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Content ArticleHow can NHS provider organisations and systems reliably and sustainably improve care? Historically, most improvement interventions have been discrete, small-scale efforts run by individual teams, often without reference to what else is taking place in their trust. However, it is now widely accepted that a patchwork of local interventions is unlikely to deliver sustained improvement or efficiencies on the scale that policymakers and local leaders want. This report by the Health Foundation outlines learning from the evaluation of the NHS partnership with Virginia Mason Institute, which examined how five NHS trusts in England attempted to build a culture of continuous improvement.
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Content ArticleThe Patient safety incident response framework (PSIRF) represents a new approach to responding to incidents. Under PSIRF, those leading the patient safety agenda within provider organisations, together with internal and external stakeholders (including patient safety partners, commissioners, NHS England, regulators, Local Healthwatch, coroners etc), decide how to respond to patient safety incidents based on the need to generate insight to inform safety improvement where it matters most. Key issues must first be identified and described as part of planning activities before an organisation agrees how it intends to respond to maximise learning and improvement. This guidance has been developed collaboratively between Stop the Pressure Programme, National Wound Care Strategy leads and members of the Patient Safety Team, with the support from the Patient Safety Incident Response Framework (PSIRF) Implementation and Working Groups.
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Published on 19 October 2022, the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Foundation Trust revealed a series of serious patient safety failings between 2009 and 2020, which resulted in avoidable harm to patients and deaths. The investigation found that if nationally recognised standards had been followed, the outcome could have been different in 97 of the 202 cases reviewed. In this article, Patient Safety Learning analyses the findings of this report from a broad patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years. It sets these in their wider context and highlights the need for a fundamental transformation in our approach to patient safety if similar scandals are to be prevented in the future.- Posted
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Content ArticleThis article in the HSJ explores the challenges in implementing the Patient Safety Incident Response Framework (PSIRF) and looks at how it will help achieve effective learning and improvement. Liz Hackett, health advisory partner at Hempsons law firm, addresses the following questions: Who does PSIRF apply to? How does PSIRF help achieve effective learning and improvement? What is required? Involving patient safety and addressing inequalities The challenge
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Content ArticleOn the 18 October it was announced that NHS Trusts have been given an optional six-month extension to implement Learn From Patient Safety Events (LFPSE). There are a lot of messages being talked about and there has been some confusion over what this means. So, what do organisations need to have in place by 31 March 2023 and what has changed? In this blog*, Radar Healthcare cover some of the key information.
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Content ArticleThis paper addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the first Delphi study round was to establish how the World Health Organisation’s Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. It used a combination of closed and open-ended questions that solicited specific information about current practice and research literature, that generated ideas and allowed participants freedom in their responses. The study asked theatre managers, matrons and clinical educators that work in operating theatres and deliver the surgical safety checklist daily, and who are therefore considered to be theatre safety experts. Participants were from the seven regions identified by NHS England. The study revealed that the majority of trusts don’t receive formal training on how to deliver the SSC, checklist champions are not always identified, feedback following a ‘never event’ is not usually given and that the debrief is the most common step missed. While the intention of the study was not to establish whether the lack of training, cyclical learning and missing steps has led to the increased presence of never events, it has facilitated a broader engagement in the literature, as well highlighting some possible reasons why compliance has not yet been universally achieved. Furthermore, the Delphi study is intended to be an exploratory approach that will inform a more in-depth doctoral research study aimed at improving patient safety in the operating theatre and informing policy making and quality improvement.
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Content ArticleVisual of the Learning from Patient Safety Events (LFPSE) implementation timeline.
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Content ArticleThe investigation and tribunal hearing of Dr Manjula Arora generated significant anger and anxiety among the medical profession. The case raised once again the perception of a regulatory process lacking in fairness; of a system in which the stakes seem much higher if you are a black and minority ethnic doctor. The General Medical Council (GMC) acknowledged that strength of feeling, making clear it would not oppose Dr Arora’s appeal against the sanction and commissioning a review of the case to understand lessons to be learned for future cases.
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Content ArticleIf you want to find out what the new Patient Safety Incident Response Framework is all about, and how it will support the NHS to learn and improve, this video provides a helpful introduction.
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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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On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare. Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. Here, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject. The full transcript of the interview is available to download in the attachment at the end. -
Content ArticleIn February 2020 the UK Government commissioned Dr Bill Kirkup to undertake a review into maternity and neonatal care services between 2009 and 2020 in two hospitals, the Queen Elizabeth The Queen Mother Hospital (QEQM) at Margate and the William Harvey Hospital (WHH) in Ashford. Both these services fall under the East Kent Hospitals NHS Foundation Trust. The report found that over this period those responsible for these services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor. It identifies four key areas for action which must be addressed to improve patient safety in maternity and neonatal care services.
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Content ArticleThis NHS England podcast examines how the application of system-based approaches to learning from patient safety incidents will be vital to the success of the Patient Safety Incident Response Framework (PSIRF). Guests Darren Thorne from the consultancy Facere Melius, Jane Carthey, a Human Factors and Patient Safety Consultant and Laura Pickup from the Healthcare Safety Investigation Branch (HSIB) discuss NHS England's learning response toolkit.
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Content ArticleA thematic review can identify patterns in data to help answer questions, show links or identify issues. Thematic reviews typically use qualitative (e.g, open text survey responses, field sketches, incident reports and information sourced through conversations and interviews) rather than quantitative data to identify safety themes and issues. Thematic reviews can sometimes use a combination of qualitative data with quantitative data. Quantitative data may come from closed survey responses or audit, for example. These top tips support health and social care staff to carry out thematic reviews, but organisations may take different approaches, depending on the purpose and scope of their review.
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Content ArticleThe Healthcare Safety Investigation Branch's (HSIB's) local investigation pilot aimed to evaluate the organisation's ability to carry out effective locality-based patient safety investigations with actions aimed at specific NHS organisations, while still identifying and sharing relevant national learning. It differs from HSIB's usual national investigations, which make safety recommendations to organisations that can make changes at a national level across the NHS in England. The pilot published three investigations focused on cross boundary and multi-agency safety events: Investigation 1: incorrect patient identification Investigation 2: incorrect patient details on handover Investigation 3: transfer of a patient with a stroke to emergency care The report summarises how the HSIB local investigation pilot was undertaken, and shares findings applicable to local healthcare systems including healthcare organisations and Integrated Care Systems.
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Content ArticleThis is the story of the avoidable death of Glyn Davies, as told by his sister Anne. Glyn had an obstruction of the small bowel caused by adhesions from previous surgery and died from aspiration pneumonia after two weeks in intensive care at The Royal Lancaster Infirmary. Glyn's family felt that the investigation following his death had not been dealt with well, with evidence being withheld from the Coroner. This included information in Glyn's medical notes that indicated he had caught the hard-to-treat bacterial infection Stenotrophomonas Maltophilia, from either the ventilator or tubes whilst in intensive care. The family then took legal action against The University Hospitals of Morecambe Bay NHS Foundation Trust and the case was settled out of court in March 2020.
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Content ArticleSafety in aviation and maritime domains has greatly improved over the years, but there is no room for complacency. This is especially the case as we approach systems with ever more automation and use of remote control in both industries. It is also more complicated because ‘human error’ is often seen as the root cause, when usually it is the system that leads people into mistakes, and seafarers and flight crew alike so often save the day. Accidents, incidents and near misses all offer us valuable lessons from which to improve safety, to do better next time. Yet in the aftermath of adverse events, the wish to blame someone, which makes sense of something that was never intended to happen, might make us lose sight of the real causes of accidents, leading to more tragedy and loss. The key to learning is using the right tool with which to understand what happened and why. This means going beyond the surface ‘facts’ and suppositions, seeing beneath the ‘usual suspects’ of factors that yield little in terms of how to prevent the next one. The SHIELD (Safety Human Incident & Error Learning Database) taxonomy has been developed by reviewing a number of existing taxonomies - in this case, a set of related terms for describing human performance and error - to derive a means of objectively classifying events in a way that helps us develop safety countermeasures afterwards. Whilst it can analyse single events it is particularly insightful when looking - and learning - across related events
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Content ArticleLearning from mistakes generally is considered the upside to failure. But in healthcare, where staff members regularly face stressors and systemic issues that impede a strong culture of safety, creating that standard can be difficult. To understand why medical mistakes and care complications occur repeatedly Becker's spoke with Patricia McGaffigan, vice president of safety programmes for the Institute for Healthcare Improvement. Ms. McGaffigan outlined three factors that contribute to repeat medical errors, care complications or lost progress on quality improvement initiatives: A "whack-a-mole" approach to safety. Lack of focus on systemwide changes. Unhealthy or unsafe work environments.
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Content ArticleWhen something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what the Care Quality Commission (CQC) and the provider have done about it, and the steps you can take to avoid it happening in your service.
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Content ArticleEverybody has a right to good care. Much attention is rightly focused on the occasions when people experience poor quality care, but it is also important to recognise where care is good and to celebrate the services that are getting it right. Some care providers do things well through innovative new ways of working, or by doing the basics well. Others can learn from them and solutions should be shared across the system. This publication from the Care Quality Commission (CQC) is purposely focused on celebrating good and outstanding care that CQC's inspectors have seen.
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Content ArticleHealthcare has, in many ways, always been a form of ‘learning system’. Driven by a diverse community of stakeholders, including health care professionals, patients and the public, a learning health system (LHS) uses internal and external knowledge to continually learn about and improve patient care. However, while LHSs have huge potential to support service transformation and population health, there is a lack of consensus about what an LHS actually is, and how to get started. This research report from the Health Foundation helps people understand LHSs and how they can be developed. It is the final output of HDR UK’s Better Care Catalyst Programme’s Policy and Insights workstream, which researched the barriers and enablers for implementing LHS approaches in the UK. It also identifies a range of opportunities and actions that can be taken by policymakers and system leaders to advance the LHS agenda across the UK.
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This is part of our series of Patient Safety Spotlight interviews, where we talk to different people about their role and what motivates them to make health and social care safer. Judy talks to us about the power of After Action Reviews (AARs) to promote learning and bring about lasting improvements in healthcare. She also discusses the opportunity that the new Patient Safety Incident Response Framework (PSIRF) offers to take a more people-focused approach to learning from patient safety incidents. -
Content ArticleCommunity Diagnostic Centres (CDCs) can relieve pressure on NHS acute services and bring diagnostic services closer to patients. This resource by the Chartered Institute of Ergonomics & Human Factors (CIEHF) explores ten principles for including systems thinking in the design of the diagnostic workforce and CDC services.
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Content ArticleTo be effective, clinical governance should reach every level of a healthcare organisation—it requires structures and processes that integrate financial control, service performance and clinical quality in ways that will engage clinicians and generate service improvements. In this article for the BMJ, the authors argue that because clinicians are at the core of clinical work, they must be at the heart of clinical governance. They look at problems with the prevailing model of clinical governance and describe an alternative approach.
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Content ArticleIn healthcare, there is a well-recognised gap between what we know should be done, and what is actually done. This article considers new models that look at the implementation of evidence-based practice in healthcare systems, particularly looking at the application of a conceptual model called 'sticky knowledge'.
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