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Content ArticleBoth staff and patients want feedback from patients about the care to be heard and acted upon and the NHS has clear policies to encourage this. However, doing this in practice is complex and challenging. This report from the National Institute for Health Research (NIHR) features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better. Evidence ranges from hospital wards to general practice to mental health settings. The report found that although a lot of resource and energy goes into collecting feedback data, less goes 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. Patients’ intentions in giving feedback are sometimes misunderstood. Many want to give praise and support staff and to have two-way conversations about care, but the focus of healthcare providers can be on complaints and concerns, meaning they unwittingly disregard useful feedback. The report provides insights into new ways of mining and analyzing big data, using online feedback and approaches to involving patients in making sense of feedback and driving improvements.
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Content ArticleThis article, published by Medium, looks at the story of a woman who had a stroke while pregnant. Both survived. The authors highlight a growing concern that the US is in the midst of a maternal morbidity and mortality crisis.
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Content ArticleThe National Patient Safety Agency (NPSA) issued guidance on preventing delay to follow up for patients with glaucoma [NPSA/2009/RRR004]. This followed evidence of harm to patients with glaucoma suffering visual loss after delays to follow up appointments. This came to light from incidents reported by staff in the NHS relating to glaucoma. This paper provides background information and a checklist for organisations to help implement actions in the accompanying guidance to prevent harm from delayed follow-up appointments for patients with glaucoma. It presents details of incident data and litigation data. This work was supported by an interactive event in March 2009 with input from ophthalmic surgeons (and the Royal College of Ophthalmologists), nurses, service managers and patient representatives.
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Content ArticleSHOT is the United Kingdom independent, professionally led haemovigilance scheme. Since 1996 SHOT has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. Where risks and problems are identified, SHOT produces recommendations to improve patient safety. The recommendations are put into its annual report which is then circulated to all the relevant organisations including the four UK Blood Services, the Departments of Health in England, Wales, Scotland and Northern Ireland and all the relevant professional bodies as well as circulating it to all of the reporting hospitals. As haemovigilance is an ongoing exercise, SHOT can also monitor the effect of the implementation of its recommendations.
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Content ArticleThe Care Quality Commission (CQC)’s annual report on Ionising Radiation (Medical Exposure) Regulations in England has been published. The report gives a breakdown of the number and type of statutory notifications of errors received from healthcare providers in 2018/19 where patients were exposed to ionising radiation. These notifications are where there have been significant accidental or unintended exposures, for example where a patient received a higher dose than intended or where the wrong patient was exposed.
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Content ArticleWomen can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. That’s the safety risk the Healthcare Safety Investigation Branch (HSIB) highlights in this report.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) recently published a report that highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors. The report comes after HSIB looked at the case of 75-year old Ann Midson, who was left taking two powerful blood-thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer. PRAC+TICE caught up with Scott Hislop and Helen Jones, two of the investigators, on this podcast to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
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Content ArticleEarlier this year, the World Health Organization declared 17 September the first World Patient Day and presented it as an opportunity to speak up for patient safety. A week or so beforehand, health leaders from across the world had met in Salzburg, Austria, at the request of Salzburg Global Seminar and the Institute for Healthcare Improvement (IHI) to explore ways of improving the measurement of patient safety. The Lucian Leape Institute, an initiative of the IHI, led the convening and content curation. Participants of Moving measurement into action: designing global principles for measuring patient safety agreed that there is no single measure that allows all stakeholders in all settings to assess the past, current, and future safety of their system. Participants agreed a system of measures must be carefully designed to assess the safety of patients throughout their health journey. The conversations in Salzburg have helped establish eight global principles for the measurement of patient safety. They feature in this new document, Salzburg Statement on Moving Measurement into Action: Global Principles for Measuring Patient Safety.
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Content ArticleThe nature and consequences of patient and family emotional harm stemming from preventable medical error, such as losing a loved one or surviving serious medical injury, is poorly understood. Patients and families, clinicians, social scientists, lawyers, and foundation/policy leaders were brought together to establish research priorities for this issue. I recommend that all those involved in 'engagement with harmed patients and families' read this and in particular, commit to making sure they are doing the '20 things organisations can do now' that is listed in table 3. This paper was published in the Joint Commission Journal on Quality and Patient Safety. Register for free to view the full article.
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Content ArticleA blog from Dr Linda Dykes. "Bryn was my patient. He died. He may have stood a better chance of survival had I been aware of the risk of small bowel volvulus in an adult. I produced this reflective learning resource with some colleagues - and with Bryn's widow, whom we call Fiona. Please read it... it may help you save a life one day."
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Content Article
NHS East London: QI Essentials. Beyond Projects
Claire Cox posted an article in Implementation of improvements
Improvement is now becoming a way of life and a way of being. How do we hold onto and strengthen our approach to QI projects? Have a read of Amar’s latest QI Essentials Blog. Amar Shah is a consultant forensic psychiatrist and Chief Quality Officer at East London NHS Foundation Trust. -
Content ArticleWhen patients are harmed as a result of the care they receive through Alberta Health Services (AHS), the organisation has a responsibility to understand how the harm happened and, where appropriate, respond to improve the healthcare system. This handbook has been developed to assist and support AHS staff and medical staff to retrospectively review clinical adverse events, hazards and close calls using Systems Analysis Methodologies (SAM). It is not an administrative review of individual healthcare provider performance. Using these methodologies, the complex interactions of all the components within the health system are considered, not the individual contributions of healthcare providers that have or may have led to harm. This creates opportunities to identify vulnerabilities in structures, processes and practices that can be improved and ultimately make care safer.
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Content ArticleThis is the report of the Parliamentary and Health Service Ombudsman (PHSO) second investigation into the Care Quality Commission’s (CQC) regulation of the Fit and Proper Persons Requirement (FPPR). Rob Behrens wrote to Dr Sarah Wollaston MP and Chair of the Health and Social Care Select Committee to share the findings from the report. He underlines the need for reform of the FPPR system and for the recommendations from the Kark review to be swiftly implemented.
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Content ArticleIn our Blueprint for Action, we outline some of the concerns around the quality of investigations.
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Content ArticlePublished by the Canadian Patient Safety Institute, this paper describes an investigation into engaging with patients and families that have been harmed and recommends best practices for organisations to enable such collaboration.
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BMJ: Safe handover (October 2017)
PatientSafetyLearning Team posted an article in Research papers
High quality handovers are essential for safe healthcare and are used in many clinical situations. Miscommunication during handovers can lead to unnecessary diagnostic delays, patients not receiving required treatment, and medication errors. Miscommunication is one of the leading causes for adverse events resulting in death or serious injury to patients. The process of handovers can be improved, and the aim of this article is to provide practical guidance for clinicians on how to do this better. -
Content ArticleThis Care Quality Commission (CQC) briefing document discusses the need for a change in the way that serious incidents are investigated and managed in the NHS. It is based on the findings of a review of a sample of serious incident investigation reports from 24 acute hospital trusts. This sample represented 15% of the total 159 acute hospital trusts in England at the time of review. The briefing provides a summary of the findings, linked to five opportunities for improvement and calls for all organisations to work together across the system to align expectations and create the right environment for open reporting, learning and improvement.
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Content ArticleA report for Norfolk and Suffolk NHS Foundation Trust by Verita. Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for regulated organisations.
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Content ArticleThis policy confirms the process for reviewing deaths within Lincolnshire Community Health Services (LCHS) to ensure a consistent approach is followed in order to identify if the patient’s needs were met during the end of life phase and that relatives and carers were supported appropriately. The aim of the mortality review process is to identify any areas of practice that require improvement and to identify areas of good practice. This process ensures that mortality within LCHS is managed and reviewed in a systematic way.
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Content ArticleThe preventable death of Connor Sparrowhawk in July 2013 led to a number of investigations and enquiries into practice at Southern Health NHS Foundation Trust in whose care he died. This is a review of all deaths of people in receipt of care from Mental Health and Learning Disability services in the Trust between April 2011 and March 2015. It is not a clinical case review of each service user and we have therefore not tried to identify clinically unavoidable deaths. It does seek to establish the extent of unexpected deaths in Mental Health and Learning Disability services provided by the Trust and to identify any themes, patterns or issues that may need further investigation based on a scope provided by NHS England. We were asked to benchmark this Trust with other similar organisations where this was possible. In the report, we focus on the responsibilities as they impact on the Trust to report deaths and then to secure the right level of review, enquiry or investigation. However, the responsibility for investigating deaths lies with a number of organisations across the area and we refer to these responsibilities where appropriate.
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Content ArticleEAST for Health & Safety: Applying behavioural insights to make workplaces safer is a report from the Behavioural Insights Team. The EAST framework focuses on four simple principles to encourage a behaviour: make it Easy, Attractive, Social and Timely (EAST).
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IHI: Leadership guide to patient safety (2006)
PatientSafetyLearning Team posted an article in Clinical leadership
This US White Paper from the Institute of Healthcare Improvement shares the experience of senior leaders who have decided to address patient safety and quality as a strategic imperative within their organisations. It presents what can be done to make the dramatic changes that are necessary to ensure that patients are not harmed by the very care systems they trust will heal them. -
Content ArticleSpreading successful improvement work across the NHS is an essential part of improving health care quality and efficiency. Yet all too often an idea that has been shown to work well in one place is not adopted by others who could benefit from it. This guide from the Health Foundation, intended for those actively engaged in health care improvement, draws on this experience and empirical evidence, to provide practical information about how communications approaches can be used to spread improvement ideas.
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NHS Quality Accounts FAQs
PatientSafetyLearning Team posted an article in Patient safety standards
A Quality Account is a report about the quality of services offered by an NHS healthcare provider.The reports are published annually by each provider, including the independent sector, and are available to the public. Quality Accounts are an important way for local NHS services to report on quality and show improvements in the services they deliver to local communities and stakeholders. The quality of the services is measured by looking at patient safety, the effectiveness of treatments patients receive, and patient feedback about the care provided. -
Content Article
The harms of promoting ‘Zero Harm’
Claire Cox posted an article in Research papers
In their paper 'Managing risk in hazardous conditions: improvisation is not enough', Almaberti and Vincent ask "what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to". This is clearly a critical and much overdue question, as many healthcare organisations are in an almost constant state of stress from high workload, personnel shortages, high-complexity patients, new technologies, fragmented and conflicting payment systems, over-regulation, and many other issues. These stressors put mid-level managers and front-line staff in situations where they may compromise their standards and be unable to provide the highest quality care. Such circumstances can contribute to low morale and burn-out. Eric Thomas discusses this further in his Editorial published in BMJ Safety & Quality.- Posted
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