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Event
Safety-II Practical Applications conference
Patient Safety Learning posted an event in Community Calendar
untilThe 2023 Safety-II Practical Applications Conference is an opportunity for shared learning to advance organisational safety maturity. Traditional methods for safety management, while important, are limiting and often reactive. Many safety professionals have focused on Safety-II as an expanded, more proactive approach that focuses on maximizing learning. The intent of this conference is to provide practical tools for implementation of Safety-II and other next generation strategies. Major themes: Maximising proactive learning opportunities. Developing effective management and cultural systems. Observing and managing high-risk and/or error-likely situations. Learning to shift narratives and distinctions to influence culture. Case studies from many organisations. Register -
News ArticleFamilies have blasted a NHS Trust after it said it did not intend to publish an independent review into their loved ones deaths. Three young people died in nine months at the same mental health unit. A Coroner was told last week that the review will be "ready" this month. Rowan Thompson, 18, died while a patient at the unit, based in the former Prestwich Hospital, Bury, in October 2020, followed by Charlie Millers, 17, in December that year, and Ania Sohail, 21, in June last year. Earlier this year, Greater Manchester Mental Health NHS Foundation Trust (GMMH), which runs the hospital, commissioned an 'external report' into the deaths. A pre-inquest hearing into the death of Rowan - who used the pronoun 'they' - heard that the full report would be available for the coroner to read 'on or around September 30'. Asked by the Manchester Evening News if the review would be published a spokesperson for the Trust said the Trust "always act on the wishes of the family regarding publication of reports," adding "and so in line with this we have no immediate plans to make the report public." But the parents of both Rowan Thompson and Charlie Mllers said they wanted the report publishing. Charlie's mother, Sam, said: "We want it published. It needs to be put out there, otherwise there is no point in having it. We are hoping they (The Trust) will learn lessons. We want answers but it should also be published for the benefit of the wider public - and the parents of other young people who are being treated in that unit." Read full story Source: The Manchester News, 13 September 2022
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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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Community Post
Can the NHS learn from healthcare systems overseas?
Steve Turner posted a topic in Organisational
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Is it time to change the way England's healthcare system is funded? Is the English system in need of radical structural change at the top? I've been prompted to think about this by the article about the German public health system on the BBC website: https://www.bbc.co.uk/news/health-62986347.amp There are no quick fixes, however we all need to look at this closely. I believe that really 'modernising' / 'transforming' our health & #socialcare systems could 'save the #NHS'. Both for #patients through improved safety, efficiency & accountability, and by making the #NHS an attractive place to work again, providing the NHS Constitution for England is at the heart of changes and is kept up to date. In my experience, having worked in healthcare for the private sector and the NHS, and lived and worked in other countries, we need to open our eyes. At present it could be argued that we have the worst of both worlds in England. A partially privatised health system and a fully privatised social care system. All strung together by poor commissioning and artificial and toxic barriers, such as the need for continuing care assessments. In my view a change, for example to a German-style system, could improve patient safety through empowering the great managers and leaders we have in the NHS. These key people are held back by the current hierarchical crony-ridden system, and we are at risk of losing them. In England we have a system which all too often punishes those who speak out for patients and hides failings behind a web of denial, obfuscation and secrecy, and in doing this fails to learn. Vast swathes of unnecessary bureaucracy and duplication could be eliminated, gaps more easily identified, and greater focus given to deeply involving patients in the delivery of their own care. This is a contentious subject as people have such reverence for the NHS. I respect the values of the NHS and want to keep them; to do this effectively we need much more open discussion on how it is organised and funded. What are people's views? -
Content ArticleRisk managers and the insurers with whom we work have the greatest opportunity in healthcare today to improve patient safety. Our most egregious mistakes become medical malpractice claims and lawsuits. Some of these go to trial where the outcome is public; however, the least defensible cases are settled without a trial. Almost every settlement includes a confidentiality or nondisclosure clause (NDC). Such clauses become “gag orders.” Providers who could learn from the mistake of a colleague do not, and the same mistake is repeated, often many times over. The stories of these settlements are a rich source of learning, and it’s time to tell them—anonymously. No naming names, no disclosure of settlement amounts, no “blame and shame.” Stories are powerful, attention-grabbing, and memorable. Telling them is a unique opportunity to link the prevention of patient harm to the healing mission of healthcare and acknowledge the common wish of every plaintiff that “this won’t happen to someone else.”
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Content ArticlePEOPLE FIRST is a CQC resource to help system leaders and service providers.
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Content ArticleDiagnostic errors are major contributors to patient harm. Strategies to identify and analyse these events are still emerging, but several show promise for use in operational settings. The Agency for Healthcare Research and Quality (QHRQ) has developed Measure Dx to help healthcare organisations identify diagnostic safety events and gain insights for improvement. Measure Dx can be used by any healthcare organisation interested in promoting diagnostic excellence and reducing harm from diagnostic safety events. Potential users include clinicians, quality and safety professionals, risk management professionals, health system leaders, and clinical managers.
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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 ArticleTo provide high quality services in increasingly complex, constantly changing circumstances, healthcare organisations worldwide need a high level of resilience, to adapt and respond to challenges and changes at all system levels. For healthcare organisations to strengthen their resilience, a significant level of continuous learning is required. Given the interdependence required amongst healthcare professionals and stakeholders when providing healthcare, this learning needs to be collaborative, as a prerequisite to operationalising resilience in healthcare. As particular elements of collaborative working, and learning are likely to promote resilience, there is a need to explore the underlying collaborative learning mechanisms and how and why collaborations occur during adaptations and responses. The aim of this study from Haraldseid-Driftland et al. was to describe collaborative learning processes in relation to resilient healthcare based on an investigation of narratives developed from studies representing diverse healthcare contexts and levels.
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Content ArticleIn this blog, Ian Lavery, Senior Investigation Science Educator at the Healthcare Safety Investigation Branch (HSIB) summarises a presentation given to HSIB staff by healthcare improvement expert Professor Mary Dixon-Woods. The presentation highlighted that a recommendation alone could fall short of the intended impact on the healthcare system. It looked at creating recommendations to respond to real world working, the importance of involving people most affected by patient safety incidents and why it's vital to look at when things go right.
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Content Article
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Copy of the speech from Helen Hughes, Chief Executive of Patient Safety Learning, given at the Professional Standards Authority for Health and Social Care (PSA) Parliamentary launch of the publication 'Safer care for all - Solutions from professional regulation and beyond'. -
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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Content ArticleReducing errors in diagnosis is the next big challenge for patient safety. This article highlights ways in which healthcare organisations can pursue learning and exploration of diagnostic excellence (LEDE). Building on current evidence and their recent experiences in developing such a learning organisation at Geisinger in Pennsylvania, the authors propose a 5-point action plan and corresponding policy levers to support the development of LEDE organisations.
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Content ArticleOn 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years. Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was: 1a refractory shock 1b sepsis 1c pancreatic transection (operated) 1d abdominal trauma.
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Content ArticleSharing her story in the Guardian, Merope gives a heart breaking account of how her daughter, Martha Mills, was allowed to die, but also what happens when you have blind faith in doctors – and learn too late what you should have known to save your child’s life.
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Content Article
This blog provides an overview of a discussion at a Patient Safety Management Network (PSMN) meeting on 26 August 2022. The discussion considered the use of two different system-based approaches for learning from patient safety incidents recommended by the NHS Patient Safety Incident Response Framework (PSIRF). The PSMN is an informal voluntary network for patient safety managers. Created by and for patient safety managers, it provides a weekly drop-in session with guests to talk through issues of importance, offer peer support and create a safe space for discussion. You can find out more about the network here -
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 Article
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. Soojin talks to us about how her personal experience of harm motivated her to work in healthcare and campaign for patient safety, the power of collaboration in improving healthcare safety and how healthcare workers can take steps to improve their own patient interactions. -
Content ArticleSafety reporting systems are widely used in healthcare to identify risks to patient safety. But, their effectiveness is undermined if staff do not notice or report incidents. Patients, however, might observe and report these overlooked incidents because they experience the consequences, are highly motivated, and independent of the organsation. Online patient feedback may be especially valuable because it is a channel of reporting that allows patients to report without fear of consequence (e.g., anonymously). Harnessing this potential is challenging because online feedback is unstructured and lacks demonstrable validity and added value.
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Content Article
Can being open and transparent make us more opaque?
Anonymous posted an article in Florence in the Machine
‘Neo’ is an Allied Health Professional working on the frontline and asks what being open and transparent actually means and whether publishing a report or an investigation is just another tick box exercise if lessons aren't learned. -
Content ArticleWelcome to the being better together podcast, from Learning from Excellence and Civility Saves Lives. This podcast from Learning from Excellence and Civility Saves Lives is a series of conversations with people who inspire us, about making healthcare a better place to work. It covers a wealth of topics, from workplace cultures, through inspiration, laughter and joy, to appreciative inquiry and how do work safely.
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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 ArticleHistorical and current methodologies in patient safety are based on a deficit-based model, defining safety as the absence of harm. This model is aligned with the human innate negativity bias and the general philosophy of health care: to diagnose and cure illness and to relieve suffering. While this approach has underpinned measurable progress in healthcare outcomes, a common narrative in the healthcare literature indicates that this progress is stalling or slowing. It is important to learn from and improve poor outcomes, but the deficit-based approach has some theoretical limitations.
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News Article
New approach to safety incidents will see fewer investigations
Patient Safety Learning posted a news article in News
Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families. The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations. According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework. NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition. However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required. Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”. However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements. She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.” Read full story (paywalled) Source: HSJ, 16 August 202 -
Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS's approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety It is intended to support one of the key aims of the NHS Patient Safety Strategy, to help the NHS improve its understanding of safety by drawing insight from patient safety incidents. This will replace the Serious Incident Framework with organisations expected to transition to PSIRF within 12 months of its publication, by Autumn 2023.
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