PatientSafetyLearning Team

It can be confusing to know what to do when your baby or child is unwell during the coronavirus pandemic. The Royal College of Paediatrics and Child Health has developed posters for families living in England, Scotland, Wales (in English and Welsh languages) and Northern Ireland about when and how to get medical help for your child, or for your young baby, or for yourself as a young person.

The impact of COVID-19 has created an extremely challenging time for the social care workforce. Skills for Care have identified training that remains a priority during this period to ensure there is a skilled and competent workforce. The training is available as three individual packages of learning,  rapid induction programme (aimed at new staff), refresher training (aimed at existing staff) and a volunteer programme. Find out more on each area via the link below.

Nursing and midwifery are unarguably stressful endeavours requiring high levels of psychological capital and coping strategies. The impact of the work environment on patient safety outcomes suggests that high nurse/midwife stress may be associated with more adverse patient events. The purpose of this study, published in Nursing and Health Sciences, was to explore the psychological capital of clinical nurses and midwives and identify explanatory factors (including psychological capital, well‐being and health related behaviours) contributing to attitudes to patient safety.The findings suggest that nurse and midwife wellbeing is an important consideration when striving to improve patient safety.

Despite the extensive attention and public commitments towards patient safety over the last two decades, levels of avoidable harm in healthcare around the world remain unacceptably high.  This book is free to download. By creating a book with broad scope and clear descriptions of the key concepts and thinking in patient safety, the authors have aimed to connect with a much wider readership than those with a professional or academic interest in the subject. They have not limited themselves to theoretical models or risk management methodologies. They have aimed to address safety in various medical specialties. For example, there is a discussion of the causation and solutions in conditions such as infantile cerebral palsy; today in many health systems this has a high human and economic cost, some of which are preventable. They have also dealt with how the structure, culture and leadership of healthcare organisations can determine how many patients suffer avoidable harm and how safe they and their families should feel when putting their trust in local services. Safety problems relating to non-technical skills are also discussed; this is a topic of great importance but under-represented in medical and nursing educational and training curricula.

Hip-fracture patients are vulnerable to the outcomes of COVID-19. Authors of this study, published in The Journal of Hospital Infection, performed a cross-sectional survey to determine measures employed to limit nosocomial spread of COVID-19 in 23 orthopaedic trauma departments in the North-West of England. Nineteen (87%) hospitals admitted patients to a ward prior to a negative swab, and only 9 (39%) patients were barrier nursed. Hip-fracture patients were operated in non-COVID-19-free theatres in 21 (91%) hospitals. Regular screening of doctors working in trauma and elective areas for COVID-19 was undertaken in three (13%) and five (22%) hospitals, respectively. Doctors moved freely between trauma and elective areas in 22 (96%) hospitals.

Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.By having discussions that are informed by the doctor, but take into account what’s important to the patient too, both sides can be supported to make better decisions about care. Often, this will help to avoid tests, treatments or procedures that are unlikely to be of benefit. The link below takes you to a Choosing Wisely UK webpage dedicated to resources on shared decision making. These include: Leaflet for patients to help them make the right choices for them at their healthcare appointment using the BRAN questions.Poster to be displayed to encourage the patients to ask the BRAN questionsGuidance on professional standards and ethics for doctorse-learning and video resources for cliniciansLeaflet for healthcare professionals to understand shared decision making.

This survey has been designed by the Long Covid Support Group to collate information on the patient experience of Long COVID clinics in England (also referred to as Assessment Centres), announced on December 18th, 2020. Data collected will be anonymised and analysed to produce a report to inform medical professionals, health organisations and interested stakeholder groups such as NHSE, Royal Colleges and research bodies. This survey is initially open for a 4 week period, with results expected to be published in Spring 2021. 

A significant number of patients with COVID-19 experience prolonged symptoms, known as Long COVID. Few systematic studies have investigated this population, particularly in outpatient settings. Hence, relatively little is known about symptom makeup and severity, expected clinical course, impact on daily functioning, and return to baseline health.  Davis et al. conducted an online survey of people with suspected and confirmed COVID-19, distributed via COVID-19 support groups and social media. Patients with Long COVID reported prolonged, multisystem involvement and significant disability. By seven months, many patients have not yet recovered (mainly from systemic and neurological/cognitive symptoms), have not returned to previous levels of work, and continue to experience significant symptom burden.

Recent work has emphasised the benefits of patient-physician concordance on clinical care outcomes for underrepresented minorities, arguing it can boost communication and increase trust. Authors of this study explored concordance in a setting where racial disparities are particularly severe: childbirth. In the United States, Black newborns die at three times the rate of White newborns. Results examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggest that newborn-physician racial concordance is associated with a significant improvement in mortality for Black infants. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. They found no significant improvement in maternal mortality when birthing mothers share race with their physician. You can also read the news coverage in the Washington Post here.  To access the research, follow the link below. 

Save The Children are further strengthening their policy and regulatory frameworks to assure medical safety, while promoting a culture of learning to minimise medical incidents and maximise patient safety across their programmes. This article discusses why reduction of avoidable harm within healthcare is so important, and why more can be done within the international development sector.

Safety systems are socio-cultural in nature, characterised by people, their relationships to one another and to the whole. This study, publishe in the International Journal for Quality in Health Care, aimed to (i) map the social networks of New Zealand’s quality improvement and safety leaders, (ii) illuminate influential characteristics and behaviours of key network players and (iii) make recommendations regarding how networks might be optimised.

Towards the end of December 2020 the Minister for Mental Health, Suicide Prevention and Patient Safety, Nadine Dorries MP, indicated that the Government would be accepting one of the key recommendations made in the First Do No Harm report, published earlier this year by the Independent Medicines and Medical Devices Safety Review, by creating a Patient Safety Commissioner for England. In this blog, Patient Safety Learning Chief Executive, Helen Hughes, sets out some early thoughts on this proposal and considers what impact it may have on patient safety. Last week the UK Government confirmed that it would accept one of the key recommendations in the First Do No Harm report, published earlier this year by the Independent Medicines and Medical Devices Safety Review (more commonly known as the Cumberlege Review). Nadine Dorries MP, Minister for Mental Health, Suicide Prevention and Patient Safety, was quoted as saying that this would be tabled as an amendment to the Medicines and Medical Devices Bill.[1] This announcement has been welcomed by the Review’s Chair, Baroness Julia Cumberlege, and members of the newly formed All-Party Parliamentary Group for First Do No Harm, which has recently been set up to raise awareness and build support for the implementation of the Review’s recommendations.[2] But what this role will look like in practice, and what impact will it have on patient safety? What was proposed by the Cumberlege Review? The Cumberlege Review examined how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices.[3] It focused on three specific medical interventions: Hormone pregnancy tests, Sodium valproate and Pelvic mesh implants. Its report, published in July this year, set out the shocking scale of avoidable harm that resulted from these three interventions over a period of decades. It made a series of recommendations and actions for improvement, the second of which was: “The appointment of a Patient Safety Commissioner who would be an independent public leader with a statutory responsibility. The Commissioner would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices.”[3] The Review envisioned this role as sitting outside of the existing healthcare system with “a direct line of accountability to Parliament through the Health and Social Care Select Committee”.[3] It explained that the Commissioner should focus on two aims: Promoting and improving patient safety. Promoting the views and interests of patients and other members of the public in relation to the safety of medicines and medical devices. Independence, aims and resourcing The Cumberlege Review includes in an appendix with further information about how a Patient Safety Commissioner for England would work in practice, providing suggestions on its powers, appointment, accountability, and organisational structure. Until we see more details following the passing of the Medicines and Medical Devices Bill into law, the extent to which these suggestions will be adopted remains an unclear. Some elements that we think are essential are: 1) Independence The Patient Safety Commissioner must be independent of those funding and delivering healthcare and free to speak their mind without fear or favour. The Review suggests the Commissioner should be appointed by the Privy Council and funded by the Cabinet Office, maintaining a level of separation from the healthcare system. This is to be welcomed, especially as other Commissioners do not always that degree of independence. For example, this is not the case in the role that this proposal draws much inspiration from, the Children’s Commissioner, who is directly appointed by the Secretary of State for Education and funded by their Department. 2) Aims The First Do No Harm report states that the Patient Safety Commissioner should aim: “… to improve identification of systemic safety issues and to improve the system’s coordinated response. Through a renewed focus on patients’ needs and a drive for cooperation and coordination, the Commissioner will help to release the wider benefits for the healthcare system from individual organisations’ safety improvements.”[3] This is a welcome ambition, but is it achievable? The Commissioner’s main role is promoting the rights of patients. This must be more than just listening and promoting. The Commissioner should be able to recommend and/or lead inquiries and reviews. This is a recommendation that we believe is essential to turn words into action and we would strongly commend the Government to agree to this in its response. 3) Resourcing The healthcare system, or broader health and social care systems depending on the Commissioner’s final remit, is incredibly complex. The Commissioner’s Office will need to be properly resourced to enable it to: Listen to the many individual patients and patient groups who will want to raise their concerns. Engage with regulators, providers, commissioners, policy makers and the very many stakeholders in health and social care. Engage with and influence the media. Resources must be made available to the Commissioner to support their remit. This will prove to be instrumental as to whether they are able to achieve their objectives. 4) Collaboration with patient safety groups and networks While the role of the Patient Safety Commissioner will be a new one, there are already a diverse range of groups outside of the NHS that can provide a helpful source of knowledge, insight, information, and support. By bringing these organisations into a network, the Commissioner could amplify the voices of many already actively promoting patient safety. By no means an exhaustive list, but this could include: AvMA, The Patients Association, Healthwatch, Care Opinion, patient campaigning groups and of course, Patient Safety Learning. Our free knowledge sharing platform for patient safety, the hub, could provide valuable resources and a community forum for listening to patients’ voices. The need for system-wide change We believe that a well-resourced Patient Safety Commissioner could play a vital part in improving patient safety in England. The Commissioner must have the resources and powers to influence change. It will not be sufficient for the Commissioner to raise patients’ concerns if the healthcare system is not compelled to listen and respond. We consider that the Commissioner alone will not be able to bring about the fundamental change that is required to tackle unsafe care and empower patients. What is required is a step change in how we support and engage patients in patient safety and how the health care system transforms itself to put patient safety at its core. Many of these changes are needed throughout the health and social care system, from the bottom up. We describe the action that is needed in our report A Blueprint for Action and highlight 6 foundations for safer care that are urgently needed.[4] Another one of the recommendations of the Cumberlege Review was to establish a task force to implement its findings. If we are to make the wide-ranging changes needed for safe care, we believe that any such task force needs to look at patient safety issues beyond this report. Such a task force should include recommendations made by other major patient safety reports, such as: Recent reports by the Care Quality Commission, including Opening the door to change: NHS safety culture and the need for transformation, Out of sight – who cares? Restraint, segregation and seclusion review and CQC Inspections and regulation of Whorlton Hall: second independent report.[5] [6] [7] Report of the independent Inquiry into the issues raised by Paterson.[8] Ockenden Report: Emerging Findings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.[9] The Life and Death of Elizabeth Dixon: A Catalyst for Change.[10] Implications for devolved health and social care One final notable issue posed by the commitment of the Government to establish a Patient Safety Commissioner for England is how this will work within the devolved health and social care system across the UK. The Scottish Government announced in September that they would be seeking to establish such as role, confirming this in a subsequent parliamentary debate.[11] [12] However at this time it is unclear whether these arrangements will be replicated across each of the four nations. In Wales, the Government is yet to issue a formal response on the Cumberlege Review’s recommendations, indicating in a recent response to a parliamentary question that they were still considering this.[13] Meanwhile in Northern Ireland, at the end of November the Minister for Health Robin Swann MLA stated in a Assembly debate that this was one of a number of issues being considered by a working group looking at the Cumberlege Review’s recommendations.[14] This was not an issue for the Cumberlege Review to consider, with its remit specifically concerning England. However, thought needs to be given as to how multiple Patient Safety Commissioners may interact and work together, or how this might work in practice if some parts of the UK are covered by such a Commissioner and others are not. There would be likely be significant common ground between the different Commissioners, resulting from similarities in healthcare provision across the UK. If significant patient safety issues who identified by one nation, there would be a value in ensuring a significant degree of coordination is in place to ensure that similar issues are not missed in other parts of the country. References Health Service Journal, Government finally accepts need for ‘independent’ national patient safety commissioner, 17 December 2020. APPG for First Do No Harm, Homepage, Last Accessed 21 December 2020. The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. Care Quality Commission, Opening the door to change: NHS safety culture and the need for transformation, December 2018. Care Quality Commission, Out of sight – who cares? A review of restraint, seclusion and segregation for autistic people, and people with a learning disability and/or mental health condition, October 2020. Care Quality Commission, CQC Inspections and regulation of Whorlton Hall: second independent report, 15 December 2020. The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Emerging findings and recommendations form the independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, 10 December 2020. Dr Bill Kirkup CBE, The Life and Death of Elizabeth Dixon: A Catalyst for Change, November 2020. The Life and Death of Elizabeth Dixon: A Catalyst for Change - November 2020 (publishing.service.gov.uk) Scottish Government, Protecting Scotland, Renewing Scotland: The Government’s Programme for Scotland 2020-2021, 1 September 2020. Scottish Parliament, Official Report: Meeting of the Parliament, Session 5, 8 September 2020. Senedd Cymru – Welsh Parliament, Written Question 81592, 26 November 2020. Northern Ireland Assembly, Official Report, 30 November 2020.

Neonatal herpes simplex virus (HSV) disease is a rare, and potentially fatal, disease which usually occurs in the first four weeks of a baby's life. Early recognition and treatment of the virus has been shown to significantly improve babies' chances of making a full recovery. Kit Tarka Foundation works to prevent newborn baby deaths; primarily through raising awareness of neonatal herpes, funding research and providing advice for healthcare professionals and the general public. Content includes: What is neonatal herpes? What is the herpes simplex virus? How can a baby catch herpes? What are the signs & symptoms of neonatal herpes? How do I know if my baby has an infection? What is the treatment for neonatal herpes? What can I do to prevent my baby from getting neonatal herpes? I am pregnant or breastfeeding, how can I protect my baby? I have a cold sore, what should I do to make sure I don't pass the virus to a baby? How do I wash my hands properly to help keep babies safe? Follow the link below to Kit Tarka Foundation's website, to find out more.

The British Society for Immunology (BSI) has created two video question and answer sessions about vaccines for COVID-19. They took vaccine questions and concerns from the public on their Instagram channel and put them to expert immunology scientists, Dr Megan MacLeod and Prof Sheena Cruickshank. In the videos, Megan and Sheena answer these questions and explore the details of when vaccines may become available, who will receive the vaccines, how long immunity might last to a vaccine, how herd immunity can protect us and lots more. It’s important to understand and address vaccine concerns that are prominent in public discussion and may lead to hesitancy to vaccination. By answering your vaccine questions, the BSI hopes to provide expert information to help everyone make informed decisions about vaccines and their health. Follow the link below to watch the videos. 

We’ve come to the final instalment of our 2020 blog series, where we’ve reflected on key patient safety issues we’ve seen this year and our work in those areas. First, our Chief Executive, Helen Hughes, introduced the series, giving an overview of the year. We then looked at: The impact of the COVID19 pandemic on patient safety Advice and support for people living with Long COVID Painful hysteroscopies Staff safety. Lastly, we turn our attention to one of the most significant reports we’ve responded to this year, First Do No Harm – also known as the Cumberlege Review – by the Independent Medicines and Medical Devices Safety Review. As an additional option to the text below, you might like to watch the following short video from Helen Hughes, Patient Safety Learning's Chief Executive. Using our voice to help create awareness and change Part of how we work towards our goals at Patient Safety Learning is by responding to official reports, using our independent voice for patient safety to help raise awareness of key issues and make the case for change. In July, we set out our analysis of the Cumberlege Review, a week after it was first published. We considered the review’s findings and highlighted the key patient safety themes running throughout, many of which were consistent with those found in other patient safety scandals in the last 20 years. We looked at what needs to change to prevent these issues from recurring and made the case that patients should not be asked to ‘join the dots’ for patient safety, concluding that it is “the responsibility of healthcare leaders who must seize this opportunity to drive the changes needed for safer care”. We also published two shorter blogs on our patient safety platform, the hub, looking in more detail at the patient safety issues around informed consent and patient complaints, highlighted by the review. In August, Helen Hughes commented on the Cumberlege Review as part of our ‘2-minute Tuesdays’ series. She said that it identifies the scale and severity of harm to thousands of women and shows patient safety themes going back decades, including those found in the Paterson Report, “another report that is yet to be responded to by the Government”. Helen highlighted that the report not only highlights patient safety issues but also: “equality issues” because women claimed the issues they raised were dismissed as ‘women’s issues’ “issues of failed leadership” with Baroness Cumberlege commenting that the healthcare system, including the NHS, private providers, regulators and professional bodies, pharmaceutical and device manufacturers, and policymakers, are “disjointed, siloed, unresponsive and defensive”. Taking steps to ensure action is taken Like many others, we want to see a government response to this report, resulting in actions that will help to create a future where all patients receive safe healthcare. To help make this happen, we have been widely sharing our insights on implications for patient safety raised by this report and are seeking to work with others to ensure that its recommendations are kept on the Government’s agenda. Looking forward We will continue to use the hub to expose health inequalities, provide a public platform to those who have been harmed or dismissed and encourage people to speak up. We will use what we learn to inform the concerns we voice and the actions we take.