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Content ArticleThe publication of a new single, shared improvement approach, ‘NHS Impact’, is an exciting milestone. It reflects recognition, at the highest level in the English NHS, that improvement principles need to be part of the mainstream approach to the challenges facing the sector. Penny Pereira, Q’s Managing Director, considers the new approach, its potential impact and what it means for members and others working to improve health and care in England and beyond.
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Content ArticleThis study, published by Health Expectations, aimed to understand what people were doing during the first wave of the pandemic to protect the safety of their health, and the health of others from COVID‐19, and the resilience of the healthcare system.
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NHS Impact resources
Patient Safety Learning posted an article in NHS England
NHS Impact ‘improving patient care together’ is the term NHS England is using for the new single, shared NHS improvement approach. This includes the five components which form the ‘DNA’ of all evidence-based improvement methods, which underpin a systematic approach to continuous improvement: Building a shared purpose and vision. Investing in people and culture. Developing leadership behaviours. Building improvement capability and capacity. Embedding improvement into management systems and processes. When these 5 components are consistently used, systems and organisations create the right conditions for continuous improvement and high performance, responding to today’s challenges, and delivering better care for patients and better outcomes for communities. -
Content ArticleThis blog on the Sling the Mesh website provides an overview of research by Professor Carl Heneghan, Director of the Centre for Evidence-Based Medicine at Oxford University, into regulatory issues relating to pelvic mesh. It outlines issues uncovered by Professor Heneghan and his colleagues, including the fact that clinical trial data was not required in the regulation of mesh and that early evidence of complications was ignored in the approval of subsequent devices.
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Content ArticleIn this article, Professor Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), outlines an NES research project which aimed to critically review the safety-related content, language and assumptions of a small but diverse range of health and care safety learning reports, policies, databases and curricula.
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Content ArticleEarlier this month, 13 leaders shared thoughts in NEJM Catalyst on how healthcare organisations can get more strategic around patient safety and quality improvement - an area that has seen renewed attention after COVID-19-related setbacks. Several themes emerged across leaders' responses, namely the need for more proactive approaches to mitigate risk and intervene, rather than reviewing and assessing harms after they occur. University Hospitals nurses are leading the charge to do just that by embracing the adoption of artificial intelligence to make daily safety huddles more actionable. Read the full article, published by Becker's Hospital Review via the link below.
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Content ArticleEach year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs.
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At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; providing a space for people to come together and share their experiences, resources and good practice examples. This week is World Immunisation Week so our Content and Engagement Manager, Lotty, has picked five resources full of practical advice about vaccination in a range of settings. -
Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
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Content ArticleThis long read by the Nuffield Trust looks at priority areas where further development and action could help improve the effectiveness of virtual wards. It outlines different models for virtual wards and looks at how to ensure effective system oversight. It also highlights the need to ensure the workforce is equipped to run virtual wards effectively and safely.
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Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety. -
Content ArticleIn this blog, Sonia Barnfield, Clinical Adviser for Maternity Investigations at the Healthcare Safety Investigation Branch (HSIB), looks at risk assessments during the maternity care pathway, following HSIB's recent national learning report on the same subject. Sonia outlines the need for change in the way that risk during pregnancy is assessed and managed, highlighting that there is currently no single national guidance and that HSIB identified repeated examples of insufficiently robust, continuous risk assessment in the maternity pathway. She lays out six key themes highlighted in HSIB's report and looks at how risk assessments should change to improve safety for pregnant women and their babies.
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Content ArticleMany people see their GP with symptoms that could either get better without treatment, or be a sign of serious illness; their diagnosis is uncertain. This article from the National Institute of Health and Care Research (NIHR) summarises recent research looking at how GPs and patients can work together to develop follow-up plans (a process known as safety-netting). The study highlights the importance of patients understanding: why they are receiving this advice what actions are required, and by whom.
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Content ArticleThis document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
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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 ArticleDuring periods of extreme pressure, often exacerbated by a surge in respiratory conditions, demand on supplies of oxygen cylinders, especially the smaller sizes, increases in the NHS due to the need to provide essential oxygen treatment in areas without access to medical gas pipeline systems. This surge in demand increases the known risks associated with the use of oxygen gas cylinders, and introduces new risks, across three main areas: patient safety fire safety physical safety A search of incidents reported to the of the National Reporting and Learning System (NRLS) and Learn from Patient Safety Events (LFPSE) service in the last 12 months identified 120 patient safety incidents, including those with these themes: cylinder empty at point of use cylinder not switched on cylinders inappropriately transported cylinders inappropriately secured Some of these reports described compromised oxygen delivery to the patient, leading to serious deterioration and cardiac or respiratory arrest. In addition there is a need to conserve oxygen cylinder use to ensure a robust supply chain process. As a result of current pressures on the NHS, NHS England issued providers with a summary of best practice guidance on the ‘Safe use of oxygen cylinders’ on Friday 06 January 2023 to support providers to optimise and maintain the safe use of oxygen cylinders. This guidance was issued via the Patient Safety Specialist and Emergency Preparedness, Resilience and Response (EPRR) networks. Actions To be completed as soon as possible, and not later than 20 January 2023. 1. The chair of acute trust medical gas committee, working with key clinical/non-clinical colleagues including the local ambulance trust, should review the NHS England ‘Safe use of oxygen cylinders’ best practice guidance and ensure a risk assessment is undertaken in all areas where patients are being acutely cared for (either temporarily or permanently) without routine access to medical gas pipeline systems. Risk assessment should pay particular attention to: avoiding unnecessary use of cylinder oxygen and excessive flow rates by ensuring oxygen treatment is optimised to recommended target saturation ranges. ensuring safe use of oxygen cylinders by clinical staff including; - safe activation of oxygen flow - initial and ongoing checks of flow to patient - initial and ongoing checks of amount of oxygen left in the cylinder - especially during transfer or whilst undergoing diagnostic tests. fire safety, including: - appropriate ventilation (both in physical environments and in ambulances), safe storage of cylinders physical safety, including: - awareness of manual handling requirements - safe transportation of cylinders using appropriate equipment - safe storage of cylinders. 2. Once the risk assessments have been undertaken, convene the acute trust medical gas committee as soon as possible to review the findings of the risk assessments and formalise an action plan. Ensuring that the committee has executive director representation and ambulance trust input.
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Content ArticleUp to 30% of healthcare spending is considered unnecessary and represents systematic waste. While much attention has been given to low-value clinical tests and treatments, much less has focused on identifying low-value safety practices in healthcare settings. This study in the Journal of Patient Safety surveyed healthcare staff in the UK and Australia to identify safety practices perceived to be of low value. Staff who took part in a survey as part of the study frequently identified the following categories of practices as being low-value: paperwork, duplication and intentional rounding. Five cross-cutting themes (for example, 'covering ourselves') offered an underpinning rationale for why staff perceived these practices to be of low value. The authors conclude that in healthcare systems under strain, removing existing low-value practices should be a priority.
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Content ArticleDisruptive behaviours have been shown to have a significant negative impact on staff collaboration and clinical outcomes of patient care. Disruptive episodes are more likely to occur in high stress areas such as the Emergency Department (ED). Having the structure, process, and skills in place to effectively address this issue will lower the likelihood of preventable adverse events. This study assessed the status of disruptive behaviours and staff relationships in the ED setting. It concluded that disruptive behaviours in the ED have a significant impact on team dynamics, communication efficiency, information flow, and task accountability, all of which can adversely impact patient care. EDs need to recognise the significance of disruptive behaviours and implement appropriate policies and protocols to address this issue.
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IHI: Quality Improvement essentials toolkit
Patient-Safety-Learning posted an article in Quality Improvement
This toolkit from the Institute for Healthcare Improvement (IHI) includes the tools and templates you need to launch a successful Quality Improvement (QI) project and manage performance improvement. The QI tools include: Cause and effect diagram: Also known as the Ishikawa or fishbone diagram, this tool helps you analyse the root causes contributing to an outcome. Failure modes and effects analysis: Also used in Lean management and Six Sigma, FMEA is a systematic, proactive method for identifying potential risks and their impact. Run charts: These charts help you monitor performance over time. PDSA worksheet: Plan-Do-Study-Act rapid-cycle testing helps teams assess whether a change leads to improvement using a methodical learning process. You will need to create an IHI account in order to download the toolkit. You can then download the complete toolkit with all ten tools, or download individual tools as you need them to guide your continuous improvement work. -
Content ArticleThis study in Health Expectations aimed to identify barriers and facilitators to implementing a parent escalation of care process: Calling for Help (C4H). Guided by the Theoretical Domains Framework, the authors carried out audits, semi-structured interviews and focus groups in an Australian paediatric hospital where a parent escalation of care process was introduced in the previous six months. The authors found that although there was a low level of awareness about C4H in practice, there was in-principle support for the concept. Initial strategies had primarily targeted policy change without taking into account the need for practice and organisational behaviour changes.
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Content ArticleThis paper in the Journal of Patient Safety and Risk Management addresses the issue of untested products being used on the basis of 'equivalent' products having undergone regulatory testing. Manufacturers of competing products often use each other’s evidence, arguing that the published evidence is generally applicable even if the original tests and trials were performed on only one specific product. In this study, the authors looked at prophylactic dressings for pressure injury prevention to demonstrate how patient safety may be compromised if study conclusions are projected onto unstudied products.
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Content ArticleThis document outlines the Escalation Policy for Leicester Children’s Emergency Department. It identifies five particular factors that lead to difficulty within the department. Acknowledging that these issues can be closely interlinked and may not occur in isolation, it provides practical way to deal with these factors to try and prevent secondary events. Staffing Overcrowding Inflow Outflow Acuity
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On his last day in office at the Healthcare Safety Investigation Branch (HSIB), outgoing Chief Investigator Keith Conradi wrote to the Secretary of State for Health and Social Care reflecting on his time at HSIB. He outlined concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB and the need to introduce a safety management system approach at all levels of healthcare. Patient Safety Learning also shared our thoughts on the issues raised in this letter and we were keen to explore these issues, and Keith’s experience as HSIB’s first Chief Investigator, in greater depth. Here, Patient Safety Learning provides an overview of the recent interview we had with Keith Conradi on this subject. The full transcript of the interview is available to download in the attachment at the end. -
Content ArticleBariatrics is the branch of medicine that deals with the causes, prevention and treatment of obesity and its associated diseases. This pathway written by East Kent Hospitals University Foundation NHS Trust (EKHUFT) provides guidance for multidisciplinary teams to allow them to provide appropriate care for each bariatric patient according to their unique shape, size and body dynamics.
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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. Tony talks to us about making patient safety everyone’s responsibility, the importance of open communication and how his understanding of different global health systems has broadened his perspective on what matters in patient care.
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