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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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Content ArticleThis guidance from the General Medical Council sets out the how doctors should raise and act on concerns about patient care, dignity and safety.
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Content ArticleThis study in the International Journal of Radiation Oncology, Biology and Physics assesses the impact of the early Covid-19 pandemic on incident learning through evaluation of events reported to the Radiation Oncology Incident Learning System® (RO-ILS) in the USA. The authors conclude that reporting to RO-ILS declined during the early Covid-19 pandemic, especially in hotspot areas, suggesting that resources and time were diverted away from incident reporting to address other critical needs. However, three of the five top reporting practices that stopped reporting during early Covid have since reported events after the analysis timeframe, suggesting the decline may be temporary.
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Content ArticleThis systematic review in Nursing Open synthesises the best available evidence on the impact of nurses' safety attitudes on patient outcomes in acute care hospitals. The review included nine studies and found that nurses with positive safety attitudes reported: fewer patient falls and medication errors fewer pressure injuries and healthcare-associated infections fewer mortalities fewer physical restraints and vascular access device reactions higher patient satisfaction. The authors also found that effective teamwork led to a reduction in adverse patient outcomes. They conclude that a positive safety culture results in fewer reported adverse patient outcomes, and that nurse managers can improve nurses' safety attitudes by promoting a non-punitive response to error reporting and promoting effective teamwork and good communication.
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Content ArticleThis paper by Biophorum, a membership organisation for the biopharmaceutical industry, looks at how companies in the sector can adopt a human performance approach to operations. It highlights the need to move away from a focus on reducing human error and towards integrating fundamental systems changes that will enhance human performance.
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Content ArticleThis report provides an overview of the work of Healthcare Inspectorate Wales (the independent inspectorate and regulator of healthcare in Wales) during 2020-21. It discusses National Reviews undertaken in this period and trends emerging from its quality checks of health services. It also highlights areas of innovation, new methods of public and staff engagement and the delivery of care in new settings as a result of the COVID-19 pandemic.
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Content ArticleThis article, published in the BMJ Quality & Safety, discusses the value of incident reporting systems. Reporting systems, both local and national, are overwhelmed by the volume of reports they receive and fall short in defining recommendations for improving healthcare safety. Focusing incident reporting systems on the local learning process of healthcare providers could mitigate many of the problems that have been attributed to reporting systems.
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Content ArticleThis study, published in the International Journal for Quality in Health Care, examined the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. It highlighted the complexities involved and the difficulties faced by staff in learning from incident data.
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Content ArticleThis article, published by the BMJ, discusses mandatory and voluntary medical error reporting programmes and comments that voluntary reporting by practitioners is usually more useful.
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Content ArticleThis article in the Journal of Patient Safety & Quality Improvement examines the impact of the Covid-19 pandemic on patient safety reporting and procedures in 33 healthcare settings in Indonesia. The authors found that: patient safety data was recorded and reported less often during 2020, partly due to fewer hospital attendances. the pandemic has had a significant positive impact on hospital staff's compliance with handwashing policies. surgical procedures were less accurate during 2020, as surgical staff sought to reduce infection risk by missing safety procedures such as the surgical checklist.
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Content Article
SKYbrary: Safety occurrence reporting (2 October 2020)
Becky T posted an article in Implementation of improvements
This article, published on SKYbrary, discusses the importance of correct safety reporting in the aviation industry. Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies; the aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware. Although for the aviation industry, some of the principles can be applied to healthcare. -
Content ArticleAt the age of 15, Helen Haskell's son, Lewis, died due to treatable surgical complications. Following a routine elective surgery, he developed signs of sepsis, a life-threatening response to infection. Like most patients in postsurgical distress, Lewis deteriorated slowly. As he became weaker and weaker over the course of many hours, his bedside caregivers downplayed the significance of his mounting pain and unstable vital signs. Finally, his blood pressure became undetectable and he went into cardiac arrest, from which he could not be saved. His death, like thousands of others, was preventable. In this article, Helen discusses the erosion of patient safety reporting at the United States' CMS. Each year, CMS proposes changes to quality reporting programmes. Longstanding evidence-based patient safety measures, especially those used to detect harm to patients, are gradually being removed. These measures are largely extrapolated from hospital records and do not add to the workload of hospital staff. But they are embarrassing to hospitals, and hospital representatives lobby against them. The trend of downgrading patient safety is concerning.
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Content ArticleNumerous studies show a link between a positive safety culture (where safety is a shared priority) and improved patient safety within a healthcare organisation. The evidence is so convincing that the US National Patient Safety Foundation (NPSF) lists leadership support for a safety culture as the most important of eight recommendations for achieving patient safety. This overview from the Emergency Care Research Institute (ECRI) provides guidance and recommendations on how to embed approaches to safety culture within healthcare organisations.
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Content ArticlePennsylvania is the only state that requires healthcare facilities to report all events that cause harm or have the potential to cause harm to a patient. These patient safety events are reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS), which is the largest repository of patient safety data in the United States and one of the largest in the world, with over 3.9 million acute care records. This article, published in Patient Safety, shows details of the PA-PSRS acute care data along with longitudinal and categorical insights that can be used to improve patient safety.
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Content ArticleA new national NHS Learn from patient safety events service (previously called the patient safety incident management system – PSIMS – during development) is in the final stages of development as a central service for the recording and analysis of patient safety events that occur in healthcare. NHS England has now commenced the public beta stage, where some organisations can begin using the system, instead of the NRLS. LFPSE is replacing the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS), to offer better support for staff from all health and care sectors.
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Content ArticlePeople increasingly provide feedback about healthcare services online. These practices have been lauded for enhancing patient power, choice and control, encouraging greater transparency and accountability, and contributing to healthcare service improvement. Online feedback has also been critiqued for being unrepresentative, spreading inaccurate information, undermining care relations, and jeopardising professional autonomy. Through a thematic analysis of 37 qualitative interviews, this paper explores the relationship between online feedback and care improvement as articulated by healthcare service users (patients and family members) who provided feedback across different online platforms and social media in the UK.
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Content ArticleThe Defective Medicines Report Centre (DMRC) is part of the Medicines and Healthcare products Regulatory Agency (MHRA). The role of the DMRC is to minimise the hazard to patients arising from the distribution of defective medicines by providing an emergency assessment and communication system between manufacturers, distributors, wholesalers, pharmacies, regulatory authorities and users. This guide is for patients, healthcare professionals, manufacturers and distributors for reporting, investigating and recalling suspected Defective Medicinal Products.
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Content ArticleDiagnostic error occurs more frequently in the emergency department than in regular in-patient hospital care. This study in BMC Emergency Medicine sought to characterise the nature of reported diagnostic error in hospital emergency departments in England and Wales from 2013 to 2015. The authors identified the priority areas for intervention to reduce the occurrence of diagnostic error. The study found that system modifications are needed to support clinicians in assessing patients and interpreting investigations. Interventions to reduce diagnostic error need to be evaluated in the emergency department setting, and could include standardised checklists, structured reporting and technological investigation improvements.
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Content ArticleIn this article, Andrew Ottaway discusses the five primary components (Just Culture, Reporting Culture, Flexible Culture, Learning Culture and Challenging Culture) that forms a safety-conscious, informed and engaged organisation that is able and willing to deliver an effective Safety Management System.
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Content ArticleThis document describes and sets out the NHS Delivery Framework 2018-2019, Reporting Guidance, NHS Delivery Measures, Summary of Revisions to Measures, Reporting Templates and Measures from 2017-18 that have not been carried forward into the 2018-19 NHS Delivery Framework.
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Content ArticleThis report sets out the findings from the Healthcare Inspectorate Wales (HIW) COVID-19 themed national review. The purpose of the review is to understand how healthcare services across Wales met the needs of people and maintained their safety during the pandemic. It considers how services supported the physical and mental well-being of staff, reviewing all HIW assurance activity since March 2020. HIW is the independent inspectorate and regulator of healthcare in Wales.
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Content ArticleThese professional standards describe good practice and good systems of care for reporting, learning, sharing, taking action and review as part of a patient safety culture. The accompanying guidance and information support the implementation of the standards. These professional standards are for pharmacists, pharmacy technicians and the wider pharmacy team across the United Kingdom. This may also be of interest to the public, to people who use pharmacy and healthcare services, healthcare professionals working with pharmacy teams, regulators and commissioners of pharmacy services.
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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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Content ArticleImproving the design of technology relies in part, on the reporting of performance failures in existing devices. Healthcare has low levels of formal reporting of performance and failure of medical equipment. This paper from Tase et al. examines methods of reporting in the car industry and healthcare and aims to understand differences and identify opportunities for improvement within healthcare.
