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Content ArticleThe CQC inspection framework now includes multidisciplinary teams (MDTs) for end of life care, tumours and weekly MDTs for people with complex needs. However lack of time and staff availability for this is a real problem. MDTs are under increasing pressure and are already seeing an erosion of their power to assure safe and appropriate care. Anecdotally, non-attendance by key MDT members is a significant quality issue for many hospitals. This is not a problem of engagement — all MDT members and are willing to provide input — but staffing pressures and the complexity of rostering makes holding these MDT meetings near-impossible. So how do we stop this degradation? How can hospitals better manage the burgeoning requirement for MDTs? One possible answer is to change the emphasis from a single meeting to a managed series of recorded opinions and decisions. If properly supported by the right workflow technology, we can move away from the ‘single-point’ MDT meeting (MDTM) to a ‘multi-point’ MDT process (MDTP) which could allow better and more auditable decisions to be made. Where significant differences of opinion exist, then a meeting can be called – but the MDT members could act independently and in parallel using a suitable recording and monitoring system. In this article, Dr D J Hamblin-Brown explains how this might work.
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Event
Investigation and learning from deaths in NHS Trusts
Sam posted an event in Community Calendar
The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts and will reflect on learning from deaths during the Covid pandemic and how mortality investigation should be managed in these cases. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. This conference will also update delegates on the New National Patient Safety Incident Response Framework including sharing experience from an early adopter site. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/investigation-and-learning-from-deaths-in-nhs-trusts or email kate@hc-uk.org.uk Follow the conference on Twitter @HCUK_Clare #CQCDeathsreview hub members receive a 20% discount. Email info@pslhub.org for discount code. -
Content Article
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In this blog, Patient Safety Learning’s hub Editor, Samantha Warne, summarises a recent Patient Safety Management Network (PSMN) session she joined to hear from James Munro, Chief Executive of Care Opinion, about how patients are using Care Opinion to share their experiences and how Trusts are using the feedback. -
Content ArticleReporting to the National Reporting and Learning System (NRLS) is largely voluntary, to encourage openness and continual increases in reporting to facilitate learning from error. Increases in the number of incidents reported reflects an improved reporting culture and should not be interpreted as a decrease in the safety of the NHS. Equally, a decrease cannot be interpreted as an increase in the safety of the NHS. This report covers the early stages of the COVID-19 pandemic in England, from April 2020 through to the end of March 2021, when cases had declined rapidly. The number of incidents reported from April 2020 to March 2021 was 2,109,057, and represent a small decrease of 6.1% compared to April 2019 to March 2020 (2,246,622).
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Content ArticleHealthcare leaders are bringing renewed attention to patient safety issues that have been overshadowed by another year of the COVID-19 pandemic. Becker's Hospital Review asked patient safety experts the following question: "If you could fix one patient safety issue overnight, what would it be and why?" Read the answers Cynthia Barnard, Vice President of Quality at Northwestern Memorial Healthcare (Chicago), Patricia McGaffigan, Vice President of Safety Programs at the Institute for Healthcare Improvement, Ana Pujols McKee Vice president and CMO and Chief Diversity, Equity and Inclusion Officer at The Joint Commission and Gary Stuck, CMO at Advocate Aurora Health gave.
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Content ArticleHuman factors and ergonomics (HF/E) is concerned with the design of work and work systems. There is an increasing appreciation of the value that HF/E can bring to enhancing the quality and safety of care, but the professionalisation of HF/E in healthcare is still in its infancy. In this paper, Sujan et al. set out a vision for HF/E in healthcare based on the work of the Chartered Institute of Ergonomics and Human Factors (CIEHF), which is the professional body for HF/E in the UK. The authors consider the contribution of HF/E in design, in digital transformation, in organisational learning and during COVID-19.
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Content ArticleIn this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. The authors also examine the impact that learning projects based on incident reporting can have on clinicians involved in the initial incidents, highlighting that revisiting errors may prevent individuals from moving on from them.
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Content Article
Recently an enduring discussion evolved on Twitter on why safety culture is important for patient safety. My reaction, of course, was: it isn’t. Let me explain why. I think it is possible to address safety without addressing safety culture. Or, rather, to focus on actions that will improve both safety performance and safety culture (as a by-product) at the same time. In this blog I propose some of these actions – showing how to create an understanding of how work is (actually) done (rather than what it says on paper), seeing what makes it difficult and identifying what resources are missing. If we address these challenges, then surely we will be able to improve safety and safety culture will follow naturally. -
News Article
Elizabeth Dixon: Lessons not learned after baby death cover-up, says family
Patient Safety Learning posted a news article in News
The family of a baby who died after errors in her care have criticised the failure of the NHS to learn lessons. Elizabeth Dixon died due to a blocked breathing tube shortly before her first birthday and a subsequent independent investigation found a 20-year cover-up. A year on, Elizabeth's mother Anne told the BBC: "My daughter has not been a catalyst for change." The Department of Health said it was working on the report's recommendations and will publish "a full response". Elizabeth Dixon, known as Lizzie, was born prematurely at Frimley Park Hospital, in Surrey, in December 2000. But a series of errors by the hospital and by Great Ormond Street Hospital, which took over her care shortly after birth, left Elizabeth with brain damage and needing to breathe through a tracheostomy. She was further let down by Nestor Primecare, a private nursing agency, which was hired to support her parents when Elizabeth returned home. She died 10 days before her first birthday. An official investigation, published last year, found a "20 year cover-up" by health workers, with some of those involved described as "persistently dishonest". "I would have expected them to take it seriously," Mrs Dixon said in response to the lack of action. She believes that if a similar incident happened today, there would be a danger it would also be covered up. "That's the default option - if its bad enough, they'll cover up," she said. Read full story Source: BBC News, 1 December 2021 -
EventThis Westminster Forum conference will be an important opportunity to examine the next steps for improving patient safety in the NHS in the context of the ongoing pandemic, the updated Patient Safety Strategy, and the MHRA consultation launched to improve patient safety and regulation around medical devices. Delegates will also discuss priorities in the context of the Health and Care Bill, which includes measures aiming to strengthen the role of the Healthcare Safety Investigation Branch (HSIB) in improving patient safety. Key areas for discussion include: system learning - assessing approaches, sharing best practice, supporting the workforce, education and training, and building a learning culture patient involvement - examining priorities for involving patients and the public within patient safety regulation - options for a more flexible and adaptable approach clinical negligence - how best to improve the negligence system the role of the HSIB - including its scope going forward and informing whole system learning COVID-19 - looking at what has been learned for patient safety and how best to drive improvements in recovery from the pandemic and into the future. Register
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Content ArticleAt the moment, we’ve got maternity scandals day in, day out, which are pure evidence of the fact that our maternity units are just not up to scratch. They’re unsafe for mothers, unsafe for babies, and that is not acceptable. Suzanne White, a former radiographer and a clinical negligence lawyer for the past 25 years, looks at the maternity safety scandals across the NHS and considers if any lessons have been learnt.
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Content ArticleThe NHS is looking for patients, carers and staff to talk about their positive or negative care experiences with participants on NHS Leadership Academy programmes. Being an experience of care partner is a voluntary role.
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Content ArticleIn this blog Patient Safety Learning provides an overview of the key points included in its response to the call for evidence for the Health and Social Care Select Committee Inquiry examining the case for reform of NHS litigation.
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Content ArticleJudy Walker, iTS Leadership, presented at the recent Patient Safety Management Network drop-in session on After Action Reviews. View the presentation below.
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Content ArticleJulie Avery and Brian Edwards, Chartered Institute of Ergonomics and Human Factors, presented at the recent Human Error Forum. They share their presentation slides on human performance and organisational learning and how to integrate human performance into existing systems.
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Content ArticleThis scoping paper explores the question ‘what would it take to build a culture of learning at scale?’. It focuses on systems-wide learning that can help to inform systems change efforts in complex contexts. To answer this question, literature was reviewed from across diverse disciplines and the realms of education, innovation systems, systems thinking and knowledge management. This inquiry was also supported by in-depth interviews with numerous specialists from the for-purpose sector and the examination of several case studies of learning across systems. The goal was to derive common patterns to inform a ‘learning for systems change’ framework. In this paper, a ‘learning networks’ approach is proposed, one that draws upon individual, group and systems-wide learning to build capacity and resilience for systems change in uncertain environments. This fills a gap in the literature where the focus is largely on learning within organisations. Instead, the focus here is on what is required to support learning to occur across scales and boundaries - from the individual to system-wide. A simple meta-framework for developing learning networks is proposed that includes high level guidance on the enabling conditions - the mindsets, relationships, processes and structures - that would enable learning networks to flourish.
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Content ArticlePatient safety incidents (PSIs) are common and can lead to fatal outcomes. Effective investigation of PSIs is essential to optimise learning and take action to prevent further incidents occurring. The Yorkshire Contributory Factors Framework is a tool which has an evidence base for optimising learning and addressing causes of patient safety incidents by helping clinicians, risk managers and patient safety officers identify contributory factors of PSIs. Incidents that occur in a hospital setting have been well studied and all contributory factors have been mapped. Based on this research, a team of practicing clinicians with human factors experts has adapted the evidence to a pragmatic 2 page framework. The document suggests questions that you might want to ask of those involved in the incident. The underlying aim of this tool is not to ignore individual accountability for unsafe care, but to try to develop a more sophisticated understanding of the factors that cause incidents.
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Content ArticleThere has been little applied learning from organisations engaged in making evidence useful for decision makers. More focus has been given either to the work of individuals as knowledge brokers or to theoretical frameworks on embedding evidence. More intelligence is needed on the practice of knowledge intermediation. This paper from Tara Lamont and Elaine Maxwell describes the evolution of approaches by one UK Centre to promote and embed evidence in health and care services.
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Content ArticleTwo years ago, a patient safety incident at North Bristol Trust led to the introduction of Swarm – a step change in how the trust responds to safety incidents. Swarm is a form of safety incident huddle that takes place as close as possible in time and place to the incident, allows blame-free investigation and leads to prompt action. This article describes how Swarm works, its advantages over root cause analysis, and how it is being embedded in the safety culture of North Bristol Trust.
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Content ArticleThe national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is to support standardised perinatal mortality reviews across NHS maternity and neonatal units. Unlike other reviews or investigation processes, the PMRT makes it possible to review every baby death after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,981 reviews which were completed between March 2020 and February 2021.
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Content Article
'Whistleblowing': a definition for reflection in Speak Up Month
Steve Turner posted an article in Whistle blowing
It's that time again. 'Speak Up Month' in the NHS. In this blog, I discuss the definition of 'whistelblowing' and why this is important. I believe that although the Francis Report has stimulated some positive changes, the only way to successfully move forward on this is to celebrate and promote genuine whistleblowers. This includes using the word 'whistleblowing', not a euphemism. It also needs us to involve everyone, including patients, in the changes. "Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. The more we move away for labelling and stereotyping the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and reconciliation." What is whistleblowing? "In the UK, NHS bodies have been guilty of muddying the waters. Sometimes implying that whistleblowers are people who fail to use the proper channels, or are troublemakers, especially when they go outside their organisation with their concerns. In fact, the Public Interest Disclosure Act makes no distinction between ‘internal’ and ‘external’ whistle-blowers..."- Posted
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Content ArticleOn 22 September 2021 the Health and Social Care Select Committee launched a new inquiry examining the case for reform of NHS litigation, identifying concerns regarding a significant increase in clinical negligence costs and missed opportunities for learning to improve patient safety. Here is the Association of Personal Injuries Lawyers' response to the call for evidence for the Health and Social Care Select Committee Inquiry. Related reading Patient Safety Learning's response to the NHS Litigation Reform AvMA's response to the NHS Litigation Reform
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Content Article
The Journal of Patient Safety
Patient-Safety-Learning posted an article in Research
Full articles require a subscription to the journal but the abstracts can be viewed free of charge. -
Content ArticleThis report by The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust identifies successes and areas for improvement in the Trust's response to the COVID-19 pandemic. The pandemic resulted in rapid and large-scale changes to ways of working and this report recognises that staff were largely responsive and adaptable to these changes in challenging circumstances. The report looks at learning and recommendations from: the Duty of Candour exercise carried out for patients who contracted COVID-19 in hospital the Trust's clinical teams.
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Content ArticleThis template has been published to guide local PSIRP early adopter organisations in prioritising investigation quality over quantity. NHS providers should follow this template when developing their local patient safety incident response plan.
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