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Content Article
Near misses or great catches? A blog by Emma Walker
Patient Safety Learning posted an article in In health care
After attending a recent Patient Safety Management Network session, Emma Walker reflects on reporting on near misses. -
EventuntilWorld Patient Safety Day, observed annually on 17 September, aims to raise global awareness about patient safety and calls for solidarity and united action by all countries and international partners to reduce harm to patients. Patient and family engagement is one of the main strategies to eliminate avoidable harm in healthcare and ‘Engaging Patients for Patient Safety’ is the defining theme for World Patient Safety Day 2023. Access to safe, quality, and affordable medicines and their correct administration and use is critical for patient treatment and satisfaction. However, harm from medication treatment, including that resulting from a medicine shortage, in hospitals is common. 80 million people in Europe report experiencing a serious medication error during hospitalisation. With the outcomes of enhanced pharmacovigilance practices on medication safety practices in hospitals unclear and widespread deployment and adoption of digitalisation that can contribute to medication safety lagging, error reporting remains one of the most effective strategies to improve patient safety from medication harm. The 72nd World Health Assembly affirms that informed patients and carers could support the elimination of avoidable harm during care delivery. However, in many cases, patients nor their families are unaware of what systems are available to report the error. Therefore, awareness, access and use of patient-centred, user-friendly, reporting systems, will strengthen the evidence base that medication errors are not an unfortunate occupational hazard in healthcare delivery. This webinar will raise awareness of the importance of all stakeholders engaging with patients to improve medication safety in hospitals. It will discuss the importance of ensuring that patients are informed about medication safety and know how to report an unintended medication error when it occurs. Register
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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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News Article
Global COVID-19 data gap grows as countries stop reporting to WHO
Patient Safety Learning posted a news article in News
Fewer than 20 countries worldwide still report COVID-19 hospitalisation and ICU data to the World Health Organization (WHO), leaving the UN health body blind to the impact and evolution of the virus in most of the world, agency leaders have said. The decline in data reporting is a major setback for the WHO’s efforts to track the pandemic. Without reliable data, the WHO cannot accurately assess the burden of disease, identify new variants, or target its resources where they are most needed. “We don’t have good visibility of the impact of COVID-19 around the world,” said Dr. Maria Van Kerkhove, who leads the WHO’s COVID-19 task force. “It is really important that surveillance continues, and this is on the shoulders of governments right now.” “While we are certainly not in the same situation that we were in a year ago or two years ago, SARS-Cov-2 circulates in all countries right now,” said Van Kerkhove. “It is still causing a large number of infections, hospitalisations, admissions to the ICU and deaths.” The current set of dominant COVID-19 variants can still cause the “full spectrum” of disease, from asymptomatic infections to severe disease and death, Kerkhove said. Read full story Source: Health Policy Watch, 25 August 2023 -
News Article
Norfolk and Suffolk NHS trust deaths report 'watered down to spare bosses'
Patient Safety Learning posted a news article in News
A critical report into how a mental health trust mismanaged its mortality figures was edited to remove criticism of its leadership, the BBC has found. In June, auditors Grant Thornton revealed how the Norfolk and Suffolk NHS Foundation Trust (NSFT) had lost track of patient deaths. But earlier drafts included language around governance failures that were missing in the final version. NSFT and Grant Thornton said the changes were due to fact-checking. A number of drafts of the report were produced, with the first dated 23 February this year. The first version described "poor governance" in the way deaths data was managed, with governance also being called "weak" and "inadequate". But many of these critical words were missing from the report released to the public, with "governance" also being replaced with "controls", according to leaked documents. After losing her son Tim in 2014, Caroline Aldridge has been highlighting what she and others claimed had been the trust's undercounting of deaths. "I think people need to know what was removed and what was changed, because I suspect that the first report is a lot nearer to the truth," she said. Ms Aldridge added: "It takes all responsibility from governance, removing the words 'inadequate', 'poor', 'weak' governance, removing significant pieces of information that's not factual accuracy. "We cannot have people watering it [the report] down when it's about deaths." Read full story Source: BBC News, 29 August 2023 -
Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Kath talks to us about why she set up Sling the Mesh and the significant impact that campaigning has on her life. She also highlights the need to establish systems that will identify and prevent avoidable harm, including long term tracking to investigate trends of harm, reporting of industry payments to clinicians and making logging side effects mandatory for healthcare professionals. -
Content Article
On 18 August 2023, Lucy Letby was found guilty of murdering seven babies and convicted of trying to kill six other infants at the Countess of Chester Hospital. Looking ahead to the forthcoming independent inquiry into this case, Patient Safety Learning, reflecting on the inquiries of the past, sets out some key patient safety themes and issues that should be considered as part of this.- Posted
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Content ArticleThis guide published by NHS England & Improvement describes the validation rules relating to the LFPSE project, specifically around submitting an Adverse Event via the Adverse Event Application Programming Interface (API). It covers several types of validation rules, which have been split into three sections. Bespoke business validation rules which have been implemented based on the dependencies between responses and extensions that cannot be captured by the FHIR resource validation. FHIR validation responses which may be returned from the API when native FHIR validation checks the submission body against the LFPSE FHIR profiles defined for an adverse event. Invalid operations and similar responses which are external to validation of the submission, including responses pertaining to permissions, personal information and any other responses that do not fit into the two categories above.
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Content ArticleThis NHS dentistry and oral health update has a special focus on patient safety. It includes an introduction by newly appointed Interim Chief Dental Officer (CDO) for England, Jason Wong and covers the following topics: Quality and safety in dental care Contributing to patient safety learning Using the Learning from Patient Safety Events (LFPSE) service Patient safety incidents and harm Patient Safety Incident Response Framework (PSIRF) Spotlight on Project Sphere Regulatory support Clinical leadership in patient safety
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Content ArticleThis guidance for users of the new Learn from Patient Safety Events (LFPSE) service provides context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate options for the Levels of Harm categorisation required within Patient Safety Incidents. It covers the following topics: Definitions – event types Definitions – harm grading When are harm grading fields mandatory? Recording guidance questions and answers
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Content ArticleJust like near-miss reporting, a formal good catch program promotes reporting and learning while providing important metrics that can be tracked and trended over time. It turns a company’s safety philosophy into a clear reality. This article, published by Safety Management Group (SMG), looks at the importance of reporting 'good catches' and the positive impact this can have on safety culture and behaviour.
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Content Article
Near-miss and good-catch reporting
Patient_Safety_Learning posted an article in Quality and safety reports
In this article, published by Incident Prevention, authors define what a 'near miss' or 'good catch' is and look at why it is so important to report them. -
Content ArticleA good catch in healthcare is recognised as an employee interception of a potential safety event before a patient is harmed. Both near misses and good catches present healthcare organisations with opportunities for learning to reduce harmful events, which is why reporting near misses in healthcare should be a priority for all organisations, regardless of type or size. It is important that all employees can recognise common examples of good catches in healthcare that prevent patient harm before it reaches the patient. This article, published by Performance Health Partners, includes five situations in which harm can likely occur when no action is taken. It also looks at how to establish a good catch program and how to recognise staff for reporting.
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Content ArticleWales' national policy on patient safety incident reporting and management.
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Content Article
This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. -
News Article
NHSE and government reprimanded for ‘selective reporting’ of cancer performance
Patient Safety Learning posted a news article in News
NHS England and the government have been criticised for “selective reporting” of statistics by an influential Westminster committee. The chair of the Public Accounts Committee Meg Hillier wrote to NHS England CEO Amanda Pritchard requesting “greater realism about the scale of the challenge” on cancer services. It follows the government and NHSE claiming in a government response to the committee that they had “implemented” one of its earlier recommendations, to “bring cancer treatment back to an acceptable standard”. In their February report on backlogs and waiting times, MPs said cancer delays were “unacceptable” and services should be recovered “as a matter of urgency”. The report also criticised NHSE for “over-optimism” when drawing up cancer and elective recovery plans. Read full story (paywalled) Source: HSJ, 4 July 2023 -
Content ArticlePennsylvania is the only state that requires acute care facilities to report all events of harm or potential for harm. The Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest repository of patient safety data in the United States and one of the largest in the world, with over 4.5 million acute care event reports dating back to 2004. Herein, we examine patient safety event reports submitted to the PA-PSRS acute care database in 2022 and compare them to prior years. The authors extracted data from PA-PSRS and obtained data from the Pennsylvania Health Care Cost Containment Council (PHC4). Counts of reports were calculated based on report submission date, and rates were calculated based on event occurrence date and calculated per 1,000 patient days for hospitals or 1,000 surgical encounters for ambulatory surgical facilities (ASFs). The study found there was a decrease in the number of incident reports submitted to PA-PSRS in 2022 and an increase in serious and high harm event reports.
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Content Article
Adverse incidents arising from suboptimal healthcare are a major cause of worldwide morbidity and mortality. Arriving at an understanding of the conditions under which adverse incidents occur has the potential to improve the safety of healthcare provision. Staff working in the NHS have been contributing their experiences via a narrative data capture platform – SenseMaker – to help gain contextual insights on a wide range of topics under exploration by the NHS Horizons team. This blog by Rosanna Hunt (Senior Associate, NHS Horizons) in collaboration with Lizzy MacNamara (Junior Research Consultant, The Cynefin Co.) and Taj Nathan (Consultant Forensic Psychiatrist, Cheshire & the Wirral Partnership Foundation Trust) describes how the SenseMaker® platform could be used to extract staff experiences on the topic of patient safety incidents both reported and unreported by staff, and the facilitated conversations that would be needed to transform the data into actionable insights and commitment to change. -
Content ArticleOver time and across the world, the need to be transparent with patients and families when care has not gone well is now recognised as a key element of high-quality, safe and patient-centred healthcare. However, a significant gap still persists and some organisations have yet to welcome a transparent and accountable approach, while others fail to turn these principles into reliable actions. This editorial in BMJ Quality & Safety highlights the vulnerable position patient and families are in after error disclosure and looks at how data on processes around error disclosure are key to improvement. The authors call for healthcare organisations to redouble their engagement with patients and families who have been harmed by their healthcare and use the principles of accountability, compassion and transparency to drive their response.
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Content ArticleThe Pennsylvania Patient Safety Reporting System (PA-PSRS) is the largest database of patient safety event reports in the US. In addition to over 4.5 million acute care reports, the PA-PSRS database contains more than 396,000 long-term care healthcare-associated infection (HAI) reports. This study in Patient Safety aimed to look at trends in HAIs in long term care using data from the PA-PSRS database. The study found that there was an increase in the total number and rate of infections reported to PA-PSRS in 2022.
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News Article
Hundreds died on same day as being discharged, trust review finds
Patient Safety Learning posted a news article in News
An independent review has raised concerns about a mental health trust’s reporting systems and has highlighted a significant number of patient deaths shortly after leaving the trust’s care, including almost 300 who died on the same day they were discharged. However, the review into how Norfolk and Suffolk Foundation Trust collects, processes and reports mortality data made no conclusions on the number of avoidable deaths – the issue which had originally prompted the probe. Local NHS leaders argued the review’s purpose was focused on auditing the trust’s processes, and this had been delivered. But a local MP, Clive Lewis, accused it of “explicitly dodg[ing] the big questions”. The report, which looked at data from between April 2019 and October 2022, has however raised concerns about the number of patients dying soon after being discharged. Read full story (paywalled) Source: HSJ, 28 June 2023 -
Content ArticleThis report examines the reporting of patient deaths at the Norfolk and Suffolk Foundation NHS Trust (NSFT) between April 2019 and October 2022. It was undertaken by Grant Thornton on behalf of the NHS Suffolk and North East Essex and NHS Norfolk and Waveney integrated care boards at NSFT’s request.
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Content ArticleNHS England published the new Patient Safety Incident Response Framework (PSIRF) in August 2022 outlining how organisations providing NHS-funded care should respond to patient safety incidents to facilitate ongoing learning and improvement. From Autumn 2023, PSIRF will replace the current Serious Incident Framework. It will change the way all healthcare providers, which deliver NHS funded care, including independent healthcare organisations respond to patient safety incidents. Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how we’re supporting members to be ready.
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Content ArticleA hot briefing template for the purpose of sharing lessons learned across Scotland particularly for rare or unusual events.
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Content ArticleAre whistleblower reward programmes a charter for malicious complaints, as some claim, or are they a genuine incentive providing a safety net against retaliation? How successful are these programmes in recovering fraud and other proceeds of crime and serious organised crime? This paper aims to answer these questions—it was produced by WhistleblowersUK in collaboration with US lawyers who contributed to the development and improvement of US reward programmes. It aims to address questions about the legislation around US reward programmes, dispel some of the myths and look at some of the objections attributed to British attitudes about rewarding whistleblowers.
