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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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Content Article
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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 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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Content Article
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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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News Article
CQC suspends routine inspections amid covid-19 outbreak
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has suspended its routine inspections due to the coronavirus outbreak following pressure from system leaders and NHS bosses. The decision to suspend inspections where there are no immediate safety concerns is understood to have been taken by the CQC’s executive team this morning, senior sources told HSJ. Both the NHS Confederation and The Royal College of GPs said the decision had been made. NHS Confederation called the move a “sigh of relief” for front-line staff, while the RCGPs said it would enable GPs to dedicate their time to providing care. NHS Confederation chief executive Niall Dickson said: “Front-line staff will breathe a sigh of relief that CQC has responded to our concerns and will now postpone its inspections where there is no immediate safety concern so that they can gear themselves up to prepare for the huge task ahead in dealing with the coronavirus pandemic.” Read full story Source: HSJ, 16 March 2020 -
Content ArticleThe Community Pharmacy Patient Safety Group conducted this anonymous survey on patient safety culture in Autumn 2021 and invited pharmacy staff from across the UK to participate. The aim of the survey was to understand patient safety practice from the perspective of frontline pharmacy teams. Both the full results and an infographic of key results are available to download.
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Content ArticleHuge numbers of patients suffer avoidable harm in US hospitals each year as a result of unsafe care. In this blog, published in the Harvard Business Review, the authors argue that these numbers could be greatly reduced by taking four actions: Make patient safety a top priority in hospitals’ practices and cultures, establish a National Patient Safety Board, create a national patient and staff reporting mechanism, and turn on EHRs machine learning systems that can alert staff to risky conditions.
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Content ArticleIn this blog for The Health Foundation, the authors make five recommendations for strengthening NHS management and leadership: Support providers and systems to tackle variation in management practice Improve access to training and development opportunities Ensure training equips managers and leaders with the skills they need today Tackle the reporting burden and 'priority thickets' facing managers Ensure the role of managers and leaders is better understood and valued
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Content ArticleThis webpage provides an overview of how human factors affect outcomes in surgical emergencies. It includes: An introduction to human factors Video exploring the case of Elaine Bromiley Explanation of human error and the Swiss Cheese Model Table of factors that reduce human error 'What if?' video showing how simple changes could have resulted in a different outcome in Elaine Bromiley's case Practical tips for managing the paediatric airway in a critically ill child
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Content Article
Safe to speak up? NHS Staff Survey Results 2021
Patient Safety Learning posted an article in Culture
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In this blog, Patient Safety Learning analyses the results of the NHS Staff Survey 2021, specifically focusing on responses relating to reporting, speaking up and acting on safety concerns. It reflects on the importance of staff feeling able to speak up about patient safety incidents and the implications when this is not the case. It describes the NHS’s current approach to creating a patient safety culture and emphasises the need for NHS England and NHS Improvement, in partnership with the National Guardian and Care Quality Commission, to bring forward robust and specific commitments to drive this work forward. -
Content ArticleRaDonda Leanne Vaught faced criminal charges over a fatal medication error she made in 2017. Her trial has raised important questions over medical errors, reporting and process improvement, as well as who bears responsibility for widespread use of tech overrides in hospitals. There is debate over whether automated dispensing cabinet overrides are a reckless act or institutionalised as ordinary given the widespread use of IT workarounds among healthcare professionals. The Nashville District Attorney's Office described this override as a reckless act and a foundation for Ms. Vaught's reckless homicide charge, while some experts have said cabinet overrides are used daily at many hospitals.
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Content Article
Learning from Coroner's reports
Patient Safety Learning posted an article in Coroner reports
When a patient dies because of preventable avoidable harm it is crucial that we learn from the event and implement changes to ensure it does not reoccur. Implementing the findings and recommendations of Coroner’s Prevention of Future Deaths (PFD) reports can play a key role in this. This blog reflects on a recent discussion at a Patient Safety Management Network (PSMN) meeting about PFD reports and how their insights can be used for learning and improvement. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. You can find out about the network here.- Posted
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Content ArticleThis independent external quality assurance review looks at the independent investigation into the care and treatment of mental health service user Mr M at Greater Manchester Mental Health NHS Foundation Trust.
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Content ArticleIncident reporting is an important aspect of clinical care. It highlights safety issues that need addressing and supports clinicians in learning how to keep our patients safe from avoidable harm. Sian Rodger, patient education and health coaching lead at London Spinal Cord Injury Centre shares with the Nursing Times how nurses are learning from incident reporting at her trust.
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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 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 webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust
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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 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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