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Content ArticleIn 1999, the pivotal report “To Err is Human” by the Institute of Medicine led to sweeping changes in healthcare. This report outlined how blaming individuals does not change the underlying factors that contribute to medical errors. It also stated that blaming an individual does little to make the system safer – or prevent someone else from similar errors. It is unusual for a nurse to be charged criminally, when there is no intent to harm a patient. However, the recent trial in America of nurse RaDonda Vaught could set a precedent for future medical errors to be treated as criminal cases. The case may ensure that for every step that has been taken forward in patient safety, we have now taken two steps backwards. This article from Human Factors 101 looks at the case of RaDonda Vaught, the criminal trial and conviction, and discusses the impact this will have on healthcare.
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Blog - Long Covid: A catalogue of shame (2 November 2022)
Patient-Safety-Learning posted an article in Blogs
In this blog, Roger Kline, Research Fellow at Middlesex University Business School, highlights the lack of support from the Government and NHS that healthcare staff with Long Covid face. He looks at the impact of the Government’s decision to scrap extended sick pay for NHS staff with Long Covid and argues that healthcare workers deserve better support. The blog includes accounts from 31 NHS nurses and midwives with Long Covid; some are having to use annual leave as they cannot work their full hours and some have been threatened with redundancy. Others describe their experiences of phased return to work and applying for the NHS Injury Allowance or ill health early retirement. -
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Blog - Is human error a crime? (2 November 2022)
Patient-Safety-Learning posted an article in Legal matters
Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place. -
Content ArticleThis webinar hosted by GovConnect features three presentations about digital wound management:Digital data and information (National Wound Care Strategy Programme)York Community Services approach to engagement of staff in digital changeDigitising wound care in the community: The challenges and successes (Livewell Southwest)
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Content ArticleMany nurses also act as family caregivers, and this study in the journal Nursing Outlook aimed to examine the impact of family caregiving on nurses, their colleagues and the organisations they work for. Nurse caregivers and healthcare organisation leaders completed two surveys about views on family caregiving. The authors found that healthcare leaders perceived family caregiving to have a larger impact on the nurses’ health and work performance than nurses themselves. Family caregiving was also identified as a potential contributor to burnout, and the authors highlight that lack of workplace support for family caregiving may influence nurses decisions about leaving or reducing their role.
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This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Kathy tells us about the importance of breaking down barriers to share patient safety tools, and talks about changes she has implemented to make surgery safer. -
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SAPHNA - Eating disorder toolkit (October 2022)
Patient-Safety-Learning posted an article in Eating disorders
This toolkit has been co-produced by the School and Public Health Nurses Association (SAPHNA) with school nursing services, mental health campaigners, eating disorder experts, education colleagues and young people with lived-experience of eating disorders. It is aimed at qualified, trained and skilled nurses who have access to robust supervision. The toolkit is free of charge, but you will need to enter your details in order to receive a PDF copy by email. -
Content ArticleNursing education has long utilised simulation in different forms to teach the principles and skills of nursing care, from anatomical models to computer-based learning. This chapter from Patient Safety and Quality: An Evidence-Based Handbook for Nurses looks at simulation training as a strategy to prevent healthcare errors. It explores the value of human patient simulation in nursing education programs.
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Content ArticleDespite the constant pressures and chronic shortages, the number of nurses leaving the NHS had flatlined over recent years. Now our analysis of new data shows there has been a large increase in nurses leaving the NHS, and that this trend is being driven by younger workers. The last year's data (June 2021 - June 2022) saw a 25% increase in the number of NHS nurses leaving their role, with an additional 7,000 leaving compared to the previous year. The largest increase in numbers leaving was seen among the younger nurses, two thirds of leavers were under 45 years of age. In this article, Jonathon Holmes explores why there is a sudden increase in vacancies.
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Content ArticleThis article published by the Royal College of Nursing (RCN) aims to explain how health services in the UK protect patient safety during industrial action by nurses. It describes the principle of derogations, an exemption from taking part in strike action given to particular RCN members or services. Any RCN industrial action must follow the life-preserving care model. This exempts: emergency intervention for the preservation of life or the prevention of permanent disability. care required for therapeutic services without which life would be jeopardised or permanent disability would occur. urgent diagnostic procedures and assessment required to obtain information on potentially life-threatening conditions or conditions that could potentially lead to permanent disability. The article goes on to explain the process by which derogations are granted, and talks about balancing the need to maximise the impact of the strike while keeping patients safe.
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Content ArticleThis framework from NHS England supports nurses, midwives and care staff in ensuring care remains at a high standard, as well as demonstrating the contribution to the Long Covid response. It aims to give the opportunity to embrace collective leadership in supporting people and communities served and showcase good practice as it emerges across England.
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Content ArticleThe Francis Inquiries in 2010 and 2013 highlighted nurse staffing as a patient safety factor contributing to the care failings identified at Mid Staffordshire NHS Trust. The reports and government response led to the development of national ‘safe staffing’ policy. This two-year study by the University of Southampton and Bangor University examined the impact of safe staffing policies nationally and explored variation in local responses. The authors concluded that: Policies provided leverage and raised the profile of nursing workforce issues at board level, contributing to a willingness to invest in increasing nursing numbers. However, a lack of assessment of the likely scale of investment (and human resources) required nationally to achieve ‘safe staffing’ led to financial considerations becoming a barrier to achieving the policy vision. External pressures, such as lack of workforce supply and reduced access to temporary staffing, have constrained Trusts’ abilities to fully implement policies aimed at ensuring safe staffing on acute wards.
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Content ArticleThis longitudinal study in BMJ Quality & Safety aimed to examine the impact of nursing team size and composition on inpatient hospital mortality. The authors found that registered nurse staffing and seniority levels were associated with patient mortality. The lack of association for healthcare support workers and agency nurses indicates they are not effective substitutes for registered nurses who regularly work on the ward.
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Content ArticleNursing is the single largest profession in the NHS, but it suffers from substantial staffing shortages. This analysis from Billy Palmer and Lucina Rolewicz for the Nuffield Trust reflects on the rate at which the health service is losing nurses, and considers the reasons why.
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EventuntilHow can we better support nurses and midwives to flourish and thrive in their work? Join the King's Fund at this free online event to discuss the changes needed to empower nurses and midwives to shape and provide the compassionate, high-quality care that they aspire to in a sustainable way – through the COVID-19 pandemic and beyond. The conversation will explore: workplace stressors, work conditions and ways of working – including workload, shift patterns and supervision – that have an impact on nurse and midwife wellbeing, and how these can be positively transformed organisational cultures and leadership styles – including those around diversity and inclusion, psychological safety and compassionate leadership at all levels – that need to be cultivated, and how progress can be achieved lessons and examples of good practice from across the health and care system, from both before and during the COVID-19 pandemic. Register
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Content ArticleIn this video, Barts Health NHS Trust explain what measures frontline medical staff can take to help avoid the risk of pressure ulcers.
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Content ArticleActive surveillance (AS) is an option in the management of men with low-stage, low-risk prostate cancer. These patients, who often require prolonged follow-up, can put a strain on outpatient resources. Nurses are ideally placed to develop advanced roles to help meet this increased demand—a model Martin et al. have utilised since 2014. The authors set about to comprehensively evaluate their nurse-led AS (NLAS) programme. The study found that nurse-led active surveillance is safe and effective. Patients and stakeholders alike held positive views of the programme.
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Content ArticleThe aim of this study from Choi et al. was to investigate the scope and severity of the second victim problem among nurses in South Korea by examining the experiences and effects of patient safety incidents (PSIs) on them. The study found a considerable number of nurses experienced psychological difficulties due to PSIs at levels that could interfere with their work. The effect of PSIs on nurses with direct experience of PSIs was greater compared with those with indirect experience. There need to be psychological support programmes for nurses to alleviate the negative effects of PSIs.
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Content ArticleThis resource, written by the Royal College of Nursing, is intended for any registered nurse working with medicines as part of their role. The principles of medicines management however, apply across all health care settings and for non-registered staff.
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Content ArticleThe quality and safety of patient care relies on good communication, teamwork and respect between staff. However, in many areas of the NHS hierarchical attitudes lead to a dictatorial approach in which senior nurses make decisions affecting their colleagues without any discussion or consideration of the impact and practicality of these decisions. This can lead to dysfunctional organisational cultures in which staff either tolerate and emulate disrespect or leave the profession. Ellen Wightman, a staff nurse at University Hospitals Bristol NHS Foundation Trust, reflects on the importance of nurses being supported in developing leadership skills – and having the motivation to create collaborative and positive cultures.
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Content ArticleThis article, published by the Journal of Clinical Nursing, argues there can be no healthy patient safety culture where Datix or other electronic incident reporting systems (EIRS) are trivialised and weaponised. Nurses at every level can support and enable the blame free culture where nurses use Datix to genuinely promote patient safety. Follow the link below to download the full article. Other blogs you may also be interested in: “I’m going to Datix you” – a blog from Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan Silent witness: My experience when filing an incident report – newly qualified nurse describes what happened when she reported her first Datix for a serious incident. Marking your own homework – an anonymous blog
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Content Article
Are agency healthcare practitioners adequately covered to work in private hospitals?
Anonymous posted an article in Occupational health and safety
I would like to share with you my experience of an injury I sustained when working as an agency nurse doing bank shifts in a private hospital and highlight to colleagues the importance of knowing your entitlements when working for an Agency. Please make sure you are adequately covered for injury. -
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In this joint open letter, the UK’s Chief Nursing Officers write about how they are supporting professionals during the pandemic. They encourage the profession to “speak up” if they feel unsafe at work amid the latest surge of COVID-19. The letter also includes information on: supporting to deliver care helping to strengthen the workforce capacity supporting the roll-out of vaccines support for health and wellbeing.- Posted
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Content ArticleNursing 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.
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Content ArticleNurses often express a desire to serve others as a volunteer. They volunteer within their communities and across borders in global settings. While nurses considering participation or serving as a volunteer express altruistic intention, their actions may result in unintended adverse consequences to the host community. The purpose of this position statement is to promote ethically responsible volunteer efforts classified as short-term (six months or less) practice experiences in local and global healthcare and public health.
