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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content ArticleThis month, the Institute of Public Policy Research (IPPR) published their new Injury Prevention Policy, Better Than Cure.[1] In this report they call on the Government to make injury prevention a public health priority and to take further action to prevent the transmission of Covid-19 in the workplace. Patient Safety Learning welcomes the publication of this report and its recognition of the importance of improving patient safety. We concur with its identification of unsafe care as being driven by a range of underlying systems issues, such as the culture of fear, barriers to resource sharing and insufficient focus on patient safety training and skills. These closely relate to the six foundations of safer care we have set out in A Blueprint for Action.[2] We also agree about the importance of two core areas which they highlight for action in this respect: 1) The Government should commit to long-term safe staffing This is particularly an important issue as we return to more normal levels of care following the peak of the Covid-19 pandemic, with the need to ensure that organisations and staff transition to this safely.[3] We consider that system wide (health and social care) workforce modelling is needed to inform resourcing and ensuring safe staffing. 2) The NHS should use patient safety networks to share best practice We strongly agree about the importance of sharing learning for patient safety. We need people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. This is why we have created the hub, a patient safety learning platform. Designed with input from patient safety professionals, clinicians and patients, the hub provides a community for people to share learning about patient safety problems, experiences, and solutions. References 1. IPPR. Better Than Cure: Injury Prevention Policy, August 2020. 2. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 3. Patient Safety Learning. Patient Safety Learning’s response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, June 2020.
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Content ArticleIn this article, published by Refinery 29, author Sarah Graham talks about gender bias in healthcare and the risk to patient safety.
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Keeping patients safe from falls
Claire Cox posted an article in International patient safety
Tens of thousands of patients fall in health care facilities every year and many of these falls result in moderate to severe injuries. Find out how the participants in the Center for Transforming Healthcare’s seventh project are working to keep patients safe from falls. -
Content ArticleIn our final 2-minute Tuesday session of July 2020, Patient Safety Learning's Chief Executive, Helen discusses Baroness Cumberlege’s report ‘First Do No Harm’. She focuses on how the report amplifies the voices of women, identifying the scale and severity of harm going back decades to thousands of women. She adds: "This has been a problem hidden in plain sight that is now being exposed." Helen asks listeners whether they agree that transformational change is needed in the health and social care system to address these issues. Read more on our thoughts and the actions in response to the Cumberlege Review.
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Content ArticleSince the release of the report Hearing and Responding to the Stories of Survivors of Surgical Mesh in December 2019, the New Zealand Ministry of Health, in collaboration with other health sector agencies, has been working to progress the agreed actions and support those who have been affected and minimise future harm. An update on each of the actions is detailed in the report is provided below.
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Content ArticleRestorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the Liverpool region, implemented restorative justice (or what it termed a 'Just and Learning Culture') to fundamentally change its responses to incidents, patient harm, and complaints against staff. This study highlights the qualitative benefits from this implementation and also identifies the economic effects of restorative justice.
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Content ArticleThis methodological review of racial/ethnic disparities in patient safety in the United States was published in the Journal of Patient Safety. The paper concludes that although there is extensive evidence on disparities in the process and outcomes of health care, data on racial and ethnic disparities in patient safety remain inconclusive in the United States.
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Content ArticleChaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – patient complaints.
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Content ArticleChaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review report, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – informed consent.
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Content ArticleOn Wednesday 8 July 2020 the Independent Medicines and Medical Devices Safety Review published its report First Do No Harm, examining how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. Chaired by Baroness Julia Cumberlege, the review focused on looking at what happened in relation to three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. In this blog Patient Safety Learning consider the reports findings in more detail, highlighting the key patient safety themes running through this, which are also found in many other patient safety scandals in the last twenty years. It also looks at what needs to change to prevent these issues recurring and asks whether NHS leaders stick with the current ways of working, make a few improvements, or take this opportunity for transformational change.
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Content ArticleThis Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media.
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Premature discharge from hospital (June 2020)
Claire Cox posted an article in Keeping patients safe
This is a report of a qualitative survey that explored unsafe, premature discharge from hospital. The Patients Association has regularly heard from helpline callers that patients believed that they had been discharged too early from hospital,and that as a result they had either suffered harm or been at risk of harm. -
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The Salford Medication Safety Dashboard (SMASH)
Claire Cox posted an article in Medication administration
The Salford Medication Safety Dashboard (SMASH) was successfully used in general practices with the help of on-site pharmacists. SMASH is a web application that flags up a list of patients who are potentially at risk from medicines they have been prescribed. -
Content ArticleAdverse events in hospitals constitute a serious problem with grave consequences. Many studies have been conducted to gain an insight into this problem, but a general overview of the data is lacking. The authors of this paper, published in BMJ Quality & Safety, performed a systematic review of the literature on in-hospital adverse events.
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Content ArticleThe Professioan Records Standards Body are a unique collaboration of groups representing those who receive and provide health and social care across the UK, as well as those providing the IT systems that support care. Emma Robertson is the patient lead on the Professional Records Standards Body (PRSB), work to accredit apps and digital health technologies. She speaks to PRSB about why she got involved with the work and the benefits and challenges of using apps to support health and care.
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Errors in medicine (June 2009)
PatientSafetyLearning Team posted an article in Research papers
The authors of this paper, published in Clinica Chimica Acta, argue that in the current health care organisational environment in most hospitals, at least six major changes are required to begin the journey to a culture of safety: We need to move from looking at errors as individual failures to realising they are caused by system failures We must move from a punitive environment to a just culture We move from secrecy to transparency Care changes from being provider (doctors) centred to being patient-centred We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, inter-professional teamwork Accountability is universal and reciprocal, not top-down. -
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Apologies and medical error (October 2008)
PatientSafetyLearning Team posted an article in Research
Patients indicate they want and expect explanations and apologies after medical errors and physicians indicate they want to apologise. However, in practice, physicians tend to provide minimal information to patients after medical errors and infrequently offer complete apologies. Although fears about potential litigation are the most commonly cited barrier to apologising after medical error, the author of this article, published in Clinical Orthopaedics and Related Research, argues that the link between litigation risk and the practice of disclosure and apology is tenuous. Other barriers might include the culture of medicine and the inherent psychological difficulties in facing one’s mistakes and apologising for them. Despite these barriers, incorporating apology into conversations between physicians and patients can address the needs of both parties and can play a role in the effective resolution of disputes related to medical error. -
Content ArticleThere are few validated tools to identify treatment‐related adverse events across cancer care settings. This study seeks to develop oncology‐specific 'triggers' to flag potential adverse events among cancer patients using claims data.
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Content ArticleMark Chassin, M.D., president and CEO of The Joint Commission, sat on the Institute of Medicine committee that authored the landmark 1999 report, To Err is Human. In this podcast, he speaks to Nancy Foster, AHA vice president for quality and patient safety, about its impact on health care safety. He speaks about the need to reflect more on the type of culture that exists within zero harm organisations. He also argues that we need to ensure people feel free to speak up and ensure that everyone is accountable for consistently upholding safety processes and standards.
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BMJ Editorial: Abandon the term "second victim"
Patient Safety Learning posted an article in Second victim
Families of patients who died after medical errors argue that it’s time to abandon the term “second victim” to describe doctors who are involved in a medical error. In an editorial published by The BMJ, Melissa Clarkson at the University of Kentucky and colleagues say that by referring to themselves as victims, “healthcare providers subtly promote the belief that patient harm is random, caused by bad luck, and simply not preventable.” This mindset “is incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers,” they argue. -
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The real second victims
Patient Safety Learning posted an article in Second victim
In many professions, specific terms – both old and new – are often established and accepted unquestioningly, from the inside. In some cases, such terms may create and perpetuate inequity and injustice, even when introduced with good intentions. One example is the term ‘second victim’. The term ‘second victim’ was coined by Albert W Wu in his paper ‘Medical error: the second victim’. Wu wrote the following: “although patients are the first and obvious victims of medical mistakes, doctors are wounded by the same errors: they are the second victims”. In his blog, Stephen Shorrick discusses the term second victim, what patients and families think of this term, and proposes that healthcare professionals are perhaps the 'third victims'. -
Content ArticleIn this Editorial in the BMJ, Albert Wu introduced the phrase ‘second victim’ in an attempt to highlight the emotional effects for staff involved in a medical error and the need for emotional support to help their recovery.
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Content ArticleEveryday across the NHS, patients, their supporters and the professionals caring for them deal with the aftermath of healthcare harm and, on rare occasions, wrongdoing. Every healthcare system in the world confronts exactly the same problem, but none deal well with the aftermath of harm. In this article published in the Journal of Patient Safety and Risk Management, Anderson-Wallace and Shale introduce a set of standards that aims to make the consequences less devastating for everyone.
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Content ArticleThis study, published in the BMJ Open, aims to examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives.
