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  1. Content Article
    The Government’s response and action needed The Government’s response to the publication of the Inquiry’s report advised that they would look at these recommendations and report back ”in three to four months’ time”.[3] When doing this it is vital that these recommendations are considered holistically as part of the wider change that is needed, where patient safety is treated as a strategic purpose of healthcare. Patient safety is currently treated as one of many priorities to be weighed against each other. We think it is wrong that safety is negotiable. Patient safety must be core to the purpose of healthcare, reflected in everything that it does. We look forward to the Government’s response to the Inquiry recommendations. This must include action for change, including: Culture change Creating a culture in healthcare where staff feel safe and secure in reporting patient safety concerns, knowing their concerns will be actively welcomed, listened to and acted upon. Healthcare organisations should regularly and independently assess their organisational culture and have programmes of action to ensure a just and learning culture is in place. Staff reporting concerns An open and learning culture clearly signposting staff on how to raise concerns and that these concerns are acted upon. Harmed patients are supported Patients receive the support they need when things go wrong. ‘Harmed patient care pathways’ outline the provision of advice, guidance, practical and psychological support to patients and families. Learning from complaints All private patients have the right to mandatory independent resolution of their complaint. Patient safety applies to all, irrespective of whether care is provided for in the NHS or independent sector. #Share4Safety Organisations develop systems and measurements to improve patient safety, collecting data on patient safety and sharing learning. We strongly support the recommendation made by the Inquiry that where a healthcare professional is suspended with a perceived risk to patient safety, these concerns should be communicated to other providers that they work for. Leading and owning patient safety A new model for leadership and governance for patient safety that operates in both the NHS and independent sector. There should be high standards and behaviours set for our leaders and they should be supported by specialist patient safety experts in executive and non-executive board roles. Organisations need clear and published goals for patient safety with board focus and effectively oversight on reducing patient harm. The healthcare system operates as one coordinated system with patient safety as a core purpose. If action isn’t taken, then the Paterson Inquiry will become yet another report of unsafe care where sympathetic noises are made but no real learning and change occurs. If Government and leaders say that ‘lessons have been learned’ then they need to tell us what those lessons are, what actions they are taking, and publish updated reports on their progress and share these publicly. Without having these measures in place, how can the public and patients be assured that there won’t be future reports of unsafe care? As the Inquiry Chair said, “it is wishful thinking that this could not happen again”. References The Guardian. Ian Paterson inquiry: more than 1,000 patients had needless operations. 4 February 2020. The Right Reverend Graham Jones. Report of the Independent Inquiry into the Issues raised by Paterson, February 2020. House of Commons Debate, Paterson Inquiry, 4 February 2020, Volume 671.
  2. News Article
    The number of British cases of coronavirus has doubled to eight – with two healthcare workers among those testing positive – while a GP surgery in Brighton was closed amid fears of the infection spreading. Brighton’s County Oak medical centre closed on Monday with a warning notice on its door telling patients it was “closed due to operational difficulties”. According to reports, one of those infected was a GP, who was at work for one day but did not see any patients. Workers wearing protective suits were pictured cleaning the surgery and pharmacy on Monday afternoon. The government has since classified the virus, which has infected more than 40,000 people in China and led to the death of more than 1,000, as a “serious and imminent threat” to public health while activating emergency powers that can see it force people to remain in quarantine. “I will do everything in my power to keep people in this country safe,” Matt Hancock, the Health Secretary, said in a statement. “We are taking every possible step to control the outbreak of coronavirus. NHS staff and others will now be supported with additional legal powers to keep people safe across the country.” Read full story Source: The Independent, 11 February 2020
  3. Content Article
    Hi Sue, can you tell us a little about yourself? My background is in tissue viability and I retain the clinical and leadership role with tissue viability as part of this role. I have been in tissue viability for 17 years and developed and continue to lead the service at Ashford and St Peter's Hospital NHS Foundation Trust. During this time I was seconded into the post of Acting Assistant Chief Nurse 0.5WTE for 1 year. Previous to this, I worked as a Deputy Head of Practice Development and a Ward Sister. You are the first harms prevention nurse consultant in the UK. How did the role come about? The Trust Chief Nurse had the vision to look at hospital associated harms as a whole and how this needs to be managed in a strategic way across the Trust. The role ties in with the NHS Patient Safety Strategy 2019. Where does your role sit within the governance structure? The role sits within the corporate division and has close ties and associations with all of the divisions and their governance structures. The post reports into the Trust Safety and Quality Committee. How long have you been in post? This is the start of my fourth week. What are the main purposes of the role? My role includes: Leading and developing the Harms Free Care Service across the Trust. Developing the Trust Harm Free Care Strategy and monitor its effectiveness. Leading on the Harms Free Care Strategy within the Trust, working with the teams to deliver a sustained reduction in pressure damage, avoidable falls, the absence of a new venous thromboembolism (VTE), harm associated with poor nutrition and the absence of catheter associated urine infection. Being expected to develop and influence strategies and frameworks to ensure that all healthcare staff adhere to Trust policies relating to Harm Free Care, through developing practice linked to the clinical governance and performance frameworks and Trust corporate objectives. Supporting the Trust to develop and implement systems for performance monitoring and performance improvement programmes for pressure ulcers, VTE, falls, nutrition and catheter associated urinary tract infection. Talk us through a typical day. It's a little early to talk about a typical day yet. I still have a clinical role in tissue viability 2 days per week as part of my role and so these days are spent assessing and planning care for patients with complex wound needs, providing education and training. The rest of my time is filled with planning for the role of Harms Free Care, looking at our present data and analysis, meeting with the harms leads, such as the VTE prevention lead nurse and the nutrition lead. Have you had a chance to see what impact the role has had on patient safety? It’s too early to look at impacts, but feedback has been positive that harms must be seen together and not separately. Meaning that we should not concentrate on the reduction of one harm at the potential cost of a rise in another, the harms are interrelated and need to be focused on as such. One of the key parts of the role will be ensuring our metrics in relation to harm are relevant and meaningful to both staff and patients. How are you measuring the impact of the role? There will be multiple measures which will be benchmarked against improvement targets for the reduction of harms. This will include data such as numbers of harms as well as other data such as patient feedback. How do you engage staff and patients in patient safety? We engage staff via various means: education, bulletins, focus days such as Worldwide Stop the Pressure Day, focus weeks such as Nutrition and Hydration Week. We are working towards engagement strategies as part of the NHS Patient Safety Strategy. How do you see this role developing? I would like to see this role being adopted by other Trusts as we have a concerted focus across the NHS to reduce patient harms.
  4. News Article
    All NHS hospitals in England have been ordered to create secure areas for coronavirus testing to “avoid a surge in emergency departments”, according to a leaked NHS letter. Hospitals have been told to create “coronavirus priority assessment pods”, where people will be checked for the virus, which will need to be decontaminated each time they are used. The letter, seen by The Independent and dated 31 January, instructs all chief executives and medical directors to have the pods up and running no later than Friday 7 February. It comes as the global death toll from the virus has reached 565 with around 28,000 infected. One hospital chief executive told The Independent he believed the requirement was “an overreaction”, adding: “I think we should be sending teams out to swab in patients homes as the advice is to stay at home and self-manage as with any other flu". In the letter, Professor Keith Willett, who is leading the NHS’s response to coronavirus, told NHS bosses: “Plans have been developed to avoid a surge in emergency departments due to coronavirus. “Although the risk level in this country remains moderate, and so far there have been only two confirmed cases, the NHS is putting in place appropriate measures to ensure business as usual services remain unaffected by any further cases or tests of coronavirus.” Read full story Source: 5 February 2020
  5. News Article
    New monitors that can detect the deadly blood condition sepsis are being fitted at a Scottish children's hospital. The equipment will be installed at the Royal Hospital for Children in Glasgow. Charlotte Cooper, who lost her nine-month-old daughter Heidi to sepsis last year, said she had "no doubt" the monitors would help save babies' lives. She told BBC Scotland: "You don't have time to come to terms with the fact that someone you love is dying from sepsis because it happens so quickly." Ms Cooper now wants to see the monitors installed in every paediatric ward in Scotland. "We need to do whatever we can to stop preventable deaths from sepsis in Scotland," she said. The monitors record and track changes in heart rate, temperature and blood pressure, and can pick up early sepsis symptoms. The machines, which have been installed in a critical care area, use the Paediatric Early Warning Scores to monitor the children for any signs of deterioration in their condition. Sepsis Research said early warning of the changes would mean sepsis being diagnosed and treated faster. The monitors were accepted on behalf of the hospital by senior staff nurse Sharon Pate, who said: "In a very busy paediatric word it is vital all our patients are monitored regularly and closely for signs of deterioration. The addition of these new monitors will greatly improve our ability to monitor patients and provide vital care." Read full story Source: BBC News, 4 February 2020
  6. Content Article
    Managing neuropenic sepsis My role as an acute oncology CNS is to improve cancer services. Part of my role is the treatment and management of neutropenic sepsis. Neutropenic sepsis is an oncological emergency following chemotherapy, whereby the patient’s immune system has been depleted by the treatment for their cancer. The body’s natural defense system has been wiped out from the cytotoxic drug, making the patient more susceptible to infections and, therefore, sepsis. The national standards for treatment of neutropenic sepsis are: Early warning symptoms: call the chemotherapy 24-hour hotline, manned during the day by the chemotherapy nurses and out of hours by the oncology ward nurses who are trained in giving advice to patients on chemotherapy. A high or low temperature is normally the worrying symptom. The UKONS 24 Hour Triage Tool: an algorithm used to support the nurses' advice. The patient is then advised to attend A&E or, if acutely unwell, call an ambulance. Once the patient arrives in the emergency department, the national standard 'door-to-needle time' is to receive antibiotics for suspected infection within 1 hour. How we improved cancer patient safety Monthly audits showed that for 65% of all patient's suspected to have neutropenic sepsis, none received appropriate treatment. This was usually because of contra-indicating admission i.e., came in with left flank pain, or poor triage. An alert card is given to every patient receiving cancer treatment for them to present to the emergency department, alerting everyone that the patient is receiving cytotoxic drugs and advice on how to manage this. The audits I performed highlighted that the patients who presented to the emergency department out of hours did not receive appropriate antibiotics in time. This correlated to no acute oncology nurse present. These findings led to us changing our practice to a nurse-led service. We asked the chemotherapy hotline to alert us to anyone they had advised to attend the emergency department. This allowed us to meet the patient at the front door, and to support and arrange for doctors and nursing staff to give the correct management in time, expediting and eliminating error. The errors I speak of were never incompetence; they were human error. One nurse to 20 unwell patients in the emergency department is unsafe. The emergency department is the frontline in all acute trusts. In the trenches, fantastically skilled but overworked and under-valued. This was noticed by the acute oncology team. I derived that we as a team needed to change our working hours. 10 hours days, 4 days a week. Excluding weekends, where the oncology registration would stand in for the acute oncology service. This worked on days where neutropenic sepsis admissions were many, but still did not support the out of hours admissions. Teaching and training were my next focus. I set up a trust-wide acute oncology conference where I invited all trust staff to attend, inviting guest speakers, experts in their field, to teach and train nurses, doctors, the receptionist, anyone who would meet a patient on cancer treatment. We trained emergency department nurses to be able to prescribe and administer the first dose of antibiotics to ensure the door-to-needle time less than 1 hour was adhered to. Training empowered the emergency staff. Training is investing not scolding. Following these changes, our monthly audit numbers went from 65% to 80–90% over the course of 3 months, which showed a huge success. However, then January came, ambulances queuing down the hill from the emergency department. 345 admissions with only two beds within the trust. 25 staff shortage. Door-to-needle times became 3 hour rather than 1 hour. Our team consisted of three CNS to cover the acute hospitals with emergency departments. 50 referrals a day predominately for new diagnosis of cancer. Door-to-needle times on audit were at an all-time low of 25%. The worst I had seen it. Look at the contributing factors: 25 staff nurses down, huge demand on admissions and beds, limited capacity to review patients. During this month, acute oncology CNS predominantly lived in the emergency department, prescribing and administering the antibiotics ourselves to ensure safe practice. This did not come at a cost to the rest of our service and ensured patient safety. It dramatically improved our door-to-needle times. Acute oncology CNS are a necessity and, I personally think, the unsung heroes of an acute trust. We can prevent hospital admissions and avoid delayed discharges, freeing up beds and supporting and advising doctors to investigate patients appropriately and safely. Why I love my role I enjoy my role. It is a rewarding role. I have had the privilege to meet and work with the most beautiful people in the most harrowing of times. The worst times. But it is worth it. Meeting someone who has been in pain and suffering for 3 months at home who has come into hospital because the pain had got to much. They are aware something is wrong but isn’t sure what. Breaking the bad news that this is a cancer and having the time and resources to support that patient and their family. Knowing I am making a difference. Even when the outcome is that this person is not fit enough for further investigations or would not be safe enough to have chemotherapy, but advising them that the main focus of care should be symptom management and palliative care to ensure quality of life. To feel that I have made a difference and, more importantly, to hear that I have. Ensuring patient safety through diagnosis to treatment and to the end of life care. Something we must not overlook the importance of. Although acute oncology CNS is not as well-known as critical outreach nurses or heart failure nurse specialists, it is equally important and necessary. A case study I would like to end this blog with a case study of a patient named Brendan*. Brendan was a 24-year-old man who presented with a 3-day history of right upper quadrant pain. Clinically jaundice. 10/10 pain. Unable to move. He had an ultrasound in the emergency department on Wednesday pm. He was referred to acute oncology in light of suspicious radiological diagnosis of cancer. Within 48 hours, acute oncology had reviewed him and broken the bad news to him that he had cancer. Cancer of unknown primary. The young man was discharged from hospital. We ensured a support service in system (given him our CNS number), managed his pain, arranged further investigations and discussed in a multidisciplinary meeting the best site for biopsy. We booked the biopsy and arranged a clinical appointment 1 week later with our acute oncology consultants. We called this young man every day for symptom reviews and holistic support for him and his family. He received chemotherapy within 3 weeks of diagnosis and is alive to this day, with a cancer that is rare and difficult to treat. Having only had six hospital admissions. This is why acute oncology are a necessity to any hospital and community service. *Name has been change to ensure confidentiality.
  7. Content Article
    Clare Wade and Professor Allen Hutchinson discuss the National Mortality Case Record Review (NMCRR) and the structured judgement review process at the RCP's Patient Safety Seminar:
  8. Content Article
    Medical Examiners of Deaths Proposed Change: We propose to include a new requirement for acute providers (NHS Trusts and Foundation Trusts only) to establish a Medical Examiner’s Office, in accordance with guidance published by the National Medical Examiner. The Office will, initially, review those deaths occurring on the Trust’s premises and not referred to the coroner, ensuring that the certification of death is accurate and scrutinising the care received by the patient before death. Patient Safety Learning supports this proposal. We welcome the decision to make the establishment of a Medical Examiner’s Office a requirement for acute providers. This proposal was first recommended following the Shipman Inquiry (2002-2005) and recent media coverage has revealed that a significant number of NHS trusts have still yet have appoint a Medical Examiner. Medical Examiners can play a key role in improving patient safety in cases where the patient’s death was the result of avoidable harm. They can provide vital insights into these cases and help to identify effective remedial actions to prevent their recurrence, as well as sharing this information for wider learning beyond their specific trusts. Patient Safety Incident Response Framework Proposed Change: The NHS Patient Safety Strategy indicates that the current NHS Serious Incident Framework and Never Events Policy Framework will be replaced, over the next two years, by a new single Patient Safety Incident Response Framework. To accommodate and signpost this planned change, we propose adding a specific reference to “successor frameworks” to the existing requirements relating to the current Frameworks. Patient Safety Learning supports the proposal to update requirements. We welcome the review of these frameworks and the development of a new Patient Safety Incident Response Framework (PSIRF). However, we have concerns about the delay in its release, which was initially expected towards the end of 2019 and now instead subject to a limited release this year with pilot organisations, rather than being shared more widely. We are also concerned about the lack of stakeholder engagement in this process, particularly for patients and families. Despite providing a valuable source of information when incidents occur, they are often not included in investigation processes. The failure to include and listen to patients and families in investigations can often result in more harm and increasing the likelihood of complaints and litigation. In updating these processes therefore it is vital their views are taken into account. National Patient Safety Alerts Proposed Change: The National Patient Safety Alerting Committee is establishing new, co-ordinated and accredited arrangements for the issuing of National Patient Safety Alerts to providers. We propose to include a new requirement for providers to ensure that they can receive each relevant National Patient Safety Alert, identify appropriate staff to coordinate and implement actions required within the timescale the Alert prescribes, and confirm and record when those actions have been completed. Patient Safety Learning supports this proposal. We welcome steps to ensure providers have appropriate arrangements in place to coordinate and implement actions required by national patient safety alerts and record when these have been completed. A recent report by Action Against Medical Accidents, An organisation losing its memory?, has indicated that a number of trusts have experienced significant delays in introducing safer practices highlighted by national patient safety alerts. They found in many cases that the trusts experiencing delays ‘indicated that they were in the process of improving internal systems for overseeing the implementation of patient safety alerts’. It is a positive step to see this is now being added to the NHS Standard Contract as a formal requirement for them to do so. However, we have concerns beyond the scope of these contractual obligations that this process does not appear to be monitored at a national level. While these measures place specific responsibilities on providers, we are not clear on what, if any, oversight arrangements will be put in place to accompany these. We think such national monitoring and public reporting is essential and would look for this to be implemented as a priority. Patient Safety Specialists Proposed Change: The NHS Patient Safety Strategy envisages the establishment of a network of patient safety specialists, one in each provider, to lead safety improvement across the system. We therefore propose to include a requirement on each provider to designate an existing staff member as its Patient Safety Specialist. Patient Safety Learning supports this proposal. We support this proposal in principle but have reservations about how this will be implemented in practice. The requirement to appoint a Patient Safety Specialist, as set out in the NHS Patient Safety Strategy, currently lacks detail about the nature of this role. What do we mean by a ‘Safety Specialist’? What knowledge and training should they have? Will the appropriate governance arrangements be in place to make sure their voice is heard by the organisation’s leadership? We think these arrangements should be specified, resourced, monitored and transparently reported. We will be responding to the separate consultation on this which opened on the 30 January 2020 in more detail. Common sources of harm to patients in hospital/Safety Thermometer Proposed Change: Feedback suggests that the existing Contract requirements on use of the Safety Thermometer are creating too great a bureaucratic burden, and not facilitating learning. We therefore propose to remove the specific requirements relating to use of the Safety Thermometer and, instead, introduce a higher-level obligation on acute providers to ensure and monitor standards of care in the four clinical areas which the Safety Thermometer addresses – venous thromboembolism, catheter-acquired urinary tract infections, falls and pressure ulcers. At Patient Safety Learning we believe that the health and social care system should develop models for measuring, reporting and assessing patient safety performance. This data should be gathered centrally and then used for learning and to implement actions that improve care. With regards to the removal of Safety Thermometer requirement, while we recognise that it has been noted that this has not been effective in facilitating learning, we would expect the newly proposed measures to follow these principles. We would also expect patient safety measurement to apply to all NHS organisations, rather than being an obligation limited to acute providers.
  9. Content Article
    Getting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings. Importantly, GIRFT is led by frontline clinicians who are expert in the areas they are reviewing. This means the data that underpins the GIRFT methodology is being reviewed by people who understand those disciplines and manage those services on a daily basis. The GIRFT team visit every trust carrying out the specialties they are reviewing, investigating the data with their peers and discussing the individual challenges they face.
  10. Content Article
    “After he died, the little plastic ID band that was around his tiny wrist should have been slipped onto mine. There was nothing more that could have been done for him, but there was plenty that needed to be done for me. I needed an infusion of truth and compassion. And the nurses and doctors who took care of him, they needed it too." Leilani Schweitzer[1] When someone is hurt, it is reasonable to expect the healthcare system to provide care to alleviate symptoms or to cure. It is also reasonable to expect those providing the care to be adequately trained and supported to do so. Yet, when harm is caused by healthcare, the spectrum of harm suffered is not well understood, care needs are not fully recognised and, therefore, the care needed to facilitate optimum recovery is not being provided.[2] In fact, with outrageous frequency, at a time when exceptional care is so desperately needed, those hurting describe how they are further harmed from ‘uncaring’ careless and injurious responses. Healthcare harm is a ‘double whammy’ for patients Healthcare harm is a ‘double whammy’. There’s the primary harm itself – to the patient and/or to those left bereaved – but there is also the separate emotional harm caused specifically by being let down by the healthcare professionals/system in which trust had to be placed.[3] This additional emotional harm has been described as being the damage caused to the trust, confidence and hope of the patient and/or their family.[4] Trust – you rely on professionals to take responsibility for what you cannot do yourself. Confidence - you believe that the system will protect you from harm. Hope – you have the conviction that things will turn out well. Anderson-Wallace and Shale[4] For the patient and family to be able to heal from healthcare harm, appropriate care must be provided not only for the primary injury and any fall out from this, but also this additional emotional injury (being let down by healthcare) and any fall out from that. For example, a parent who loses a child as a result of failures in care will need help to cope with the loss of their child and all of the processes that occur as a result. But they will also need support to cope with having had to hand over responsibility for their child’s safety to healthcare professionals, only to be let down, and all the feelings and processes associated with that. Much needs to happen to restore that parent’s trust, confidence and hope in our healthcare system and the staff within it. This is different to the parent of a child who has passed away from an incurable illness despite exemplary healthcare. A parent let down by healthcare has specific additional care and support needs that need to be met to help them cope and work towards recovery. Healthcare harm also causes emotional harm to the staff involved In 2000, 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.[5] The term has recently been criticised, since families should be considered the second victim,[6] and the word victim is believed “incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers.”[7] While the term itself may be antagonistic, or misrepresentative, the sentiment – that staff involved in incidents need support to cope with what has happened, and to give them the confidence to do what is needed to help the patient/family heal – certainly stands. When staff are involved in an incident of patient harm, they may lose trust in their own ability and the systems they work in to keep patients safe, and they may worry about their future.[5],[8] They need care and support in order to recover themselves and, crucially, so that they feel psychologically safe and are fully supported to be open and honest about what has happened. They need to feel able to do this without fearing personal detrimental consequences for being honest, such as unfair blame or a risk to their career. This is essential to the injured patient/family receiving the full and truthful explanations and apologies they need in order to regain trust, confidence and hope, and, ultimately, to heal as best they can. So, in addition to patients and families there should be a ‘care pathway’ for staff involved in incidents of harm. A google search on ‘second victim’ reveals a wealth of research on the emotional effects of medical error for staff involved and the best ways to provide support for this, and this is resulting in the emergence of staff support provision to aid recovery.[9] In contrast, very little research has been done into the emotional effects and support needs of families and patients. How is ‘care’ for emotional harm given? The ‘treatment’ of the emotional harm has been described as ‘making amends’ – by restoring trust, confidence and hope.[4] Once a patient has been harmed by healthcare, every interaction (physical, verbal or written) they have with healthcare after that will either serve to help them heal or to compound the emotional harm already suffered. Trew et al.[10] describe harm from healthcare as a “significant loss” and conclude that “coping after harm in healthcare is a form of grieving and coping with loss”. In their model, harmed patients and families proceed through a ‘trajectory of grief’ before reaching a state of normalisation. Some can move further into a deeper stage of grief and seemingly become stuck in what is referred to as complicated grief. They can display signs of psychiatric conditions "if there are substantial unresolved issues, or where there is unsupportive action on the part of individuals associated with the healthcare system and the harm experience”. At the point of the harmful event, the patient/family experiences losses, including a drop in psychological wellbeing. From this point on, healthcare staff and organisations have opportunities to respond. If the response is supportive it may be helpful for the patient/family in coping with the losses. If the response is not supportive, this may cause ‘second harm’ complicating the healing process, leaving the patient/family with unresolved questions, emotions, anger and trust issues. The patient’s psychological wellbeing and ability to return to normal functioning are severely affected. “Most healthcare organizations have proved, in the past at least, extraordinarily bad at dealing with injured patients, resorting at times, particularly during litigation, to deeply unpleasant tactics of delay and manipulation which seriously compounded the initial problems. My phrase ‘second trauma’ is not just a linguistic device, but an accurate description of what some patients experience.” Charles Vincent[11] There is no shortage of individuals who have suffered extensive ‘second harm’ sharing their experiences in the hope this will lead to better experiences for others and some help for themselves to recover. Many are, wrongly, being ‘written off’ as historical cases that can no longer be looked at. This cannot be right – when these people are suffering and need appropriate responses to heal their wounds. The extent of suffering that exists now, in people who have been affected by both primary trauma and then second harm from uncaring defensive responses, or responses that have not taken into account the information patients and families themselves have, or relevant questions they ask, is no doubt nothing short of scandalous. There is a pressing urgency for the NHS to stop causing secondary trauma to affected patients and families. ‘Patient safety’ has to start applying to the harmed patient and their family members’ safety after an adverse event, and not just focus on preventing a repeat of the event in the future. Yes, future occurrences must be prevented, learning is crucial, but so is holistically ‘looking after’ all those affected by this incident. If they are not looked after, their safety is at risk as their ability to heal is severely compromised; in fact they are in danger of further psychological trauma. These same principles apply to affected staff. Avoiding second harm: what happens now and what is needed? This series of blogs will highlight that every interaction a harmed patient or family member has with staff in healthcare organisations (not just clinical staff) after a safety incident should be considered as ‘delivery of care’. With this view, the ‘care interaction’ should be carried out by someone trained and skilled and supported to do so, with the genuine intention of meeting the patient/families’ needs and aiding the patient/family to recover and heal (restore trust, hope and confidence). The interaction / response must not cause further harm. Stress or suffering, and the content of the interaction, for example a letter, should not have been compromised, as often occurs, by competing priorities of the organisation to the detriment of the patient/family. Thus, these blogs will look at: The processes that occur after an incident of harm (Duty of Candour, incident investigation, complaint, inquest) with the aforementioned focus. The care the patient and family need and the obligation (that ought to exist) to meet that need. Processes that are core to the package of ‘care’ to be provided to the harmed or bereaved and to be delivered by skilled and supported ‘care providers’. The blog series will seek to show that meaningful patient engagement in all of these processes is crucial for restoring trust, confidence and hope; therefore, aiding healing of all groups in the aftermath of harm. “It is important to respect and support the active involvement of patients and their families in seeking explanations and deciding how best they can be helped. Indeed at a time which is often characterised by a breakdown of trust between clinician and patient, the principle of actively involving patients and families becomes even more important.” Vincent and Coulter, 2002[3] It will also consider the additional care and support needs that might need to be met alongside these processes in a holistic package of care, such as peer support, specialist medical harm psychological support and good quality specialist advice and advocacy. It will describe what is currently available and what more is needed if healthcare is to provide adequate care for those affected by medical error in order to give them the best chance of recovery. Alongside this, the needs of the staff involved will also be considered. We welcome opinion and comments from patients, relatives, staff, researchers and patient safety experts on what should be considered when designing three harmed patient care pathways: for patients, families and staff. What is the right approach? What actions should be taken? How can these actions be implemented? What more needs to be done? Join in the discussion and give us your feedback so we can inform the work to design a harmed patient care pathway that, when implemented, will reduce the extra suffering currently (and avoidably) experienced by so many. Comment on this blog below, email us your feedback or start a conversation in the Community. References 1. Leilani Schweitzer. Transparency, compassion, and truth in medical errors. TEDxUniversityofNevada. 12 Feb 2013. 2. Bell SK, Etchegaray JM, Gaufberg E, et al. A multi-stakeholder consensus-driven research agenda for better understanding and supporting the emotional impact of harmful events on patients and families. J Comm J Qual Patient Saf 2018;44(7):424-435. 3. Vincent CA, Coulter A. Patient safety: what about the patient? BMJ Qual Saf 2002;11(1):76-80. 4. Anderson-Wallace M, Shale S. Restoring trust: What is ‘quality’ in the aftermath of healthcare harm? Clin Risk 2014;20(1-2):16-18. 5. Wu AW. Medical error: the second victim: The doctor who makes the mistake needs help too. BMJ 2000;320(7237):726-727. 6. Shorrock S. The real second victims. Humanistic Systems website. 7. Clarkson M, Haskell H, Hemmelgarn C, Skolnik PJ. Editorial: Abandon the term “second victim”. BMJ 2019; 364:l1233. 8. Scott SD, Hirschinger LE, Cox KR, McCoig M, Brandt J, Hall LW. The natural history of recovery for the healthcare provider “second victim” after adverse patient events. Qual Saf Health Care 2009;18(5):325-330. 9. Second victim support for managers website. Yorkshire Quality and Safety Research Group and the Improvement Academy. 10. Trew M, Nettleton S, Flemons W. Harm to Healing – Partnering with Patients Who Have Been Harmed. Canadian Patient Safety Institute 2012. 11. Vincent C. Patient Safety. Second Edition. BMJ Books 2010.
  11. Community Post
    Can any one share? The trust I work in delivers patient safety training as part of the mandatory training. I was wondering if any other trust does this, if so would they mind sharing Thier slides as I'm not sure what it should include. Thanks!
  12. Content Article
    This course, is for all members of the multidisciplinary team who provide airway support to patients, or care for patients with a compromised airway. This includes anaesthetists, anaesthesia associates, operating department practitioners, nurses, physiotherapists, adult and paediatric intensivists, prehospital and emergency medicine physicians, paramedics, head and neck surgeons and members of the cardiac arrest team. By the end of the course, you'll be able to: improve your strategies to deal with the unexpected difficult airway and explore guidelines to use in special circumstances. identify the key learning points and recommendations from the 4th National Audit Project (NAP4) on major complications of airway management in the UK. apply the principles of multidisciplinary planning, communication and teamwork in shared airways interventions. describe the technical and non-technical aspects of safe airway management for patients undergoing elective or emergency surgery, and the critically ill. engage in a global discussion on airway matters with health professionals from around the world.
  13. Content Article
    In his report, Mr Justice O'Hara found that: While investigating the death of Adam Strain, the inquiry had been met with "defensiveness and deceit" and that "information was withheld" about what happened to Adam in the operating theatre. There "was a cover up" in the death of Claire Roberts, whose death was not referred to the coroner immediately to "avoid scrutiny" Poor care was "deliberately concealed" in the death of Lucy Crawford. There was a "reluctance among clinicians to openly acknowledge failings" in the death of Raychel Ferguson. In the death of Conor Mitchell, there was a "potentially dangerous variation in care and treatment afforded to young people at Craigavon Hospital". In total, the inquiry made 96 recommendations including the establishment of a duty of candour on medical professionals "to tell patients and their families about major failures in care and to give a full and honest explanation".
  14. Content Article
    Key messages The report calls for: All public services to become trauma- and agenda-informed. NICE to incorporate trauma-informed principles into guidance. Service commissioners to adopt trauma-informed principles. All inspectorate bodies to incorporate trauma-informed principles. Government to lead the way in putting these principles into practice.
  15. News Article
    The NHS is spending millions of pounds encouraging patients to give feedback but the information gained is not being used effectively to improve services, experts have warned. Widespread collection of patient comments is often “disjointed and standalone” from efforts to improve the quality of care, according to a study by the National Institute for Health Research (NIHR). Nine separate studies of how hospitals collect and use feedback were analysed. They showed that while thousands of patients give hospitals their comments, their reports are often reduced to simple numbers – and in many cases, the NHS lacks the ability to analyse and act on the results. The research found the NHS had a “managerial focus on bad experiences” meaning positive comments on what went well were “overlooked”. The NIHR report said: “A lot of resource and energy goes into collecting feedback data but less into analysing it in ways that can lead to change, or into sharing the feedback with staff who see patients on a day-to-day basis. NHS England's chief nurse, Ruth May, said: "Listening to patient experience is key to understanding our NHS and there is more that that we can hear to improve it. This research gives insight into how data can be analysed and used by frontline staff to make changes that patients tell us are needed." Read full story Source: 13 January 2020