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Content ArticleWe 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).
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EventThe Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members will receive 20% discount. Email info@pslhub.org for a discount code.
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EventThis one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace and is aligned with the new Patient Safety Syllabus and subsequent Patient Safety Incident Response Framework (PSIRF). The new Patient Safety Strategy advises that organisations must adopt a new and broader approach to stimulate learning from patient safety incidents. This course is designed to assist healthcare professionals involved in this important work. The main purpose is to provide learners with a full understanding of the various approaches that can now be used to conduct patient safety incident investigation (PSIIs). Traditionally, root cause analysis has been used as a blanket approach to diagnosing why patient safety have been compromised, but healthcare teams are henceforth being encouraged to adopt a wider range of methods that will both save time and facilitate enhanced learning. The focus is now on appropriate proportionality in response to incidents that occur in their organisation. Key learning objectives: Understand the new patient safety landscape Understand the need for proportionality of investigation Learn how to use a range of techniques for conducting PSIIs Understand how to write an impactful improvement plan Consider how your current approach to patient safety investigations compares to the agreed national standards Understand typical pitfalls and traps associated with this wider work stream and tips for avoiding them. The course is facilitated by Tracy Ruthven and Stephen Ashmore who have significant experience of undertaking patient safety reviews in healthcare. They were commissioned to write a national RCA guide by the Healthcare Quality Improvement Partnership. They have also authored articles on significant event analysis and clinical audit/quality improvement, all techniques seen as increasingly relevant to improving patient safety. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
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HSIB: Demystifying thematic analysis
Patient Safety Learning posted an event in Community Calendar
This session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points. Register- Posted
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HSIB: Demystifying thematic analysis
Patient Safety Learning posted an event in Community Calendar
untilThis session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points. Register- Posted
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HSIB: Demystifying thematic analysis
Patient Safety Learning posted an event in Community Calendar
untilThis session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points. Register- Posted
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HSIB: Demystifying thematic analysis
Patient Safety Learning posted an event in Community Calendar
untilThis session will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. This course is 3 hours long. On completion of the course you will receive a certificate of attendance, and as this course is CPD accredited you are awarded 3 CPD points.- Posted
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Content ArticleDespite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework.
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Content ArticleIncident 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.
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Content Article‘Compassionate communication, meaningful engagement’ is a handbook for all NHS staff which aims to improve collaboration with patients, their families and carers following a patient safety event. Developed with NHS Trusts across England in partnership with Making Families Count, the guide includes principles of compassionate engagement, roles and responsibilities of healthcare professionals, and information about the processes following an incident. It also brings together a range of signposting information and resources for families and staff.
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News Article
Strikes caused 22 ‘critical incidents’, government claims
Patient Safety Learning posted a news article in News
The NHS has declared 22 ‘critical incidents’ due to disruption caused by industrial action since December, including having to transfer critical care patients, according to the Department for Health and Social Care. Critical care and gynaecology patients have had to be moved to other hospitals due to staffing shortages, urgent cancer surgery and chemotherapy appointments have had to be rescheduled and urgent surgery on trauma patients “could not go ahead” during critical incidents declared in periods of strike action since December, the Department of Health and Social Care said. There have been strikes by both doctors and Agenda for Change staff over pay during 2023, and Wednesday sees junior doctors and medical consultants strike on the same day for the first time. The DHSC has not previously revealed critical incidents caused by strikes, nor details of them. Trusts typically have different triggers for declaring critical incidents, but they indicate severe strain on services, and it is not unusual for them to happen during high winter pressures. Read full story (paywalled) Source: HSJ, 20 September 2023 -
Content ArticleThe '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.
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Content ArticleHave 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.
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Content ArticleIn 2008, five ‘serious untoward incidents’ occurred on a small maternity unit in a hospital in the UK. The prevailing view, held by clinical staff, hospital managers, and executives, was that these events were unconnected and did not signal systemic failures in care. This view was maintained by the testimony of staff and governance procedures which prevented the incidents from being considered together. Drawing on the inquiry report of the Morecambe Bay Investigation (2015), Dawn Goodwin examines how the prevailing view was built and dismantled, eventually being replaced with a very different description of events. Overturning this view required affected parents to engage with governing bodies and legal processes, challenge clinical staff, lobby for inquests, and mobilise social media and the national press. Tracing how different descriptions of events weaken or gather force as they travel through different forums, processes, and are presented to different audiences, she explores the sociology of knowledge around establishing failures of care.
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Content ArticleChris 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.
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Content ArticleEvent analysis is a valuable tool to improve patient safety and quality of care by identifying root causes of incidents and implementing corrective actions to prevent future similar events from occurring. When we analyse adverse events in healthcare and do not incorporate an equity lens, however, we are missing a crucial piece of the investigative puzzle. Health equity is essential to improving health and well-being and can be costly if not addressed as explained in this Institute for Healthcare Improvement (IHI) blog
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Content ArticleOn 7 March 2023 the coroner commenced an investigation into the death of Ian Darwin, aged 42. The investigation has not yet concluded and the inquest has not yet been heard. However, during the course of the investigation the inquiries revealed matters giving rise to concern. The coroner concluded that in his opinion there is a risk that future deaths could occur unless action is taken.
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Content ArticleThe horrifying case of neonatal nurse Lucy Letby, convicted of murdering seven babies and attempting to murder six others at the Countess of Chester Hospital, has raised hard questions for NHS leaders about how organisations respond to concerns about staff, but could digital systems help detect NHS staff who harm patients at an earlier point? If the pattern connecting Letby to the babies’ deaths had been detected by a digital system, would the response from the trust have been different? Would a machine have been believed? Alison Leary, chair of healthcare and workforce modelling at London South Bank University and a leading expert on nursing and data, suggests there is potentially a much bigger role for digital in patient safety.
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Content Article
Pieces: Claudia's story of a serious incident
Patient_Safety_Learning posted an article in Maternity
This digital story produced by Patient Voices, hears from Claudia who reflects on the unexpected death of a baby she helped care for in hospital. Claudia describes her own and her team's emotions as they debriefed and embarked on their serious incident report.- Posted
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Content ArticleIn this article in the Irish Times, Niall discusses his book, Oops! Why Things Go Wrong, and explores why error is inevitable, how it affects many different industries and areas of society, sometimes catastrophically, and most importantly, what we can do about it. You can also listen to an interview with Niall on BBC Radio Ulster’s Talkback (Listen from 38 mins to 57 mins). Related reading on the hub: Oops! Why things go wrong – a blog by Niall Downey
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Content ArticleStephen 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.
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Content ArticleFrom 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.
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Event
SEIPS masterclass in healthcare
Sam posted an event in Community Calendar
The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using SEIPS in healthcare. The SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. Morning session: 9.30-12.30 Afternoon session: 1.30-4.30 Register- Posted
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Content ArticleIn the early 21st century, the patient safety movement began to talk about system safety. Recognising that people are inherently fallible, advocates for patient safety proposed that it was wrong to blame individual clinicians for poorly designed systems that were full of error traps. However, in a 2013 BMJ editorial, Kaveh G Shojania and Mary Dixon-Woods argue that we must also take seriously the performance and behaviours of individual clinicians if we are to make healthcare safer for patients. They draw on research showing that ‘bad apples’—individuals who repeatedly display incompetent or grossly unprofessional behaviours—clearly exist. This is never more evident than today, when we read about the conviction of nurse Lucy Letby.
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