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Community Post
How nurses can spot and report error traps and near misses
HelenH posted a topic in Stories from the front line
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How can nurses spot error traps and near misses so that Trusts can learn, respond and take action to prevent unsafe care? What are the barriers to nurses using their insight and where is the good practice that we can share? Any ideas, anyone?- Posted
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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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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 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 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 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 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 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 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 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.
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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 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 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 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 ArticleA hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at the Royal Sussex County Hospital were "not consistently applied" and managers were not running services well, inspectors noted. The report also said morale was low and often staff "did not have time to report incidents". The trust said it has taken "urgent action" to make improvements. Read full story Source: BBC News, 10 December 2021
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News Article
Bereaved left in limbo by report delays, says mum
Patient Safety Learning posted a news article in News
The mother of a man who took his own life said bereaved families would be left "in limbo" by a mental health trust's serious incident report delays. Local health officials have raised concerns over the "timeliness" of Cambridgeshire and Peterborough NHS Foundation Trust's (CPFT) reports. Maria Nowshadi, whose son James died in 2020, said they should be done quickly "so there's answers for families". Ms Nowshadi said: "These investigations should happen in a timely, quick manner so there's answers for families, but also in case there's any learning to be had... to make sure there's no further deaths that happen in the same way, because of any errors within the system." She said when the original date the report was due to be completed passed, she "reached the stage where I was looking at the mailbox every day". She said she told a patient liaison officer: "This is actually starting to affect my mental health. The chief nurse at Cambridgeshire and Peterborough's Clinical Commissioning Group (CCG), Carol Anderson, said there were "concerns... [around] serious incident processes and reporting" at CPFT. A CCG spokeswoman added they had agreed an extension with CPFT "for the completion of serious incident reports due to additional pressures due to the pandemic and staff redeployment". "Our overall concern is the timeliness of serious incident reporting, so that we can ensure that learning is put in place as soon as possible," she added. Read full story Source: BBC News, 17 November 2021 -
News ArticleA ‘culture of distrust’ between consultants and the use of incident reporting as a tool of ‘reprisal’ impacted patient care at a trust’s cardiology department, a review has concluded. An external review undertaken for Hull University Teaching Hospitals Trust has made a series of recommendations after looking into allegations of bullying and several examples of poor care within its cardiology services. In a report published in the trust’s board papers, the Royal College of Physicians reported a “perceived tendency to downplay clinical incidents, and, to undermine those who wanted to raise patient safety issues”. It added: “We met a group of individual consultants who did not work well as a team. There is a culture of distrust, a lack of departmental cohesion and allegations of bullying in the department. All of which reinforce a clear divide between the interventional and non-interventional consultant cardiologists." “There have been a number of allegations of belittling, intimidation and undermining…The review team heard accounts of a culture where datix has been used as a tool for possible personal reprisal along with ignoring/downplaying incidents that have been raised.” The review concludes: “This behaviour is impacting on patient care and therefore, all medical staff should be reminded of good medical practice as the [General Medical Council] code of conduct of how doctors must work collaboratively with colleagues.” Read full story (paywalled) Source: HSJ, 16 November 2021
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News ArticleThe Care Quality Commission may in future be notified when ‘secretive’ external reviews have looked at patient safety issues within trusts. Last summer, HSJ revealed guidance for trusts to publish summaries of royal colleges’ reviews was being widely ignored, with some even failing to inform the CQC. A recent BBC Panorama programme has again raised the issue, with Academy of Medical Royal Colleges chair Helen Stokes-Lampard saying she was “dismayed” the body’s guidance was not being followed. But she has now told HSJ of “advanced discussions” with the CQC about changes which would see the royal colleges routinely inform the regulator when reviews raise patient safety issues. Read full story (paywalled) Source: HSJ, 3 June 2021
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News ArticleAn NHS trust has been urged to publish the full findings of an independent review of its services after it released a heavily redacted report. University Hospitals Sussex has refused to reveal the recommendations made after a review by the Royal College of Surgeons in 2019. A patients' group said the findings should be "in the public domain". The trust said the review of its neurosurgery department "did not highlight any safety concerns". The review was discovered as part of a BBC Panorama investigation into unpublished patient safety reports. A heavily edited report was released under freedom of information laws. It showed the trust asked the Royal College of Surgeons to look at "concerns raised in respect of clinical outcomes, allocation of sub-specialties and governance arrangements". All issues and recommendations were obscured, with only positive feedback disclosed. Read full story Source: BBC News, 20 May 2021
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News Article
Unpublished hospital patient safety reports exposed
Patient Safety Learning posted a news article in News
Serious patient safety issues are being buried in confidential hospital reports, BBC Panorama has found. Freedom of Information requests revealed 111 reports, written by medical royal colleges, which NHS trusts have a duty to share. Eighty reports were given to the BBC but only 26 had been shared in full with regulators, and 16 published. The Department of Health would not comment on whether it might change the law to ensure publication. Since the 2015 Morecambe Bay maternity scandal in which 11 babies and a mother died, NHS Trusts are supposed to publish summaries of external reviews, and share them with the regulator. An earlier review into the hospital had previously identified concerns but had not been made public. Dr Bill Kirkup, who led a 2015 investigation into the Morecambe Bay scandal, said Panorama's findings were a "great disappointment". "People should know that there is something that is important enough to be looked at and they should know what the results of that scrutiny are. I can't understand what the rationale would be for withholding the existence of a report or the findings of the report. These are important matters of accountability in the public service." Read full story Source: BBC News, 19 May 2021 -
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