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Showing results for tags 'Implementation'.
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Content Article
Nasogastric tube safety: it’s personal
PatientSafetyLearning Team posted an article in Improving patient safety
Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and head of patient safety insight at NHS Improvement. -
Content ArticlePatient safety alerts are issued to providers of NHS care to support them to take specific actions to keep patients safe. Although some content of past alerts is outdated, some of the actions from previously issued alerts continue to be relevant and remain valid beyond the timescales of the original alert. Over 140 alerts issued up to November 2019 (including ‘notices’ or ‘rapid response reports’) were recently clinically reviewed to identify which actions within those alerts remain valid and should be considered as ‘enduring standards’. The review covered alerts issued by the NHS England and NHS Improvement National Patient Safety Team and its predecessor organisation, the National Patient Safety Agency (NPSA). The review also summarised other content from the alerts identified as general principles that can be applied more widely to inform wider ongoing safety improvement. The key elements from the review are highlighted. The pages do not set out any new actions for organisations to implement, but act as an aid to support providers to confirm that ‘enduring standards’ from previously completed alerts have been embedded locally, and that the general principles are considered within ongoing patient safety improvement.
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Content ArticleIn this article for NHSManagers.Net, Peter Carter, former General Secretary and chief executive of the Royal College of Nursing, questions why the First Do No Harm report didn't attract the publicity it warranted and urges the Government to address the issues raised in it as a matter of some urgency.
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News Article
NHS reforms risk sowing confusion and undermining safety, MPs warned
Patient Safety Learning posted a news article in News
A bid for more control over the NHS by ministers risks undermining patient safety and sowing confusion over who is ultimately responsible for services, MPs have been warned. The Commons Health Select Committee was told the proposals, set out in a new white paper published last month, lacked detail on the involvement of patients in local services and needed urgent clarification of the new powers the health secretary will have. The plans will give ministers new powers over the independent Healthcare Safety Investigation Branch (HSIB), including being able to tell it what to investigate and the power to remove protections for NHS staff who give evidence in secret. Last week experts warned the plans for HSIB could undermine its role and have lasting consequences on efforts to encourage NHS staff to be honest about errors. Under the proposals the health secretary would be able to remove so-called “safe space” protections for evidence given by NHS workers. Chris Hopson, chief executive of NHS Providers, told the committee hospitals were worried about the plans. He said: “We are very nervous about this relationship between the secretary of state and HSIB. In order for it to be an effective independent organisation, it does need to be free from the appearance of any kind of political control. There's a very high degree of nervousness about the ability to somehow switch safe space on and off. People need to know where they stand.” Read full story Source: The Independent, 2 March 2021 -
Content ArticleRead how Mersey Care NHS Foundation Trust has adopted and embedded its just and learning culture and its training package. The trust estimates that the just and learning culture has provided economic benefits of roughly £2.5million since 2016. A just and learning culture is one focused on fairness and learning, and absent of blame when things go wrong. It aims to encourage staff to feel able to speak up.
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Content Article
Learning from excellence in healthcare
Patient Safety Learning posted an article in Implementation of improvements
Learning from everyday work means learning from all activities regardless of the outcome. But when things go well, this is typically just gratefully accepted, without further investigation. ‘Learning from Excellence’ is changing this, as Adrian Plunkett and Emma Plunkett describe in this article. -
Content Article
The problem with policies – a blog by Lynne Williams
Lynne Williams posted an article in Improving patient safety
How can we turn the good intentions of a policy into a working model that people use? How can we ensure policies are translated into real, practical solutions? In this blog, Lynne Williams discusses why effective policy implementation is as crucial and important as the content and why we need to look at policies as a collaborative project, headed up by Governance, but written in partnership with the staff that use them to ensure we provide consistent, safe care. -
Content ArticleThis guide from the Patient Safety Movement Foundation gives actions and resources for creating and sustaining safe practices for surgical site infections.
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Content ArticleSafety governance refers to the approaches taken to minimise the risk for patient harm across an entity or system. It typically comprises steering and rule-making functions such as policies, regulations and standards. To date, governance has focused on the clinical level and the hospital setting, with limited oversight and control over safety in other parts of the health system. All 25 countries that responded to a 2019 OECD Survey of Patient Safety Governance have enacted legislation that aims to promote patient safety. These practices include external accreditation and inspections of safety processes and outcomes. Safety governance models are also moving away from punishment and shaming towards increased trust and openness. Learning from success as well as failures represents a paradigm shift in safety governance, an approach that has been increasingly adopted in OECD countries.
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Content ArticleThis Healthcare Safety Investigation Branch (HSIB) report charts the emerging patient safety risks that can come with the introduction of ‘smart’ infusion pump technology into hospitals. Smart infusion pumps are the latest generation of programmable devices that administer medication. They are seen as a way of improving safety as the smart functionality aims to prevent underdoses or overdoses – they are equipped with features such as alerts or alarms to help detect problems. The investigation was launched after one NHS Trust recorded three incidents where a smart infusion pump delivered an overdose of fentanyl, a powerful pain medication. The patients weren’t harmed as it was swiftly picked up, however it emphasised the new risks that come with introducing new technology and the potential for serious medication errors. The investigation focused on the barriers to implementing the technology effectively across the NHS, rather than on the technology itself.
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Content ArticleFalls in Pennsylvania continue to be one of the biggest contributors to patient harm and the fourth most frequently reported adverse event. Looking more broadly, falls are also a frequent cause of patient harm across the United States and globally. Allen and Wallace conducted a review of the literature to identify international strategies and novel approaches to reduce falls and falls from injury, mainly in healthcare facilities, published in the last decade. The review revealed that while no single country has been able to eradicate patient falls, several had implemented measures showing moderate levels of success. Those struggling with a high incidence of falls may benefit from reviewing and adopting one or more of these innovative techniques.
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News Article
Author of gov review forms group to fight ‘woeful’ DHSC response
Patient Safety Learning posted a news article in News
A Tory peer has attacked the Department of Health and Social Care’s ‘woeful’ response to the patient safety review she authored and has revealed she intends to create a cross-party group to force action. Baroness Julia Cumberlege - who led the “First Do No Harm” report on device and medicine safety– has said she has “not had a whisper” from the department over the report’s key recommendations since it was published in July. She told HSJ’s Patient Safety Congress she is setting up a cross-party parliamentary group to “pressure” the department to adopt the report’s recommendations. The report arose from The Independent Medicines and Medical Devices Safety Review, which spoke to more than 700 people, mostly women, who suffered avoidable harm from surgical mesh implants, pregnancy tests and the anti-epileptic drug sodium valproate. The report discovered “a culture of dismissive and arrogant attitudes” including the unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. It concluded that the NHS has “either lost sight of the interests of all those it was set up to serve or does not know how best to do this.” Health and social care secretary Matt Hancock and minister Nadine Dorries have apologised to the women who were harmed but the department has so far not responded to the report’s other eight recommendations in detail. Baroness Cumberlege said the cross party group would “[try] to open up a firmly shut departmental door. A department that doesn’t seem to get it.” She said: “We have been disappointed [in the department’s response] because we hoped by now we would have some sort of inclination about what’s going on." “The response from the department on the other key recommendations has been woeful. The reason they give is ‘there is a terrible amount of work to do’”. Read full story (paywalled) Source: HSJ, 11 November 2020 -
News Article
Basildon maternity unit handed 'urgent' safety deadline
Patient Safety Learning posted a news article in News
An NHS hospital where a woman bled to death in childbirth has been given an "urgent" deadline to keep patients at its maternity unit safe. A letter seen by the BBC reveals the Care Quality Commission (CQC) found unsafe staffing levels at the unit at Basildon Hospital throughout August. The CQC said the trust that runs it had until next Monday to implement appropriate measures. The trust said it had a "robust improvement plan in place". The seven-page document, sent by the CQC on 7 October, puts the Mid and South Essex NHS Foundation Trust on notice that it has to "implement an effective governance system", among other measures. Consequences for missing the deadline were not stated, but the CQC said it was using its powers under the Health and Social Care Act to impose conditions on the trust's registration. The Act does allow the CQC to temporarily close health services. Read full story Source: BBC News, 3 November 2020 -
Content ArticleOn 17 November, there will be a Parliamentary launch event of the Surgical Fires Expert Working Group’s report 'A case for the prevention and management of surgical fires in the UK, which focuses on the prevention of surgical fires in the NHS'. Unfortunately surgical fires are still a patient safety issue. Each year patients needlessly suffer burns during surgical procedures which leave them with long-lasting, life-changing injuries and burdens the NHS with millions of pounds of avoidable costs and liabilities. Despite this, there is not a consistent, standardised approach across the NHS to prevent them. Kathy Nabbie, a theatre scrub nurse practitioner, shares how she implemented Fire Risk Assessment Score (FRAS) into her department.
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Content ArticleFindings from the Healthcare Inspectorate Wales Chief Executive's Annual Report. This report provides an overview of the work undertaken during the past year and what has been found. Healthcare Inspectorate Wales is the independent inspectorate and regulator of healthcare in Wales.
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Content ArticleThe work presented here was undertaken by the OECD to provide a strategic background report for the Patient Safety Priority within the G20 Health Working Group (HWG) 2020. It was commissioned by the Saudi Government. ‘"Acting on patient safety requires leadership and communication, political will, and investment. Transparency across a health system is also integral to begin improving safety and reducing harm. This can only be achieved through investing in a modern information infrastructure, but also relies on sound governance, accountability and proactive leadership. The analysis is clear: unsafe care kills millions, and harms tens of millions of people each year. It also exerts a great economic cost on health systems and society, consuming valuable resources that could be put to productive uses elsewhere. Much of this can be prevented through concerted action and adequate investment. The time for action is now."
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Content ArticleProviders deliver: Resilient and resourceful through COVID-19 is the third report from NHS Providers which celebrate and promote the work of NHS trusts and foundation trusts in improving care for patients and service users. Here is a case study from the University Hospitals of North Midlands NHS Trust. It shows: Deployed thermal imaging cameras to identify people with high temperature. Developed effective guidance for staff. Boosted public confidence in safety of hospital.
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Content ArticleProviders deliver: Resilient and resourceful through COVID-19 is the third report from NHS Providers which celebrate and promote the work of NHS trusts and foundation trusts in improving care for patients and service users. Here is a case study from the Countess of Chester Hospital NHS Foundation Trust. It shows: Development of a trust wide roster for medical staff. Staff engagement – making the case for patient safety. Cultural shift – shared understanding across staff groups.
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Content ArticleAs an industry, biopharmaceuticals is immature when it comes to the integration of human performance into operations. This article from BioPhorum aims to accelerate the industry’s maturity by building a greater understanding of what is desired and explaining how to get there. Human performance is believed by many companies in the biopharmaceutical industry to be a focus on human error reduction, where work outcomes will improve by adding more requirements and coercing people to try harder to be infallible. This archaic approach is not sustainable today and is not human performance. The environment that we operate within – both externally and internally – is changing and yet we are still applying decades-old mental models of what good problem solving looks like, and how this drives overall performance and results. Human performance is the way to make a shift towards systems thinking. Without making this change, organisations will continue to stagnate and actually be unable to keep up with the increasing complexity of the environments they work in, and the environments they create. This blue-sky vision of human performance takes time and patience to properly implement and must be viewed as a fundamental change to how an entire organisation executes work. Essentially, this is a transformation of the organisation’s systems and thinking over a period of several years. This article provides guidance that has worked within the biopharmaceutical industry and the unique regulatory space it operates within.
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Content ArticleProviders deliver: Resilient and resourceful through COVID-19 is the third report from NHS Providers which celebrate and promote the work of NHS trusts and foundation trusts in improving care for patients and service users. This report showcases eight examples of great ideas put into action by trusts through the dedication and ingenuity of staff. One of the main themes in the report is the value of staff empowerment, where trust leaders support ideas and approaches developed within their workforce. Other themes such as innovation and collaboration also emerge. The case studies in this report are a timely reminder of the resilience and resourcefulness that has characterised the response of trusts and their staff to the challenges posed by the pandemic.
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News Article
‘Babies are still being damaged’ Tory peer warns ‘evasive’ ministers
Patient Safety Learning posted a news article in News
The government has been told it is ‘not sustainable’ to continue to delay its response to a major review on patient safety as ‘babies are still being damaged’. The Independent Medicines and Medical Devices Safety Review spoke to more than 700 people, mostly women who suffered avoidable harm from surgical mesh implants, pregnancy tests and an anti-epileptic drug, and criticised “a culture of dismissive and arrogant attitudes” including the “unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. The review’s author Baroness Julia Cumberlege told HSJ that “time is marching on” for the Department of Health and Social Care to implement the recommendations of her July report, which include setting up a new independent patient safety commissioner. The Conservative peer said pressure was building on government to adopt the findings of the review, since it had been endorsed by Royal Colleges and has already been adopted by the Scottish government. She said the government had given “evasive” answers in parliament on the issue. In an exclusive interview with HSJ, Baroness Cumberlege said: There is a crowded field of regulators but “there’s a void” for a service that listens and responds to patients’ safety concerns. She feels “diminished” that women’s concerns are still being dismissed by clinicians, but said young doctors are a cause for hope. She is “very optimistic” report will be implemented – but the NHS has to have the will to make changes. Read full story (paywalled) Source: HSJ, 13 October 2020 -
News Article
Maternity scandal hospital fined for not triaging A&E patients fast enough
Patient Safety Learning posted a news article in News
An NHS hospital which has faced repeated criticism by regulators for poor standards of care has been fined £4,000 for failing to assess A&E patients quickly enough. The Shrewsbury and Telford Hospitals Trust has been fined by the Care Quality Commission (CQC) after patients were not triaged within 15 mimutes of arrival in A&E – in breach of conditions set by the regulator last year and a national target. The care of emergency patients at the hospital trust, which is also facing an inquiry into poor maternity care, has been a long running concern for the watchdog which has rated the trust inadequate and put it in special measures in 2018. Earlier this year the CQC’s chief inspector of hospitals, Professor Ted Baker, wrote to NHS England warning of a “worsening picture" at the Midlands hospital and demanding action be taken. The CQC said it had issued the fixed penalty notice to the trust because it failed to comply with national clinical guidance that all children and adults must be assessed within 15 minutes of arrival. It also failed to implement a system that ensured all children who left the emergency department without being seen were followed up. After inspections in April 2019 and November 29 the CQC imposed seven conditions on the hospital over emergency care. The regulator said it was now clear the trust had not stuck to the conditions and had breached them both at Royal Shrewsbury Hospital and Princess Royal Hospital. Professor Baker said: "The trust has not responded satisfactorily to previous enforcement action regarding how quickly patients are assessed upon entering the urgent and emergency department." “We have issued a penalty notice due to the severity of the situation and to ensure the necessary, urgent improvements are made. It is essential that patients are seen in a timely way when they arrive at an emergency department; failure to do so could result in deteriorating health, harm, or even death, which is why national guidelines exist and must be followed." Read full story Source: The Independent, 12 October 2020 -
News ArticleToo many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned. Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.” Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said. He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies. “Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.” Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.” Read full story Source: The Guardian, 29 September 2020
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Content ArticleThe African Partnerships for Patient Safety (APPS) is a WHO Patient Safety Programme concerned with building sustainable hospital to hospital patient safety partnerships. The programme is focused on countries of the WHO African Region but has also opened the network and programme resources to all hospitals in all regions of the world. It sits within the programmatic area of Global Partnerships for Patient Safety. APPS is concerned with advocating for patient safety as a precondition of health care and catalyzing a range of actions that will strengthen health systems, assist in building local capacity and help reduce medical error and patient harm. The programme acts as a channel for patient safety improvements that can spread across countries, uniting patient safety efforts. APPS has taken place in a dynamic context in which insights are emerging on multiple dimensions of patient safety in African settings and political changes have seen shifts in approaches to patient safety in the United Kingdom. What is clear however is that the published literature on evidence-based patient safety interventions in the African context still lags behind high-income countries. This report highlights that issues and solutions from high income settings cannot simply be applied to African countries, and there is a need to understand the insights presented here from front-line partners to ensure that culture and context are addressed and the necessary adaptation made to existing approaches moving forward.
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Content ArticleIn this blog, Patient Safety Learning look at why complaints are important to improving patient safety and sets out its response to the Parliamentary and Health Service Ombudsman (PHSO) consultation on a new Complaint Standards Framework for the NHS.
