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Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar to address a central patient safety topic. This virtual workshop session on the importance of human factors and systems safety focuses on re-designing work as opposed to re-designing the human who does the work. Incorporating a human factors and systems safety approach allows for the development and integration of knowledge, skills and attitudes that facilitate successful performance at the front lines of care. Healthcare leaders will learn how to apply human factors and systems safety concepts to understand true hazards in their organizations while fostering a culture of safety.
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Community Post
National Patient Safety Syllabus
Jon Holt posted a topic in Professionalising patient safety
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The Academy of Medical Royal Colleges have published the first National patient safety syllabus that will underpin the development of curricula for all NHS staff as part of the NHS Patient Safety Strategy: https://www.pslhub.org/learn/professionalising-patient-safety/training/staff-clinical/national-patient-safety-syllabus-open-for-comment-r1399/ Via the above link you can access a ‘key points’ document which provides some of the context for the syllabus and answers to some frequently asked questions. AOMRC are inviting key stakeholders to review this iteration of the syllabus (1.0) and provide feedback via completing the online survey or e-mailing Rose Jarvis before 28 February 2020. I would be interested to hear people's thoughts and feedback and any comments which people are happy to share which they've submitted via the online survey- Posted
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News Article
Stroke consultant shortage 'hurtling towards crisis'
Patient Safety Learning posted a news article in News
Almost half of hospitals have a shortage of specialist stroke consultants, new figures suggest. One charity fears "thousands of lives" will be put at risk unless action is taken, with others facing the threat of a lifelong disability. In 2016, Alison Brown had what is believed to have been at least one minor stroke, but non-specialist doctors at different hospitals repeatedly told her she did not have a serious health condition. One even described it as an ear infection. Ten months later, aged 34, she had a bilateral artery dissection - a common cause of stroke in young people, where a tear in a blood vessel causes a clot that impedes blood supply to the brain. She was admitted to hospital - but again struggled for a diagnosis. A junior doctor found an issue with blood flow to the brain but she says their comments were dismissed and she was told it was a migraine. It was only when she collapsed again, days later, and admitted herself to a hospital with a dedicated stroke ward that a specialist team was able to give her the care she needed. Alison's case highlights the importance of being seen by stroke specialists. However, according to new figures from King's College London's 2018-19 Snapp (Sentinel Stroke National Audit Programme) report, 48% of hospitals in England, Wales and Northern Ireland have had at least one stroke consultant vacancy for the past 12 months or more. This has risen from 40% in 2016 and 26% in 2014. The Stroke Association charity - which analysed the data - says the UK is "hurtling its way to a major stroke crisis" unless the issue is addressed. Read full story Source: BBC News, 17 January 2020 -
Content ArticleAt the second annual Patient Safety Learning conference, held on 2 October 2019, we interviewed Dr Matt Inada-Kim. Matt is Acute Medicine Consultant at the Royal Hampshire County Hospital, Clinical Lead for Sepsis/Deterioration for Wessex Patient Safety Collaborative and National Clinical Advisor on Sepsis and Deterioration. Matt spoke at our conference on the topic of 'Patient safety as a purpose'. In this interview he talks about his personal motivation to ensure a patient safe future, why we need to integrate safety across all of health and social care and the importance of patient safety training.
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Content ArticleThe National Institute for Health and Care Excellence (NICE) provides national guidance and advice to improve health and social care. NICE guidance, advice, quality standards and information services for health, public health and social care. Guidance also contains resources to help maximise use of evidence and guidance. This guideline (NG89) covers assessing and reducing the risk of venous thromboembolism (VTE or blood clots) and deep vein thrombosis (DVT) in people aged 16 and over in hospital. It aims to help healthcare professionals identify people most at risk and describes interventions that can be used to reduce the risk of VTE.
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Content Article
Matrons Handbook (January 2020)
Claire Cox posted an article in Workforce and resources
The matron's role has evolved since publication of the matron's 10 key responsibilities in 2003, and the matron's charter in 2004. Some aspects remain the same: providing compassionate, inclusive leadership and management to promote high standards of clinical care, patient safety and experience; prevention and control of infections; and monitoring cleaning of the environment. The role has also grown significantly, to include: workforce management, finance and budgeting, education and development, patient flow, performance management and digital technology and research. Using the handbook This handbook is a practical guide for those who aspire to be a matron, those who are already in post and for organisations that want to support this important role. It can be used to prepare ward, department and service leaders for the matron's role and to support newly appointed matrons. Individual matrons can use this handbook to support their practice, and as part of their professional development discussions with their employer. Directors of nursing can use this handbook to support matrons and the development of those who aspire to this role. Local context will be important and should be considered when using the handbook. -
Content ArticleThis chapter from Patient Safety and Quality: An Evidence-Based Handbook for Nurses describes a framework for understanding how human factors affect patient safety. It illustrates how different cumulative factors result in errors and suggests that nurses have a unique role to play in identifying problems and their causes. The authors highlight staff mindfulness as a tool to transform healthcare organisations into 'highly reliable organisations'.
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News Article
NHS hospitals to employ safety experts to tackle thousands of avoidable mistakes
Patient Safety Learning posted a news article in News
Hospitals will be required to employ patient safety specialists from next April as part of efforts by the health service to reduce thousands of avoidable errors every year. NHS trusts will be told to identify staff who will be designated as the safety specialist for each organisation. These workers, who will get specific training and work as part of a network across the country, will help to tackle a fragmentation in the way safety issues are dealt with in the NHS and ensure nationwide action on key safety risks is coordinated. The proposals are part of a national patient safety strategy which is aiming to save 928 lives and £98.5m across the NHS, as well as reducing negligence claims by £750m by 2025. The specialists will be identified from existing staff, with part of the role focused on embedding a so-called “just culture” approach to safety. This means reducing blame, supporting staff who make honest errors and tackling systemic causes of mistakes. Read full story Source: The Independent, 26 December 2019 What do you think? Join the conversation on the hub. -
Content ArticleThis study by Charles Vincent and colleagues, published in the Archives of Disease in Childhood, looked at the nature and causes of reported patient safety incidents relating to care in the community for children dependent on long-term ventilation with the further aim of improving safety. Common problems in the delivery of care included issues with faulty equipment and the availability of equipment, and concerns around staff competency. There was a clearly stated harm to the child in 89 incidents (40%). Contributory factors included staff shortages, out of hours care, and issues with packaging and instructions for equipment. This study has identified a range of problems relating to long-term ventilation in the community, some of which raise serious safety concerns. The provision of services to support children on long-term ventilation and their families needs to improve. Priorities include training of staff, maintenance and availability of equipment, support for families and coordination of care.
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Content ArticleThe South Thames Paediatric Network's aim is to enable children within the South Thames region (South London, Kent, Surrey and Sussex) to have access to high-quality specialist paediatric care in the place most suitable to their needs, at the appropriate time with a focus on surgery in children, critical care, long term ventilation and gastroenterology.
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Content ArticleDesigned for faculty, medical education curricula developers, residents, medical school administration, Designated Institutional Officials (DIOs), clinical leaders at teaching hospitals, and others interested in undergraduate, graduate and continuing medical education. There have been many advancements in medical education over the past 20 years, including how outcomes such as competencies are defined and used to guide teaching and learning. To support this positive change, the Association of American Medical Colleges (AAMC) has launched the New and Emerging Areas in Medicine series. This first report in the series focuses on quality improvement and patient safety competencies across the continuum of medical education. It presents a roadmap for curricular and professional development, performance assessment, and improvement of health care services and outcomes. The competencies can help educators design and deliver curricula and help learners develop professionally.
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Content ArticleThis is the fourth annual NHS workforce trends report published by the Health Foundation. In it, they analyse the changes in the size and composition of the NHS workforce in England in the context of long-term trends, policy priorities and future projected need.
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Content ArticleA whole-system approach to nasogastric tubes led by nurses is improving patient safety at Lancashire Teaching Hospitals NHS Foundation Trust. This initiative won the patient safety improvement category in the 2018 Nursing Times Awards.
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News Article
Nine in 10 NHS bosses say staffing crisis endangering patients
Patient Safety Learning posted a news article in News
Hospitals are so short of doctors and nurses that patients’ safety and quality of care are under threat, senior NHS leaders have warned in a dramatic intervention in the general election campaign Nine out of 10 hospital bosses in England fear understaffing across the service has become so severe that patients’ health could be damaged. In addition, almost six in 10 (58%) believe this winter will be the toughest yet for the service. The 131 chief executives, chairs and directors of NHS trusts in England expressed their serious concern about the deteriorating state of the service in a survey conducted by the NHS Confederation. The findings came days after the latest official figures showed that hospitals’ performance against key waiting times for A&E care, cancer treatment and planned operations had fallen to its worst ever level. However, many service chiefs told the confederation that delays will get even longer when the cold weather creates extra demand for care. “There is real concern among NHS leaders as winter approaches and this year looks particularly challenging,” said Niall Dickson, the chief executive of the confederation, which represents most NHS bodies, including hospital trusts, in England." “Health leaders are deeply concerned about its ability to cope with demand, despite frontline staff treating more patients than ever." Read full story Source: 19 November 2019 -
Content ArticleHealthcare systems are operating in an environment that is increasingly moving toward value-based payments that reward good health outcomes and patient experience. An impediment to success in this environment, however, is that both health care delivery systems and health information are extremely complicated. The level of complexity stymies many people and hinders them from making informed preventive care and self-management decisions. Health systems are finding that they cannot achieve improved patient outcomes or experiences without improving how health care professionals communicate with and support patients. Health systems have begun to respond to the mismatch between patients’ capabilities and the health literacy-related demands of the healthcare system. A new term has emerged – the health literate organisation – that describes organisations that aspire to make it easier for people to navigate, understand, and use information and services to take care of their health. Health literate organisations, in turn, need healthcare professionals who have health literacy knowledge and skills, such as being able to communicate effectively, break down health goals into manageable steps, and connect people with the resources they need to be successful Harris et al. explores health literate care in this Commentary for the National Academy of Medicine.
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Content Article
Letter from America: a Fall tradition to learn from
lzipperer posted an article in Letter from America
‘Letter from America’ is a Patient Safety Learning blog series highlighting fresh accomplishments in patient safety from the United States. The series will cover successes large and small. I share them here to generate conversations through the hub, over a coffee and in staff rooms to transfer these innovations to the frontline of UK care delivery. -
Content Article
Health Education England: Human Factors Toolkit
Patient Safety Learning posted an article in Techniques
Health Education England have produced a toolkit on human factors in healthcare looking at example of training, simulation and speaking up. -
Content Article
The harms of promoting ‘Zero Harm’
Claire Cox posted an article in Research papers
In their paper 'Managing risk in hazardous conditions: improvisation is not enough', Almaberti and Vincent ask "what strategies we might adopt to protect patients when healthcare systems and organisations are under stress and simply cannot provide the standard of care they aspire to". This is clearly a critical and much overdue question, as many healthcare organisations are in an almost constant state of stress from high workload, personnel shortages, high-complexity patients, new technologies, fragmented and conflicting payment systems, over-regulation, and many other issues. These stressors put mid-level managers and front-line staff in situations where they may compromise their standards and be unable to provide the highest quality care. Such circumstances can contribute to low morale and burn-out. Eric Thomas discusses this further in his Editorial published in BMJ Safety & Quality.- Posted
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Content Article
Is there a ‘best measure’ of patient safety?
Claire Cox posted an article in Research papers
Despite consensus that preventing patient safety events is important, measurement of safety events remains challenging. This is, in part, because they occur relatively infrequently and are not always preventable. There is also no consensus on the ‘best way‘ or the ‘best measure’ of patient safety. Borzecki and Rosen discuss what the 'best' measure for patient safety is in this Editorial published in BMJ Quality and Safety. -
Community Post
The patient safety leader of the future
Patient Safety Learning posted a topic in Leadership for patient safety
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One of the interesting discussions at our Patient Safety Learning Annual Conference was what do future directors of patient safety look like? What are the skills and attributes that they will possess? Andy Burrell wrote an excellent blog for the hub following this: What are you thoughts and suggestions? -
Content Article
Staff safety in the mental healthcare setting
Sarahjane Jones posted an article in Staff safety
I lead a team of multidisciplinary researchers who explore the power of routinely collected data for improving our understanding of patient safety. Our hope is that this insight will be translated into improvements in patient care. On this World Mental Health Day, there is an opportunity to reflect on the implications of harm to staff who deliver care to some of the most vulnerable patients in any healthcare system and what we might do to better protect them from harm. We recently published a study that focussed on staff safety in the mental healthcare setting and I'd like to discuss some of the findings in this blog. -
Content ArticleThe National Institute for Healthcare Research (NIHR) are the nation's largest funder of health and care research and provide the people, facilities and technology that enables research to thrive. Working in partnership with the NHS, universities, local government, other research funders, patients and the public, they deliver and enable world-class research that transforms people's lives, promotes economic growth and advances science.
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Content ArticleThe Multi-professional Patient Safety Curriculum Guide (2011) was developed by the World Health Organization to assist in the teaching of patient safety in universities and schools in the fields of dentistry, medicine, midwifery, nursing and pharmacy. It also supports the on-going training of all healthcare professionals.
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Content ArticleThis education and training guide is a resource for every Guardian’s self-development, whatever their experience in the role. Commissioned by the National Guardian’s Office and Health Education England in August 2017, the Guide was compiled by Louisa Hardman from the NHS Leadership Academy with invaluable contributions and guidance from an Advisory Group comprising Freedom to Speak Up Guardians and members of the National Guardian’s Office.
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Content ArticleIdentification of hospitalised patients with suddenly unfavorable clinical course remains challenging. Models using objective data elements from the electronic health record may miss important sources of information available to nurses.
