Clive Flashman

A senior district nurse who was unfairly dismissed after blowing the whistle over valid safety concerns has told how the ordeal has left her life in "chaos" and she feels forced to quit the profession for good. Linda Fairhall, who had worked at North Tees and Hartlepool NHS Foundation Trust for 38 years, has spoken to Nursing Times about her experiences after she successfully challenged her employer's decision to sack her. Between December 2015 to October 2016, Ms Fairhall raised 13 concerns to the trust regarding staff and patient safety. At the time, she was managing a team of around 50 district nurses in her role of clinical care co-ordinator. Read full story (paywalled) Source: Nursing Times, 17 February 2020

Action must be taken now if the NHS is to avoid an even worse winter crisis next year, the chief inspector of hospitals has warned. The Care Quality Commission (CQC) said the use of corridors to treat sick patients in A&E was “becoming normalised”, with departments struggling with a lack of staff, poor leadership and long delays leading to crowding and safety risks. Professor Ted Baker said: “Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that next winter will be a greater challenge still. “We cannot continue this trajectory. A scenario where each winter is worse than the one before has real consequences for both patients and staff.” Read full story Source: The Independent, 18 February 2020

Staffing shortages remain a pervasive challenge for the NHS, risking patient safety, care standards and the pursuit of innovation. There are now 106,000 vacancies across the NHS in England, with over 44,000 vacancies in nursing. Overseas staff are a crucial way of filling those vacancies, but the message to potential workers is confused to say the least. Read full story Source: Health Europa, 14 February 2020

This is the independent public statutory inquiry into the use of infected blood. The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published. Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news

I’ve just been listening to the 10 o’clock news tonight and it has been covering the report into Paterson, the breast surgeon who may have needlessly operated on thousands on women. One of the recommendations is that patient safety should be a ‘top priority’ across the NHS (again!!). Another interesting recommendation is that the NHS (and private healthcare providers) need to be better at sharing information about medical staff. Currently, medical staff seem to be able to be investigated in one hospital, and then move to another without any of their history following them. Maybe we need some sort of central system, like Doctify for employers? What do you think?

I think that realistically, patient safety alerts can only be actively monitored for a finite period of time, say 2 years post-publication. However, one of the things that we had already identified as a future enhancement to the NRLS 16 years ago, was the desire to track incidents that resulted due to issues related to an existing patient safety alert. There was a never a clear and straightforward way to accurately track these and determine the impact (positive or negative) of a patient safety alert. Data quality (as ever) in the NHS is also an issue. In these days of AI and ML, it seems logical that these types of incidents should be more easily identifiable, trackable and remedial actions then taken if necessary,

A really great article and so important that we are reminded to use language that everyone can understand, it's so easy to lapse into those TLAs (three letter acronyms!!!)

Thanks for sharing this @Keith Bates Do you think that along with some commentary this ought to go on the Learn section too?

Hi all, do you think you could help with this. You all have investigation of some form or another as part of your job. @Gethin, @Bryony Cairnes, @Keith Bates, @Gill T, @Helen Jones, @ZMunson, @mattmansbridge, @Amanda, @Helen W All contributions most gratefully received!! Thanks, Clive

This is really useful! Thanks so much for sharing it

Interested to hear from people that actually do this as part of their role and what their views are.... @Gethin, what do you think?

Thanks for drawing my attention to this @HelenH. It's interesting that among the aims of the new AI Lab, are two that are loosely linked to safety of some kind, albeit not Patient safety as we would normally view it. It is mentioned in the Exec Summary as being of relevance to the section on Governance (Chapter 3). In Chapter 2, the limitations of the current governance framework based on a survey are said to be "perhaps limiting innovation and potentially risking patient safety". I'm not clear where the evidence comes from to make that latter point, or if it is being loosely associated with the perceived issues related to collection, management and use of patient data. This is just one aspect of patient safety - there is a lot more that is not being considered here. In Chapter 3, (from the beginning) one of the reasons given for the need for ethics & regulation is patient safety. The algorithmic considerations also mention safety, which in my view is much more fundamental to the whole discussion around patient safety and AI. There should be an awful lot more written about this in Chapter 3, the ommission is significant. Perhaps one of the most telling statements is in the appendixed case study on Genomics England: "...safety is crucial and it is vital that the system is able to guarantee the integrity in the diagnoses and treatment plans which are delivered to patients, whether these are facilitated by AI, or more traditional methods."

can you post the link please @HelenH ?

wow! I remember this being an issue that we discovered in the data being reported to the NRLS soon after we launched it in 2003. I had thought that we had issued a patient safety alert on it soon afterwards. It is sad to see that 15 years later, these incidents are still happening

As I was, in the late 90s..... seems a different world really

I know it doesn't answer your question @Haydn Williams, but I quite like this article: http://www.chriscollison.com/blog/2013/10/09/whats-wrong-with-lessons-learned-part-1 and then http://www.chriscollison.com/blog/2013/10/10/whats-wrong-with-lessons-learned-part-2 you might also find these helpful: https://cognitive-edge.com/blog/learning-lessons-or-lessons-learnt/ http://www.kmworld.com/Articles/Editorial/Features/Project-teams-and-KM-Part-3--The-benefits-of-identifying-and-sharing-lessons-learned-across-projects-122653.aspx Kind regards, Clive

Hi Luke, this sounds like a great initiative - well done. Thought it was worth alerting you to the app libraries produced by ORCHA (who also power the national NHS Apps Library). Have a look at their unfiltered Apps library to get a feel for what I am talking about (if you don't already know about this): www.appfinder.orcha.co.uk Kind regards, Clive

PRESS RELEASE - 1 July 2019 Patient Safety Learning identifies that reduced performance in two aspects of patient experience may increase the safety risks patients face as in-patients. The Care Quality Commission’s (CQC) recently published 2018 annual in-patient survey shows that improvement in two areas of patient experience has stalled while a range of issues that matter to patients have worsened. The charity, Patient Safety Learning, has identified that deteriorating performance in two of these issues is likely to make patient safety risks worse. Fewer patients informed properly when discharged home The CQC’s sixteenth annual survey of people who stayed as an in-patient in hospital was published on 20 June 2019. It shows that most people had confidence in the doctors and nurses treating them, and felt that staff answered their questions clearly. However, the survey reports that 40% of patients were discharged from hospital without written information about how to look after themselves following treatment. This is up 2% from 2017. Of patients who had been given medication to take home, 44% were not told of possible side effects for which they should watch. Fewer patients report being involved in their own care Only 54% of patients report that they are involved as much as they want to be in decisions about their care and treatment, down from 56% in 2017. The number of patients reporting that their views had been sought on the quality of care they received was down by a quarter compared with 2017, from 20% to 15%. An increasing challenge to safety Giving patients written information about how to look after themselves on discharge is clearly a patient safety issue. If this practice is reducing, then the inherent risk to patients must be increasing. Patient Safety Learning’s recent report, A Blueprint for Action, cited a wide range of evidence that communication with patients – listening to them and acting on what is heard – has a demonstrable effect on improving patient safety. The evidence from the CQC survey indicates, however, that such practice is reducing, not increasing, with corresponding implications for patient safety. Patient Safety Learning Chief Executive, Helen Hughes, said, “Effective communication and engagement with patients is essential for safe care. The CQC’s survey is a valuable tool for assessing this. It is concerning that their report evidences that communication with patients is reducing in ways that have the potential to increase the risk to patient safety. Patient safety is a core part of the purpose of healthcare and action is needed to share good practice across the wider health system.” /ENDS Note to editors Patient Safety Learning is a charity. We help transform safety in health and social care, creating a world where patients are free from harm. We identify the critical factors that affect patient safety and analyse the systemic reasons they fail. We use what we learn to envision safer care. We recommend how to get there. Then we act to help make it happen. Patient Safety Learning’s latest report, A Blueprint for Action, can be downloaded here: www.patientsafetylearning.org/resources/blueprint. For more information, contact Margot Knight, Marketing and Communications Manager, Patient Safety Learning E: margot@patientsafetylearning.org Or Helen Hughes, Chief Executive, Patient Safety Learning T: +44 (0) 7793 550855 E: helen@patientsafetylearning.org Patient Safety Learning SB 220 China Works 100 Black Prince Road London SE1 7SJ www.patientsafetylearning.org

The Nursing Times has just broken a story about the importance of safe nurse staffing levels, which has been underlined in an international white paper that calls on countries around the world to take action to ensure they have enough nurses. The paper – launched at the International Council of Nurses’ annual conference – states evidence for a clear link between nurse staffing levels, patient safety and the quality of care is now “overwhelming and compelling”.

Findings from the Care Quality Commission's (CQC’s) latest annual survey of people who stayed as an inpatient in hospital show that most people had confidence in the doctors and nurses treating them and felt that staff answered their questions clearly. However, just over a third (40%) of patients surveyed left hospital without written information telling them how to look after themselves after discharge (up from 38% in 2017), and of those who were given medication to take home, 44% were not told about the possible side effects to watch out for.