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Content Article
Why didn’t you report it? A blog by Emma Walker
Patient Safety Learning posted an article in Good practice
A minor accident makes Emma Walker reflect on the safety culture of the NHS. -
Content ArticleThis is the 15th annual clinical radiology census report by The Royal College of Radiologists. The census received a 100% response rate, meaning this report presents a comprehensive picture of the clinical radiology workforce in the UK as it stood in October 2022. Key findings The workforce is not keeping pace with demand for services. In 2022, the clinical radiology workforce grew by just 3%. In comparison, demand for diagnostic activity is rising by over 5% annually, and by around 4% for interventional radiology services. The UK now has a 29% shortfall of clinical radiologists, which will rise to 40% in five years without action. By 2027, an additional 3,365 clinical radiologists will be needed to keep up with demand for services. This will have an inevitable impact on the quality-of-care consultants are able to provide. Only 24% of clinical directors believe they had sufficient radiologists to deliver safe and effective patient care. Interventional radiologists are still limited with the care they can provide. Nearly half (48%) of trusts and health boards have inadequate IR services, and only 1/3 (34%) of clinical directors felt they had enough interventional radiologists to deliver safe and effective patient care. Stress and burnout are increasingly common among healthcare professionals, risking an exodus of experienced staff. 100% of clinical directors (CDs) are concerned about staff morale and burnout in their department. 76% of consultants (WTE) who left in 2022 were under 60. We are seeing increasing trends that the workforce is simply not able to manage the increase in demand for services. 99% of departments were unable to manage their reporting demand without incurring additional costs. Across the UK, health systems spent £223 million on managing excess reporting demand in 2022, equivalent to 2,309 full-time consultant positions.
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Content ArticleTim Fetherston provides background on the rates of critical incidences in hospitals and sets out the case for better reporting. He includes advice and examples for setting up reporting effective systems.
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Content ArticleThis study in PLOS ONE assessed the frequency of adverse event reporting in Ghanaian hospitals, the patient safety culture determinants of the adverse event reporting and the implications for Ghanaian healthcare facilities. The authors found that the majority of health professionals had at least reported adverse events in the past 12 months across all 13 healthcare facilities studied. The patient safety culture dimensions were statistically significant in distinguishing between participants who frequently reported adverse events and otherwise.
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Content ArticleThe NHS Staff Survey is an essential tool for assessing the experiences and opinions of NHS workers in Trusts in England. It also provides valuable insights to help understand the speaking up culture in the NHS. In this report the National Guardian’s Office analyse the results of the 2022 NHS Staff Survey, focusing on questions relating to speaking up.
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Content ArticlePharmacovigilance is the observation and monitoring of possible harms from exposure to a variety of pharmaceuticals, biologics and devices. In this blog, Professor of Evidence-based Medicine Carl Heneghan and Clinical Epidemiologist Tom Jefferson talk about a recent attempt to obtain data on the incidence of deaths following Covid-19 vaccination from the Medicines & Healthcare Products Regulatory Agency (MHRA) through a Freedom of Information request. They describe how the MHRA initially said they were unable to provide the information as it would cost too much to extract, and after sending a follow up request to the MHRA's Chief Safety Officer, they have not heard anything further after an initial promise to investigate. They argue that the MHRA is failing the public by failing to investigate the side effects of Covid vaccines using information from Yellow Card reports. This blog is paywalled once you have read a certain number of articles each month.
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Content ArticleThis study in the Journal of Patient Safety outlines the development of the Leapfrog composite patient safety score. The researchers aimed to develop a composite patient safety score that provides patients, healthcare providers and healthcare purchasers with a standardised method to evaluate patient safety in general acute care hospitals in the United States. The study concluded that the composite score reflects the best available evidence regarding a hospital’s efforts and outcomes in patient safety.
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Content ArticleThis study in the Journal of Patient Safety and Risk Management aimed to assess the patient safety situation in Ghana across the World Health Organization's (WHO’s) 12 action areas of patient safety. The authors used interviews and observation including a WHO adapted questionnaire across 16 selected hospitals, including two teaching hospitals selected from the northern and southern parts of the Ghana. The key strength identified in the patient safety situational analysis was knowledge and learning in patient safety, while patient safety surveillance was the weakest action area identified. There were also weaknesses in areas such as national patient policy, healthcare associated infections, surgical safety, patient safety partnerships and patient safety funding.
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Content ArticleThis mixed-methods study in the Journal of Multidisciplinary Healthcare examined how health staff in Indonesian hospitals perceived open disclosure of patient safety incidents (PSIs). The authors surveyed 262 health workers and interviewed 12 health workers. In the quantitative phase they found a good level of open disclosure practice, a positive attitude toward open disclosure and good disclosure according to the level of harm. However, in the qualitative phase they found that most participants were confused about the difference between incident reporting and incident disclosure. The authors concluded that a robust open disclosure system in hospitals could address several issues such as lack of knowledge, lack of policy support, lack of training and lack of policy. They also suggest that the government should develop supportive policies at the national level and organise initiatives at the hospital level in order to limit the negative implications of disclosing situations.
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Content ArticleThis article in USA Today looks at how the Covid-19 pandemic has caused setbacks in hospitals' patient safety progress. It looks at data from a report by the US non-profit health care watchdog organisation, Leapfrog, which show increases in hospital-acquired infections, including urinary tract and drug-resistant staph infections, as well as infections in central lines. These infections spiked during the pandemic and remain at a five-year high. The article also looks at the case study of St Bernard Hospital in Chicago, which was rated poorly by Leapfrog on handwashing, medication safety, falls prevention and infection prevention, but then made huge progress in improving safety. It describes the different approaches and interventions taken by St Bernard.
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News ArticleFresh concerns have been raised about the launch of the national incident reporting system, despite Steve Barclay taking a ‘personal interest’ in hitting the tight timetable, HSJ has learned. NHS England already delayed the launch of the “learning from patient safety events” database by six months, to September this year. It is due to replace the existing national reporting and learning system (NRLS) which is considered to be outdated and at risk of failing. But serious concerns are now being raised again by trust safety managers about whether the revised launch date can be met, HSJ has been told, with calls for it to be extended again until next year. HSJ has heard concerns from several managers that an upgrade due in July to the RLDatix risk management system – which is used by the majority of trusts – will cause knock-on problems implementing LFPSE in September. They said the timeframe was too short for testing and delivering the upgrade in time to make the transition and decommission the old NRLS. The creation of LFPSE is a key part of NHSE’s safety strategy, along with replacing the serious incident reporting system, with an aim of making it easier for staff to record safety events across all services, including primary care, which is excluded from NRLS. Read full story (paywalled) Source: HSJ, 3 May 2023
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Content ArticleThis webpage from NHS Scotland provides a proforma for writing up Enhanced Significant (learning) Event Analyses and app, booklet, cards and deskpad tools to help analyse significant events.
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Content ArticleThe ‘No Blame Culture’ being adopted by the NHS draws attention from individuals and towards systems in the process of understanding an error. This article in the Journal of Applied Philosophy argues for a ‘responsibility culture’, where healthcare professionals are held responsible in cases of foreseeable and avoidable errors. The authors argue that proponents of No Blame Culture often fail to distinguish between blaming someone and holding them responsible, They examine the idea of ‘responsibility without blame’, applying this to cases of error in healthcare. Sensitive to the undesirable effects of blaming healthcare professionals and to the moral significance of holding individuals accountable, the authors argue that a responsibility culture has significant advantages over a No Blame Culture as it can enhance patient safety and support medical professionals in learning from their mistakes, while also recognising and validating the legitimate sense of responsibility that many medical professionals feel following avoidable error, and motivating medical professionals to report errors.
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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. Jonathan talks to us about the importance of leadership in creating a safety culture and the role of Patient Safety Learning in fostering collaboration and establishing standards for patient safety. -
Content Article
In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS. -
Content ArticleThe Operating Room Black Box, a system of sensors and software, is being used in operating rooms in 24 hospitals in the US, Canada and Western Europe. The device captures video, audio, patient vital signs and data from surgical devices in an effort to improve patient safety. This article in the Wall Street Journal looks at how Black Box technology at Duke University Hospital has identified several areas for improvement, including that the hospital needed a better system for sending and tracking specimens. The article also highlights some concerns raised by healthcare professionals about the use of Black Boxes, including fear that data collected might be used to punish staff, or that it may be used as evidence in medicolegal cases outside of hospitals' control.
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Content ArticlePennsylvania hospitals are required to report patient safety events, but do you know why it’s so important? Event reports can be the first indication of underlying problems, regardless of whether harm occurs. They also can be tools to trigger change facility wide, or even nationwide. This resource from the Patient Safety Authority allows you to click one of the categories or type keywords into the search field to find stories of event reports that inspired staff to make changes that improved patient care and safety throughout their hospital.
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Content ArticleThis report is aimed at people who are working with those who have a learning disability, in the role of commissioners or providers of services. It was produced on behalf of the Hampshire Safeguarding Adults Board by a multi-agency group and seeks to understand why people with a learning disability are at greater risk of choking, looking at what can be done locally in Hampshire to improve outcomes for people who are at risk of choking, in any care setting. The report makes a number of recommendations based on common sense and good practice.
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Content ArticleThis guide by the National Patient Safety Agency offers guidance for junior doctors on what to do if they are involved in a patient safety incident. It includes case studies on: medication error competence communication patient identification reporting It also includes guidance on how to deal with a complaint.
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Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.- Posted
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Content ArticleThe Patient Safety Authority has developed a series of decision trees to determine whether a patient safety event is a serious event or incident in a range of different situations.
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Content ArticleIncomplete or inaccurate recording of ethnicity will undermine attempts to address health inequalities and improve access, experience and outcomes for Black, Asian and minority ethnic communities. This report by the Race Equality Foundation and the Office for National Statistics (ONS) looks at different aspects of the recording of ethnicity in healthcare. The authors interviewed people from a range of communities across England, as well as healthcare workers from different areas and settings to understand both sides of the process of collecting ethnicity data.
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Content ArticleIn this podcast to support providers with the transition to the Learn from Patient Safety Events (LFPSE) service, the NHS's new national system for the recording and analysis of patient safety events, NHS England talks to Zahra and Mandy, NHS England reporting leads, about the practical steps providers can take to get connected to LFPSE. It covers how to get started, what to do with your old data, the kinds of support available, what transition means for ICBs, and what the Reporting Leads have learned from the process so far.
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Content ArticleThis study, published in The New England Journal of Medicine, looks at the frequency, preventability and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during 2018. From this sample, it identified adverse events in nearly one in four admissions, approximately a quarter of which were deemed as preventable.
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Content ArticleIn September 2022, The Care Quality Commission published four reports into the care provided by Spectrum a provider of Autism services in Cornwall. All four inspections concluded that the services were inadequate.
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