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Content ArticleThis month’s Letter from America looks at perspectives examining collective responses to the COVID-19 pandemic through a systems analysis lens. Letter from America is the latest in a Patient Safety Learning blog series highlighting new accomplishments in patient safety from the United States.
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The right – and duty – of NHS staff to speak up
Hugh Wilkins posted an article in Whistle blowing
A blog from hub topic lead Hugh Wilkins on the recent messages from NHS England and NHS Improvement leaders reminding everyone, including those at board level, of the duty and right of staff to speak up about anything which gets in the way of patient care and their own wellbeing. Hugh highlights the real risk of reprisals against some staff who have raised concerns in the public interest, and points out that much needs to change before NHS staff can be sure that it is safe for them to speak up.- Posted
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The Ombudsman’s Casework Report 2019 (3 March 2020)
Patient Safety Learning posted an article in Complaints
The Parliamentary and Health Service Ombudsman (PHSO) make final decisions on complaints that have not been resolved by the NHS in England, UK government departments and other UK public organisations. The PHSO look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. The PHSO looks into complaints fairly, and the service is free for everyone. This first annual Ombudsman’s Casework Report highlights the breadth of cases received across PHSO's jurisdictions. It is only a small cross-section of the cases completed in 2019. The complaints presented here are typical of many of the complaints seen across PHSO's remit. They include complaints about government bodies and the NHS. -
Content ArticleJoanna is a Partner in the law firm Bevan Brittan LLP. In our interview, Joanna talks about her role supporting healthcare staff through the legal and investigatory processes that follow an adverse event, and why we must do all we can to maximise the opportunity to learn when things go wrong in healthcare.
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Content ArticleThis pay-walled article, published in The Sunday Times, highlights patient safety concerns identified in relation to West Suffolk hospital, with specific reference to two incidences of avoidable patient harm. In the case of Daniel Parsons, a drugs error caused an adverse affect on the functioning of Daniel's heart and led to his death. The coroner for the inquest concluded that Daniel's death could have been avoided if doctors had heeded the early warning signs of anaphylaxis. The second incident highlighted by the authors is that of Paul Farmer, who was left blind and with severe brain damage following avoidable harm. Concerns raised within the article include: Prioritisation of reputation management (an 'outstanding' status) over patient safety Reluctance to investigate Unfair reprisal for staff raising patient safety concerns Lack of response from Health Secretary Matt Hancock. Further reading: Bullying executives left West Suffolk Hospital staff ‘sobbing, shaking, rocking in despair’ (March 2020)
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Content ArticleOrganisations around the world are using 'Lean' to redesign care and improve processes in a way that achieves and sustains meaningful results for patients, staff, physicians, and health systems. Lean Hospitals, Third Edition explains how to use the Lean methodology and mindsets to improve safety, quality, access, and morale while reducing costs, increasing capacity, and strengthening the long-term bottom line. This updated edition of a Shingo Research Award recipient begins with an overview of Lean methods. It explains how Lean practices can help reduce various frustrations for caregivers, prevent delays and harm for patients and improve the long-term health of your organisation.
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Content ArticlePatient Engagement for the Life Sciences is a practical handbook for anyone striving to incorporate patient value in the delivery of medicines from research and development into a practical healthcare setting. This book provides a tangible framework of how this can be achieved with and for patients. Any profits generated from book sales will be donated to International Health Partners UK, Europe's largest coordinator of donated medicines, to support patients around the world.
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Content ArticlePatient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
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Content ArticleIncident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study, published in the International Journal of Health Care Quality Assurance, explores if intelligence from such datasets could be used to improve quality, efficiency, and safety. Results indicate that healthcare incident reporting data is underused and, with a small amount of analysis, can provide real insight and application to patient safety.
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Content ArticleThis podcast, is the first in a series, produced by Catalysis, about how to change organisational culture. This episode focuses on board engagement and the support a board needs to offer management during cultural transformation.
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Developing the next Global Patient Safety Action Plan - Part 1
PatientSafetyLearning Team posted an article in WHO
Helen Hughes, Patient Safety Learning's Chief Executive, shares her insight from a three day World Health Organisation (WHO) meeting and the development of its Global Patient Safety Action Plan for 2020-2030. -
Content ArticleShifting the mindset (2020), a report from Healthwatch, investigates how hospitals report on complaints and whether current efforts are sufficient to build public trust. In this bog, Sir Robert Francis QC explains how hospitals can cultivate public trust in complaints.
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Silent witness – My experience when filing an incident report
Anonymous posted an article in Florence in the Machine
A newly qualified nurse describes what happened when she reported her first Datix for a serious incident.- Posted
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Content ArticleThis blog, written by Human Factors expert Stephen Rice and published by Forbes, looks at what healthcare can learn from the success of the aviation industry when it comes to safety.
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Content ArticleIn this webinar, (filmed on 24 March for the International Society for Quality in Healthcare) Dr Francesco Venneri shares his experience of the response to COVID-19 in Italy from the perspective of his involvement as both a clinical risk manager and as an emergency front line worker. Dr Venneri speaks passionately of how the response was handled, the positive elements, the criticisms, and also how we can learn from COVID-19 by proposing measures that we can apply in the case of future outbreaks.
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Content ArticleIn this article, published by Birmingham City University, Criminologists Professor Elizabeth Yardley, Professor David Wilson and Emma Kelly discuss the report found that 450 patients died after being given powerful painkillers inappropriately at Gosport War Memorial Hospital. "To kill multiple people requires not just the presence of a determined killer but the absence of protectors and guardians. When no one is looking out for the interests of the vulnerable, the vulnerable become the victims. Within organisations, failed protectors and guardians find strength in each other, denying responsibility, eschewing accountability and playing ping-pong until (they hope) people will just go away and stop demanding answers."
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Content ArticleWe can use what we’ve learned from the crisis to make a 21st-century service fit for patients and staff alike, says Joel Schamroth in a blog to the Guardian. This pandemic is forcing us to rethink how we deliver healthcare. For too long patients have experienced fragmented services, administrative hurdles and unreliable lines of communication. The “patient experience” often remains an afterthought in the NHS, leading to worse health outcomes, and costing the NHS dearly. The lesson the public is learning is that money can be made available when it’s deemed to be important. In a matter of weeks COVID-19 has shown us that change is possible.
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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 ArticleThe purpose of this guide from NHS Education for Scotland is to help people working in the health and social care ecosystem capture valuable practice and improvements made during their response to COVID-19. The aim is to contribute to organisational change at a policy, strategic and operational level. If left too late, there is a real danger that positive change is not documented and will be lost as the health system emerges from the pandemic.
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Content ArticleWeaving together narratives from medicine, psychology, philosophy, and human performance, the book Still Not Safe looks at the patient safety movement and the state of the American healthcare system.
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Content ArticleSerious incidents not only have a considerable human impact, but they are also detrimental to NHS reputations and finances. The current Serious Incident Framework (SIF) is a reactive, bureaucratic process, where opportunities to reduce the recurrence of a harmful incidence is often missed. With a ‘Get It Right First Time’ mentality, the new PSIRF framework was road-tested by a number of nationally appointed ‘early adopter’ Trusts and commissioners working to implement it during the course of 2021. Now a wider implementation across the NHS is planned, starting spring 2022, with guidance informed by the early adopter pilots. This blog was written by Sian Williams, NHS Team Lead & Managing Consultant, and Paul Binyon, who in a recent assignment has worked with an NHS Trust contributing to an early adopter PSIRF pilot rollout.
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Content ArticleNHS England has published the new Patient Safety Incident Response Framework (PSIRF). Dr Tracey Herlihey, Head of Patient Safety Incident Response Policy, NHS England, and Aidan Fowler, National Director of Patient Safety and Deputy Chief Medical Office at NHS England/DHSC, discuss the new framework, the preparation behind it, and how they see PSIRF fundamentally changing the NHS’s approach to patient safety incident response, supporting learning, improvement and compassion, to make care safer for our patients.
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Content ArticleThe NHS Patient Safety Incident Response Framework (PSIRF) promotes a range of system-based approaches for learning from patient safety incidents. These national tools and guides have been developed to incorporate the well-established SEIPS framework (Systems Engineering Initiative for Patient Safety) to help support organisations implementing PSIRF.
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Content ArticleThe NHS Patient Safety Strategy was published in 2019 and describes the Patient Safety Incident Response Framework (PSIRF), a replacement for the NHS Serious Incident Framework. This document is North Bristol NHS Trust's Patient Safety Incident Response Plan (PSIRP). It describes what North Bristol NHS Trust did to prepare for “go live” with PSIRF, as an early adopter organisation, and what comes next
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Content ArticleThe Serenity Integrated Mentoring (SIM) model is described as "an innovative mental health workforce transformation model that brings together the police and community mental health services, in order to better support 'high intensity users' of Section 136 of the Mental Health Act (MHA) and public services." The SIM model is part of a 'High Intensity Network' (HIN) approach, which is now live in all south London boroughs. In this hub post, Steve Turner highlights the benefits and risks of this approach and seek your views on it.
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