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  1. Event
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    Dr Tom Rose shares how to create effective healthcare process documentation to enable more effective improvement, risk assessment and safety reviews. The documenting of healthcare processes is a key part of such an effective continuous quality improvement system. But currently very few healthcare processes are documented – which greatly hampers effective improvement, risk assessment and safety reviews. And too often Standard Operating Procedures (SOPs) are relied on, but they are not process specific which makes them difficult to apply. Dr Tom Rose will share examples of NHS Standard Process documentation, from the National safety standards for invasive procedures, Getting It Right First Time, and the World Health Organisation’s High 5s project. Tom will also share how to effectively identify the individual processes relevant to a single work team or area, such as a ward, GP practice reception or patient pathway. He will show how front line staff can dictate the design of these processes (i.e. visual representations of Work-as-Done), supported by an experienced facilitator or designer who is responsible for producing the documentation. This is an iterative process that has been designed not to take up too much of front-line staff’s time. This event is organised by the Q Community’s Process Visualisation in the NHS and Quality Management in Healthcare Special Interest Groups. All are welcome to join. Register
  2. News Article
    Nearly 70 healthcare workers with Long Covid will take their fight to the High Court later to sue the NHS and other employers for compensation. The staff, from England and Wales, believe they first caught Covid at work during the pandemic and say they were not properly protected from the virus. Many of them say they are left with life-changing disabilities and are likely to lose income as a result. The Department of Health said "there are lessons to be learnt" from Covid. The group believe they were not provided with adequate personal protective equipment (PPE) at work, which includes eye protection, gloves, gowns and aprons. In particular, they say they should have had access to high-grade masks, which help block droplets in the air from patient's coughs and sneezes which can contain the Covid virus. But the masks they were given tended to be in line with national guidance. Rachel Hext, who is 36, has always insisted that she caught Covid in her job as a nurse in a small community hospital in Devon. "It's devastating. I live an existence rather than a life. It prevents me doing so much of what I want to do. And it's been four years." Her list of long Covid symptoms includes everything from brain fog and extreme fatigue to nerve damage, and deafness in one ear. Solicitor Kevin Digby, who represents more than 60 members of the group, describes their case as "very important". He says: "It's quite harrowing. These people really have been abandoned, and they are really struggling to fight to get anything. "Now, they can take it to court and hope that they can get some compensation for the injuries that they've suffered." Read full story Source: BBC News, 6 March 2024 Related reading on the hub: Healthcare workers with Long Covid: Group litigation – a blog from David Osborn The pandemic – questions around Government governance: a blog from David Osborn
  3. News Article
    Scrapping the new Therapeutic Products Act (TPA) will leave thousands of New Zealanders exposed to ongoing harm from dodgy medical devices, warn patient safety advocates and legal experts. The act, which was due to come into force in 2026, would have modernised the regulation of medicines and natural health products, and made medical devices, as well as cell, gene and tissue therapies, subject to a similar regulatory regime as drugs. The industry has backed the move, saying the new law was heavy-handed and would stop people getting access to the latest lifesaving technological advances. However, Auckland woman Carmel Berry — who was left in constant knife-like pain from plastic mesh implanted during surgery — said she was “living proof” of the old system’s failures. It took more than 10 years of lobbying by her and the other founders of Mesh Down Under to get authorities to take action — a decade in which hundreds of other people were injured. She is horrified that the TPA, signed into law in only July, is on the chopping block. Beginning work to repeal it was No 47 out of 49 points on the Government’s to-do list for its first 100 days. “I’m horrified. After so many years of developing and rewriting the act and getting it through ... shame on them.” Read full story Source: New Zealand Herald, 18 February 2024
  4. Event
    At this webinar, WHO will launch two WHO publications on Medication Safety, “Global burden of preventable medication-related harm” and “Policy brief on Medication Without Harm”, to create awareness and to support implementation of the WHO Global Patient Safety Challenge: Medication Without Harm. Register
  5. News Article
    “I’ve seen patients take swings at doctors because they’re not happy with the time it’s taken or the doctor’s diagnosis. I’ve seen fire extinguishers set off and thrown at people, computers lifted and thrown across the emergency department and people run out of cubicles and punch other patients – people they don’t know – for no reason.” Roger Webb, a security supervisor at the Queen’s Medical Centre hospital in Nottingham, is recalling some of the more unsavoury incidents he has witnessed in the course of his work. “I’ve been struck in the groin, had scratches all over my arms where people have dug their nails in. I’ve been bitten and I’ve been spat at while trying to deal with situations. The spitting is the most depressing of those, though, because it’s so contemptuous and so horrible. And legally it’s assault.” Like staff across the NHS, those at the QMC have seen a rise in abusive, threatening and intimidatory behaviour by patients and their relatives in recent years. In 2021-22, Nottingham University hospitals (NUH), the NHS trust that runs the QMC and its sister City hospital, recorded 1,237 incidents of aggression, violence and harassment. But it had many more – 1,806 – during the following year, 2022-23. Last year brought another increase. In the six months between April to September alone, NUH recorded another 1,167 incidents, leaving 2023-24 likely to be the worst ever on record. Staff have been hit, spat at, threatened, verbally abused and racially abused during this roll call of unpleasant incidents. Racially aggravated harassment has increased notably. Some of the incidents have led to perpetrators being charged and convicted. Worryingly, in a growing number of cases, the patient has been responsible for several incidents while receiving one single episode of care. Care delays are the main trigger for abuse at the QMC. But such incidents also arise when staff are treating drunks, rival gangs, people who are high on drugs and those with mental health problems. Read full story Source: The Guardian, 25 February 2024
  6. Event
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    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  7. Event
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    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  8. Event
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    This is for those in NHS Trusts in England only. This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview. Using a structured hierarchy of questions to facilitate comprehensive, accurate information. Asking system-focused questions. Closing an interview. Learning objectives Understand and describe the working elements of a standardised and tested approach to investigative interviewing. Understand how to apply the model to plan, conduct and evaluate your investigative interviews. Conduct more ethical and professional interviews. Reach stronger defensible investigation conclusions. Increase your own and others confidence in your ability to investigate complex matters. Register
  9. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Registration
  10. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  11. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  12. Event
    This is for those in NHS Trusts in England only. This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Learning objectives: Define thematic analysis and its key concepts. Understand the relevance of using thematic analysis in the context of healthcare safety learning responses. Code a sample data set and develop themes. Relate the use of thematic analysis to your own safety learning response practice. Register
  13. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  14. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  15. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  16. Event
    This is for those in NHS Trusts in England only. This practical course is aimed at those who are planning to use, or may already be using, After Action Review (AAR) as one of their learning responses to patient safety events. It will also be useful for those in Patient Safety Incident Response Framework (PSIRF) oversight roles. The course is includes: Defining what After Action Review is. Understanding the principles of After Action Review. Discussing the attributes needed to be an After Action Review facilitator. Exploring how to conduct an After Action Review. Reflecting on the value of After Action Review. Learning objectives: Define what After Action Review is. Understand the principles of After Action Review. Know the attributes needed to be an After Action Review facilitator. Understand how to conduct an After Action Review. Register
  17. News Article
    An unprecedented number of women are being investigated by police on suspicion of illegally ending a pregnancy, the BBC has been told. Abortion provider MSI says it knows of up to 60 criminal inquiries in England and Wales since 2018, compared with almost zero before. Some investigations followed natural pregnancy loss, File on 4 found. Pregnancy loss is investigated only if credible evidence suggests a crime, the National Police Chiefs' Council says. File on 4 has spoken to women who say that they have been "traumatised" and left feeling "suicidal" following criminal investigations lasting years. Speaking for the first time, one woman described how she had been placed under investigation after giving birth prematurely, despite maintaining that she had never attempted an abortion. Dr Jonathan Lord, medical director at MSI, which is one of the UK's main abortion providers, believes the "unprecedented" number of women now falling under investigation may be linked to the police's increased awareness of the availability of the "pills by post" scheme - introduced in England and Wales during the Covid-19 lockdown. Scotland also introduced a similar programme. These "telemedicine" schemes, which allow pregnancies up to 10 weeks to be terminated at home, remain in effect. Campaigners are concerned that it is possible for women to knowingly or unknowingly use the pills after this point. MSI's Dr Lord says criminal investigations and prosecutions further "traumatise" women after abortions, and that women deserve "compassion" rather than "punishment". "These women are often vulnerable and in desperate situations - they need help, not investigation and punishment," he says. Read full story Source: BBC News, 20 February 2024
  18. News Article
    An NHS trust has concluded that its former chief executive is not a “fit and proper person” to be on an NHS board, after investigating allegations of sexual harassment and inappropriate behaviour, HSJ has learned. HSJ understands The Robert Jones and Agnes Hunt (RJAH) Orthopaedic Hospital Foundation Trust commissioned a specialist external workplace investigation into Mark Brandreth, which considered serious allegations made about his behaviour during his time as trust chief executive between April 2016 and August 2021. Mr Brandreth is understood to dispute the allegations as well as the investigation’s findings, and is seeking to challenge RJAH’s handling of the complaints and its process for deciding he did not meet the Fit and Proper Person Test. Sources with knowledge of the situation said almost 30 female RJAH staff members came forward to give information to the investigation, but it focused on 12 employees who were willing to give evidence. HSJ has been told that as a result of the investigation, which concluded at the end of last year, the trust’s chair has informed NHSE in writing that it believes Mr Brandreth does not meet the “Fit and Proper Person Test”, implying he should be ruled out of board roles – or roles with equivalent responsibility – at English NHS organisations and adult social care providers. However, the trust, in Shropshire, is not planning to publish its ruling and – with no professional regulation in place for health and care managers and/or board members – it is unclear how effective the conclusion will be if it is not made public. A female staff member told HSJ of her concerns that “nothing is being done”. Read full story (paywalled) Source: HSJ, 21 February 2024
  19. News Article
    Disrepair in NHS buildings led to thousands of potentially-harmful incidents last year including critically ill patients being moved when rainfall came through the ceiling. Sewage leaks, floods and failing equipment also featured in incident records obtained by the BBC under the Freedom of Information Act. Health chiefs called on the government to nearly double its capital spending. The government said "significant sums" had been invested to modernise the NHS. Heath Secretary Victoria Atkins said the government accepted that some hospital buildings "are not as we would wish them to be" but added that it was for NHS chief executives to decide how to spend the money. According to NHS data, the care of more than 2,600 acute hospital patients was disrupted last year by estates and infrastructure failure. The NHS Confederation, which represents trusts, has published a report setting out what health care leaders want the next government to prioritise. It has called on the government to increase capital spending on the health service from £7.7bn to £14.1bn. Matthew Taylor, its chief executive, said: "Put simply, a lack of capital funding can leave patients at risk." Read full story Source: BBC News, 21 February 2024
  20. News Article
    The head of the NHS has today announced the rollout of ‘Martha’s Rule’ in hospitals across England from April, enabling patients and families to seek an urgent review if their condition deteriorates. The patient safety initiative is set to be rolled out to at least 100 NHS sites and will give patients and their families round-the-clock access to a rapid review from an independent critical care team if they are worried about their or a loved one’s condition. This escalation process will be available 24/7 to patients, families and NHS staff, and will be advertised throughout hospitals, making it quickly and easily accessible. NHS chief Amanda Pritchard said the programme had the potential to “save many lives in the future” and thanked Martha’s family for their important campaigning and collaboration to help the NHS improve the care of patients experiencing acute deterioration. Thirteen-year-old Martha Mills died from sepsis at King’s College Hospital, London, in 2021, due to a failure to escalate her to intensive care and after her family’s concerns about her deteriorating condition were not responded to promptly. Extensive campaigning by her parents Merope and Paul, supported by the cross-party think tank Demos, has seen widespread support for a single system that allows patients or their families to trigger an urgent clinical review from a different team in the hospital if the patient’s condition is rapidly worsening and they feel they are not getting the care they need. Merope Mills and Paul Laity, Martha’s parents, said: “We are pleased that the implementation of Martha’s Rule will begin in April. We want it to be in place as quickly and as widely as possible, to prevent what happened to our daughter from happening to other patients in hospital. “We believe Martha’s Rule will save lives. In cases of deterioration, families and carers by the bedside can be aware of changes busy clinicians can’t; their knowledge should be recognised as a resource. We also look to Martha’s Rule to alter medical culture: to give patients a little more power, to encourage listening on the part of medical professionals, and to normalise the idea that even the grandest of doctors should welcome being challenged. We call on all NHS clinicians to back the initiative: we know that the large majority do listen, are open with patients and never complacent – but Martha’s doctors worked in a different culture, so some situations need to change. “Our daughter was quite something: fun and determined, with a vast appetite for life and so many plans and ambitions – we’ll never know what she would have achieved with all her talents. Hers was a preventable death, but Martha’s Rule will mean that she didn’t die completely in vain.” Read full story Source: NHS England, 21 February 2024
  21. Event
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    Are all of your severely immunocompromised patients aged 50 and over vaccinated against shingles? These patients are eligible for vaccination through the National programme Discuss identifying and vaccinating your most vulnerable patients, and how GSK can support you. This event is organised and funded by GSK­­. Further information and registration
  22. Event
    NHS Resolution’s Safety and Learning team, are hosting a virtual forum on perspectives on delivering health in the prison and justice system. The purpose is to raise awareness of the cost and scale of harm, discuss the realities, best practice, challenges and recommendations around collaborating to support healthcare delivery in the justice system. The format is interactive, with presentations followed by questions and panel discussion. Event programme: Learning from prison claims – NHS Resolution The realities of delivering healthcare in prison – Practice Plus Group The medico-legal aspect of prison health claims – Bevan Brittan Q&A panel discussion Contributors: Natalie Miller – Deputy Regional Manager for West Midland Prisons (Practice Plus Group) Ruth Kavanagh – Clinical Quality and Patient Safety Lead (NHS England) Michelle Hodgkinson – Lead Commissioner (NHS England) Jo Easterbrook – Partner (Bevan Brittan) Julie Charlton – Partner (Bevan Brittan) Samantha Thomas – National Safety and Learning Lead for General Practice (NHS Resolution) Dr Anwar Khan – Senior Clinical Advisor for General Practice (NHS Resolution) Register
  23. Event
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    The landscape of the health and care system in England is challenging and complex, and the system is facing profound challenges. At this event, which will take place virtually over two days, policy and leadership experts from The King’s Fund will help you gain a greater understanding of how the health and care system in England works and how it is changing, giving balanced and honest views about the pressures and opportunities it faces. In the run-up to the anticipated general election, our experts will also explore which health and care topics are likely to dominate at the election and which are not, and what this means for people working in the sector.  Delegates will:  make sense of how the NHS is structured and funded learn how various components at system, place and neighbourhood levels come together to create integrated care systems (ICSs) gain an understanding of the key components of primary care and the role they play in the health care system hear about health inequalities and how groups from the voluntary, community and social enterprise (VCSE) sector support wider efforts to improve health inequalities gain a clear understanding of how the social care system is structured, who works in it, and how it is funded learn about the current pressures facing the health care workforce and what this means for the sustainability of the system have the opportunity, through a dedicated session, to ask any questions not answered throughout the event. Register
  24. News Article
    A man with Down’s Syndrome and dementia died in hospital after not being fed for nine days. The 56-year-old was admitted to Poole hospital with a hip fracture after falling over at a Bournemouth care home, where he had been receiving care. On admittance, he was taken to the trauma and orthopaedics ward, where he was listed as ‘nil by mouth’, as he had trouble swallowing. Nine days later, he died of pneumonia after a ‘series of errors’ at the hospital. Now, the man’s father has been given £22,500 in compensation, after an incident investigation at the hospital. Allegations made against the hospital included a failure to feed the patient for nine days, causing "his subsequent severe deterioration and death". The hospital failed to adequately monitor and investigate his condition, while failing to provide senior doctors, it was alleged. This left unsupervised junior doctors who did not have access to senior staff or any way to escalate their concerns, allegations said. This, it was claimed, was not done when the patient was still nil by mouth after nine days, despite the fact he was suffering from pneumonia. Read full story Source: Yahoo News, 9 February 2024
  25. News Article
    The NHS has been accused of putting patients' lives at risk after it allowed hundreds of staff, including senior consultants and managers, to work thousands of miles from the UK. A Mail on Sunday investigation has discovered that NHS staff at every level are working remotely in places as far flung as Australia and Japan. Critics last night warned that the 'unacceptable and dangerous' arrangements could threaten patient safety. Professor Karol Sikora, a former director of the World Health Organisation cancer programme, said: "Allowing staff to work from abroad is a huge mistake that can only undermine patient safety and the efficacy of treatment." At least 335 NHS staff from 33 trusts have been allowed to work abroad in the past two years, according to data from Freedom of Information requests. Until last year, Constantine Fragkoulakis, 42, was employed as a consultant radiologist at Sherwood Forest Hospitals Foundation Trust in Nottinghamshire. The trust said its radiologists "routinely interpret images and write reports away from the hospitals where they are based". But Mr Fragkoulakis admitted there had been "a lot of IT issues, so there was no patient care involved or clinical work'. He added: 'Essentially it was just meetings that I did." Another consultant radiologist, Branimir Klasic, 50, is being allowed to work two weeks each month in Croatia by the Aneurin Bevan University Health Board in South Wales. It said recruitment was "increasingly challenging" and that it was "open to exploring ways of working that ensures we can provide the skills and expertise that our patients need". A Department of Health spokesman said: "We are clear that ways of working, which are agreed between NHS employers and its staff, should never impact on NHS patients or services." Read full story Source: Daily Mail, 10 February 2024

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