores for EHR support & communication. Dissatisfaction with the EHR system was highest among doctors and staff with 11 or more years tenure at the hospital.

This update by Charlie Massey, Chief Executive of the General Medical Council (GMC), outlines progress and key milestones ahead of the start of regulation for physician associates (PAs) and anaesthesia associates (AAs) in December 2024. It covers: Update on GMC consultation How the GMC will regulate PAs and AAs PA and AA registration process Upholding professional standards Setting standards for high-quality education and training Taking action when concerns arise Setting expectations for appraisal ahead of future revalidation Related reading Partha Kar: We need a pause to assess safety concerns surrounding Physician Associates

Words convey empathy, demonstrate competence and generate trust in conversations between patients and healthcare providers. Small wording changes can affect the nature of interactions and the outcomes of an appointment or visit. This JAMA article provides examples of how subtle changes in word choice affect the information patients provide, patients’ uptake of information from healthcare professionals and patients’ adherence to recommended interventions.

Rachel Wright, founder and director of Born at the Right Time, is a qualified nurse, wife of a GP and parent of a young man with complex disabilities. In this BMJ opinion piece, she describes her experience of navigating the healthcare system on behalf of her son, and highlights the gap between narratives about empowering parents and the reality of her experience as a parent carer. She describes the mistrust and institutionalised bias that the healthcare system shows parents and the impact this has on parents' mental health. She calls on the healthcare system to examine the causes of this bias, rather than focusing on empowering parents to deal with the problems the system presents as they advocate for their children.

In this Lancet article, Jeremy Greene reflects on Carl Elliott's book 'The Occasional Human Sacrifice: Medical Experimentation and the Price of Saying No'. He highlights a case that Elliott examines in the book, in which 80 people—mostly black patients on low incomes—were enrolled by Eugene Saenger to take part in human radiation experiments. Between 1960 and 1972, Saenger tested megadoses of total body radiation that were not primarly intended as therapy, but to observe the effects of different doses of radiation on the human body. Patients believed they were receiving a potentially life-saving therapy, but were being exploited in the name of research. Nearly a quarter of the patients died within two months of irradiation—the higher the dose, the higher the risk of death. After decades of denial, the hospital was forced to apologise only after the outcome of a Congressional inquiry, a Presidential bioethics commission, and a series of civilian lawsuits. Elliot highlights the difference in the way in which the victims and Saenger are treated in memorials at the University of Cincinnati Medical Center—Saenger is memorialised through a glass cabinet full of his medals, photographs of his research team and historical research instruments. In contrast, the victims are remembered in a small plaque overgrown by plants in the hospital courtyard, funded by the patients' families.

The National Audit of Inpatient Falls (NAIF) is a continuous audit of all inpatients who have a fall that results in a femoral fracture. This report looks at clinical data on falls collected in 2023. Based on 1,609 cases, it states that falls prevention activity should not focus solely on older people’s wards, finding that nearly half of all inpatient femoral fractures (IFFs) occur on general medical wards. To address the potential for harm caused by hospital-acquired deconditioning, this report presents a new approach to risk factor assessment that focuses on promoting activity to ensure each patient is fit to move as safely as possible. This covers factors such as vision, medication review, delirium, mobility and continence, and provides information on the proportion of patients affected by each in 2023, compared to 2022 and 2021. It contains five key recommendations, four of which state that Trusts and health boards should: Review their policies and practice to ensure that older hospital inpatients are enabled to be as active as possible Ensure that there are robust governance processes in place to understand when post-fall checks fail to correctly identify a fall related injury’ Have processes in place to hasten time to administration of analgesia after an injurious fall Prepare for the audit expansion in January 2025. The fifth recommendation states that NHS England and the Welsh Government should implement national drivers to ensure that all older people are screened for delirium upon hospital admission and reviewed for changes suggestive of a new onset of delirium for the duration of their admission.

Lyme disease is a tick-borne, bacterial infection that causes chronic fatigue, headaches, swollen joints and fever, among other symptoms. Following the actor Miranda Hart's having recently shared that she has been living with the effects of Lyme disease for years, Zoë Beaty looks at the issues surrounding diagnosis and treatment of the condition. She outlines why some doctors believe the condition does not exist, or that people with ME/chronic fatigue syndrome are being misdiagnosed with it. The lack of research and evidence around the condition means that many of the people who live with its symptoms—a large proportion of which are female—struggle to access effective treatment.