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Found 539 results
  1. Content Article
    We have had quite an eventful few weeks in the NHS in England, much of it not very pretty. There have been reports of a consultant dismissed from a Trust for raising concerns about safety, and, following a well-reported series of events, an experienced and essential clinician leaving the workforce. Then there were the events in Manchester where a nurse has been convicted of murdering seven children and the attempted murder of another six children. This despite the raising of concerns by not one, not two but seven senior clinicians. They faced the now repeatedly seen series of actions where they were not believed, faced counteraccusations and threatened with being reported to their regulators. Now we have the inevitable fall out, an incoming inquiry and, no doubt, the same or very similar themes to the many inquiries that have happened in the past. There has been much discussion about these events on social media, mostly focused on Lucy Letby, about patient safety, the actions that people should have taken and reasons why they did not. However, in this blog, I am choosing to look at things from a slightly different perspective, that of the Patient Safety Incident Response Framework (PSIRF). 
  2. Content Article
    Extravasation is the leakage of intravenously administered solution into surrounding tissues, which can cause serious damage to the patient. There are multiple guidelines and local policies relating to extravasation injuries but not a singular national uniform policy.  NHS Resolution share their recent slides on what can be learned from extravasation claims, presented at the IV Therapy Summit.
  3. Content Article
    The Covid-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. This study from Purchase et al. aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. The study found that PISA taxonomy can be successfully applied to patient safety incident reports to support the first stages in deriving learning and identifying areas for further enquiry. No incidents were identified that warranted new codes to be added to the PISA classification system, which may extend to other substantive public health crises, negating the need for additional, specific coding within such classification systems and related frameworks for similar system-wide constraints.
  4. Content Article
    Walkthrough analysis is a structured approach to collecting and analysing information about a task or process or a future development (for example, designing a new protocol). It is used to help understand how work is performed and aims to close the gap between work as imagined and work as done to better support human performance. Walkthrough analysis is one of the tools included in the Patient Safety Incident Response Framework (PSIRF). This guide by NHS England provides information on how to carry out walkthrough analysis. It covers: Getting started System considerations Task and tool matrix View further PSIRF content and resources on the hub.
  5. Content Article
    The protests outside the Scottish Parliament took an alarming turn recently with people wearing hospital gowns spattered with blood. The demonstrators were former patients of neurosurgeon Sam Eljamel, many allegedly harmed by him and still suffering and searching for answers years later. A public inquiry has been announced by the First Minister. As the Patient Safety Commissioner for Scotland Bill makes its way into law, Alan Clamp, chief executive officer of the Professional Standards Authority for Health and Social Care, asks what this means for Scotland and the safety of its patients? See also: Working together to achieve safer care for all: a blog by Alan Clamp
  6. Content Article
    Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. However, there is little empirical evidence about how—in real-world hospital settings—recommendations are generated or judged for effectiveness.
  7. Content Article
    Workplace-based knowledge exchange programmes (WKEPs), such as job shadowing or secondments, offer potential for health and care providers, academics, and policy-makers to foster partnerships, develop local solutions and overcome key differences in practices. Yet opportunities for exchange can be hard to find and are poorly reported in the literature. This study, published in BMJ Leader, aimed to understand the views of providers, academics and policy-makers regarding WKEPs, in particular, their motivations to participate in such exchanges and the perceived barriers and facilitators to participation. Results showed WKEPs were reported to be valuable experiences but required significant organisational buy-in and cooperation to arrange and sustain. To benefit emerging partnerships, such as the new integrated care systems in England, more outcomes evaluations of existing WKEPs are needed, and research focused on overcoming barriers to participation, such as time and costs.
  8. Content Article
    In October, the Healthcare Safety Investigation Branch will tweak its name, become independent from NHS England and the UK government, and gain new powers to strengthen investigations. With the announcement of the change in status, Health Secretary, Steven Barclay, reported it would be leading an investigation into inpatient mental health. This follows swiftly on the heels of the Strathdee rapid review into data on mental health inpatient settings, which itself was launched in response to well-documented failures in these settings. The aim of this new investigation into mental health is simple: to improve safety. In this blog, Karen West, Head of Transformation (Mental health) at Oxehealth, and Professor Dan Joyce from the University of Liverpool, discuss the importance of data in patient safety improvement and explain why inpatient mental health data is so difficult to collect and what can be done to improve this.
  9. Content Article
    Stephen Ashmore and Tracy Ruthven, Co-Directors of Clinical Audit Support Centre Limited, have created a simple, eye-catching poster to explain the new Patient Safety Incident Response Framework (PSIRF). Here they explain why they created the graphic. You can download the poster by clicking on the image or downloading it from the attachment at the bottom of the page.
  10. Content Article
    The 'Learning Response Review and Improvement Tool' is intended to be used by: Those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report. Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. Development of this tool and set of standards was informed by a research study from Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), identified ‘traps to avoid’ in safety investigations and report writing. The tool was originally developed by NHS Scotland. It has been further refined in collaboration with HSIB and NHS England after being piloted in approximately 20 NHS trusts and healthcare organisations in England. The content validity of the tool is currently being assessed.
  11. Content Article
    Have you ever stopped and considered what the link is between the Patient Safety Incident Response Framework (PSIRF) and Hollywood? Probably not. Most likely, you have spent the summer of 2023 immersed in your organisation’s transition from the Serious Incident Framework (SIF) to PSIRF. Outside work, for those of us who are cinema-goers, our main Hollywood-related dilemma has revolved around which to watch first, Barbie or Oppenheimer? At the end of April 2023, we were offered the opportunity to present at the Health Care Plus conference, held at the EXCEL centre in London. Ours was the graveyard slot: Day 2 of the conference; 3.15 pm. The time when, quite understandably, the conference participants attentional capacity is usually waning. How could we encourage participants to stay the distance? How do you make a graveyard slot at the end of a two-day conference engaging?  More importantly, how do you rise to that challenge when the topic is implementing PSIRF? Our solution? Bring in Hollywood. Make PSIRF glamorous. Our blog shares what we presented: ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of what we have learnt and reflected on along the way. 
  12. Content Article
    As this year’s World Patient Safety Day celebrates the theme ‘Engaging patients for patient safety’, Dr Alan Fletcher, the National Medical Examiner for England and Wales, explains the connection between medical examiners and patient safety, and particularly the support they provide for bereaved people, whose insights and experiences can be crucial in supporting the NHS to learn and improve.
  13. Content Article
    Chris Elston, Patient Safety Education Lead, University Hospital Southampton, shares with the hub his Trust's Patient Safety Incident Response Framework (PSIRF) frequently asked questions. Please feel free to adapt and share at your own organisation.
  14. News Article
    Dozens of young autistic people have died after serious failings in their care despite repeated warnings from coroners, BBC News has found. Their investigation found issues that were flagged a decade ago are still being warned about now. Two bereaved mothers said lessons had not been learned by their local health authority after the deaths of their teenage sons, two years apart. The coroner who oversaw both cases, noted a repeated failure in care. After the first death, the coroner criticised NHS Kent and Medway for "inadequate support" and said a similar incident may happen if this continued. Two years later, the second autistic teenager died under the care of the same authority. The same coroner found that had the victim received the recommended level of care, he might have got the therapy he needed. In the first piece of research of its kind, the BBC combed through more than 4,000 Prevention of Future Death (PFD) notices delivered in England and Wales over the past 10 years. Read full story Source: BBC News, 7 September 2023
  15. Content Article
    In the wake of the conviction of Lucy Letby, a neonatal nurse who has been found guilty of the murder of seven babies and attempted murder of six babies, the focus of the nation is on the multiple tragedies that the families have faced, the healthcare staff who tried to blow the whistle, and safety issues in hospitals. NHS England has responded to the conviction by stating that trusts should look at whistleblowing policies, that those unfit to hold directorships should not be appointed, and with that well worn phrase “lessons will be learned.” But will they? In this BMJ opinion piece Alison Leary, professor of Healthcare and Workforce Modelling at London South Bank University, looks at why the NHS has failed to learn lessons from patient safety tragedies spanning the last fifty years. She highlights that unlike other safety critical industries, healthcare is still wedded to concepts that effectively deny the complexity of work and the social structures that surround work. This includes a failure to see the value in retaining experienced staff and a hierarchical approach to the value of work. She also outlines that more focus should be placed on management listening, rather than on staff having to find the courage to speak up when they have concerns: "When workers are listened to and constructive dissent is encouraged and normalised, along with the reporting of incidents, there is little need for whistleblowing. A workforce that must resort to whistleblowing is a symptom of poor safety culture."
  16. Content Article
    Patients are increasingly describing their healthcare experiences publicly online. This has been facilitated by digital technology, a growing focus on transparency in healthcare and the emergence of a feedback culture in many sectors. The aim of this study was to identify a typology of responses that healthcare staff provide on Care Opinion, a not-for-profit online platform on which patients are able to provide narrative feedback about health and social care in the UK. The authors used framework analysis to qualitatively analyse a sample of 486 stories regarding hospital care and their 475 responses. Five response types were identified: non-responses, generic responses, appreciative responses, offline responses and transparent, conversational responses. The key factors that varied between these response types included the extent to which responses were specific and personal to the patient story, how much responders' embraced the transparent nature of public online discussion and whether or not responders suggested that the feedback had led to learning or impacted subsequent care delivery. Staff provide varying responses to feedback from patients online, with the response types provided being likely to have strong organisational influences. The findings offer valuable insight and have both practical and theoretical implications for those looking to enable meaningful conversations between patients and staff to help inform improvement. The authors suggest that future research should focus on the relationship between response type, organisational culture and the ways in which feedback is used in practice.
  17. Content Article
    Recording of a recent RLDatix and NHS England webinar on  Learn from Patient Safety Events (LFPSE).
  18. Content Article
    In this blog post, Charlotte Augst looks at the impact of the Lucy Letby conviction on views of patient safety and accountability. The case has brought debates about patient safety into the mainstream media and public consciousness, and rather than focus simply on one extreme case, she believes it is important to look into common patterns in the NHS that lead to harm. She highlights that while such an awful case—where a healthcare professional caused deliberate harm to the most vulnerable patients—is shocking, it is also rare. She outlines a need to focus on the systemic issues that are resulting in repeated harm to patients, particularly in maternity services. Patients continue to be harmed because of rifts between management and clinical staff, the inability of the healthcare and regulatory system to really listen to patients, systemic discrimination and cognitive bias. Charlotte argues that while we may find ourselves focusing on the character of a nurse who committed such heinous crimes, we need to pay equal attention to the normalised behaviours and attitudes that harm patients and take place every day throughout the NHS.
  19. Content Article
    From September 2023 all organisations who previously reported to NRLS should make the switch to recording to the new Learn from Patient Safety Events (LFPSE) service, which will replace the NRLS. From Autumn 2023 organisations will also make the transition from the Serious Incident Framework (SIF) to the Patient safety incident response framework (PSIRF). This means there will be changes to the expectations and processes associated with recording information about the response to patient safety incidents This document provides detail into where incident responses are to be recorded during the transition to LFPSE and PSIRF.
  20. Content Article
    On the 20 February 2019 an investigation commenced into the death of Bethan Naomi Harris who was born on the 16 November 2018 at the St George's University Hospitals NHS Foundation Trust. Bethan Naomi Harris died at Shooting Star Hospice on the 26 November 2018. Her mother's pregnancy had been uneventful. After admission to labour ward labour progressed very quickly indeed and Bethan sustained severe brain injury during delivery. Despite best efforts by the neonatal team she succumbed to her injuries. The Investigation concluded at the end of the Inquest on the 19 November 2019. The conclusion of the inquest was that the medical cause of Bethan's death was (1a) hypoxic ischaemic encephalopathy.
  21. News Article
    A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022
  22. News Article
    The Care Quality Commission (CQC) should not ‘sit in an ivory tower and dream up what it thinks good looks like’ when it starts rating integrated care systems, the proposed new chair for the regulator has told MPs. Ian Dilks, the government’s preferred candidate to become the CQC’s new chair, was questioned by the health and social care committee on Tuesday. During the session the committee chair’s Jeremy Hunt asked how Mr Dilks would make the rating of systems “a success”. Mr Hunt said: “We became the first healthcare system in the world to ‘Ofsted rate’ our hospitals. Under your leadership, assuming you take up this role, we will become the first healthcare system in the world to do the same for entire geographical regions of health systems.” Mr Dilks responded: “I don’t think it is up to the CQC to sit in an ivory tower and dream up what it thinks good looks like.” “It will not be in anybody’s interest if the CQC comes up with a whole bunch of ratings and ICSs say, ‘well I don’t know how you got there’.” He added: “I think involving all parties in the development process so that what emerges has a high degree of acceptance.” He was also asked at the session about what he had learnt about improving patient safety while working at NHS Resolution. Mr Dilks said: “I do not think the system is good at learning… it needs some help and encouragement to firstly really understand what’s gone wrong when you have an outcome that isn’t the correct one, and secondly how do you encourage and support the system to do better the next time around.” Read full story (paywalled) Source: HSJ, 23 February 2022
  23. News Article
    A teaching trust has had its maternity services downgraded to ‘inadequate’ after inspectors found stillbirths and massive haemorrhages were not being treated as ‘serious incidents’. Maternity services at St George’s University Hospitals Foundation Trust in south London were previously inspected in 2016, when they were assessed as “good”. The Care Quality Commission (CQC) said serious incident declaration meetings at St George’s were regularly classing serious incidents as “adverse incidents”, meaning executives were not informed and there were missed opportunities for learning and development. Inspectors also found incidents such as severe perineal tears, emergency hysterectomy, and birth injuries were rated as causing low or no harm when a higher level would have been appropriate, or and sometimes downgraded from a higher rating. Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said: “We saw areas where significant and urgent improvements are needed to ensure safe care is provided to women, people using this service, and their babies. “Both staff and people using the service were being let down by leaders who failed to respond quickly, resulting in care that was unsafe, and in the delivery suite, also chaotic.” Read full story (paywalled) Source: HSJ, 17 August 2023
  24. News Article
    Staff fell asleep while on duty at a mental health trust, inspectors found. The Care Quality Commission (CQC) said it was "very disappointed" to find patient safety being affected by the same issues it had seen previously. It said on acute wards for adults of working age and psychiatric intensive care units, five patients described staff falling asleep at night. Despite CCTV being available, managers told the CQC they could not always immediately prove staff had been sleeping as accessing the pictures could take up to a fortnight. The CQC report added trust data from June to December 2022 recorded 20 incidents of staff falling asleep while on duty but no action was taken because the video evidence had not been viewed. Rob Assall, the CQC's director of operations in London and the East of England, said: "When we inspected the trust, we were very disappointed to find people's safety being affected by many of the same issues we told the trust about at previous inspections. "This is because leaders weren't always creating a culture of learning across all levels of the organisation, meaning they didn't ensure people's care was continuously improving or that they were learning from events to ensure they didn't happen again." Read full story Source: BBC News, 12 July 2023
  25. News Article
    Today it was announced by the Secretary of State for Health and Social Care that the future Health Services Safety Investigations Body (HSSIB) will undertake a series of investigations focused on mental health inpatient settings. The investigations will commence when HSSIB is formally established on 1 October 2023. The HSSIB will conduct investigations around: How providers learn from deaths in their care and use that learning to improve their services, including post-discharge. How young people with mental health needs are cared for in inpatient services and how their care could be improved. How out-of-area placements are handled. How to develop a safe, therapeutic staffing model for all mental health inpatient services. Rosie Benneyworth, Chief Investigator at HSIB, says: “We welcome the announcement by the Secretary of State and see this as a significant opportunity to use our expertise, and the wider remit that HSSIB will have, to improve safety for those being cared for in mental health inpatient settings across England. The evidence we have gathered through HSIB investigations has helped shed light on some of the wider challenges faced by patients with mental health needs, and the expertise we will carry through from HSIB to HSSIB will help us to further understand these concerns in inpatient settings, and contribute to a system level understanding of the challenges in providing care in mental health hospitals. “HSSIB will be able to look at inpatient mental health care in both the NHS and the independent sector and any evidence we gather during the investigations is given full protection from disclosure. It is crucial that those impacted by poor care and those working on the frontlines of the inpatient settings can share their experiences, reassured that HSSIB will use this information to improve care and not apportion blame or liability. “At HSIB we will begin conversations with our national partners across the system, as well as talking to staff, patients and families. This will ensure that when investigations are launched in October, we have identified and will address the most serious risks to mental health inpatients within these areas and will identify recommendations and other safety learning that will lead to changes in the safety culture and how safety is managed within mental health services.” Read full story Source: HSIB, 28 June 2023
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