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Content Article
Community Pharmacy Standard (PRSB, May 2023)
Patient-Safety-Learning posted an article in Community pharmacies
Community pharmacies are offering an increased range of services to support care for people in the community. It is therefore essential that they are able to record and share vital information about a person’s care with GP practices and other services. Using digital standards, we can ensure that care professionals and citizens have timely access to relevant information, leading to better, safer and more personalised care in the community. This Community Pharmacy Standard developed by the Professional Record Standards Body (PRSB) defines the information that should be recorded in the community pharmacy and sent to the person’s GP, for all the services covered by the English Community Pharmacy Contractual Framework. -
EventuntilThe aim of this webinar is to share, engage and discuss with clinicians, patient safety managers, patients and leaders the latest standards. There will be 2 sessions: 17.30: Session 1 – NatSSIPs 2: what it is and why it matters Welcome and introduction The CPOC perspective The Patient Safety Learning perspective Photo review of why NatSIPPs matters The patient perspective What is new in NatSIPPs 2? Resources to support Implementation: Checklists, infographics Q&A 18.30: Session 2 – NatSSIPs 2: implementation, practical insights and tips Our NatSIPPs 2 Workshop and how to consider a NatSSIPs gap analysis Team training for NatSIPPs 2 Q&A Register
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EventThis virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. Knowing things may have gone wrong can feel a heavy burden and a complex emotional situation to be managing. Often, we avoid visiting difficult emotions in others, as well as ourselves, because we don’t feel confident or skilled, or we feel fearful of not doing it perfectly. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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News ArticlePeople concerned about the safety of patients often compare health care to aviation. Why, they ask, can’t hospitals learn from medical errors the way airlines learn from plane crashes? That’s the rationale behind calls to create a 'National Patient Safety Board,' an independent federal agency that would be loosely modelled after the US National Transportation Safety Board (NTSB), which is credited with increasing the safety of skies, railways, and highways by investigating why accidents occur and recommending steps to avoid future mishaps. But as worker shortages strain the US healthcare system, heightening concerns about unsafe care, one proposal to create such a board has some patient safety advocates fearing that it wouldn’t provide the transparency and accountability they believe is necessary to drive improvement. One major reason: the power of the hospital industry. The board would need permission from health care organisations to probe safety events and could not identify any healthcare provider or setting in its reports. That differs from the NTSB, which can subpoena both witnesses and evidence, and publish detailed accident reports that list locations and companies. A related measure under review by a presidential advisory council would create such a board by executive order. Its details have not been made public. Learning about safety concerns at specific facilities remains difficult. While transportation crashes are public spectacles that make news, creating demand for public accountability, medical errors often remain confidential, sometimes even ordered into silence by court settlements. Meaningful and timely information for consumers can be challenging to find. However, patient advocates said, unsafe providers should not be shielded from reputational consequences. Read full story Source: CNN, 30 May 2023 Related reading on the hub: Blog - It is time for a National Patient Safety Board: Pittsburgh Regional Health Initiative
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Content Article
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. Maureen discusses the important role of professional standards in building a patient safety infrastructure, the need to reframe safety as a positive idea and her experience of implementing learning processes during her time as a GP. -
Content ArticleStandardised data and integration of systems are vital for full traceability, improving patient safety, and enabling swift action in healthcare incidents. The PIP breast implant scandal was not the first and transvaginal mesh will not be the last. In fact, the next national patient safety scandal is likely manifesting today. “There needs to be better processes to ‘track and trace’ patients who have received a device when a problem arises,” says Professor Sir Terence Stephenson, Nuffield professor of child health at UCL Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England, in the Scan4Safety 2020 report. “Clear strategies and channels are needed to inform patients, the public and clinical professionals to help improve safety.” One common denominator among such incidents is the lack of traceability – limited visibility of the devices used, when and where they are used and, most importantly, in or on which patients. This is where standardised data comes into play. There is no shortage of data in the NHS. However, the ability to standardise and share that data between systems and organisations is something the health service as a whole still lacks. Today, achieving full traceability remains a key challenge for the NHS, with repercussions that continue to have a detrimental effect on patient care.
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News Article
USA: Amid hospital 'chaos,' stick to standards to improve quality
Patient Safety Learning posted a news article in News
Every time a mistake is made in a healthcare setting, there can be serious repercussions. Patients may suffer lifetime injuries or even pay the ultimate price for someone else's mistake. Hospitals may wind up paying the price literally — financially and legally — and suffer costly public reputation troubles in the aftermath. Increased patient loads combined with the workforce shortage and often decreasing financial resources have created "chaos" in hospitals, said Doug Salvador MD, chief quality officer at Baystate Health in Springfield, Mass. Safety watchdog organizations, including The Joint Commission and The Leapfrog Group, have reported the result of that chaos: soaring cases of preventable medical errors. The solution, he and several other sources who spoke with Becker's said, is to create standard operating procedures in every department, at every step of the patient journey. These SOPs are more than lists of guidelines; they require strict adherence and limited room for error thanks to built-in cross-check points. And, when instituted properly, they highlight system flaws in real time by creating what Dr. Salvador called "situational awareness." Situational awareness, he added, keeps front-line healthcare professionals on top of their safety game. Read full story Source: Becker's Healthcare, 9 May 2023 -
Content Article
PRSB: Wound care standard
Patient Safety Learning posted an article in Patient safety standards
Wound care is a critical aspect of healthcare that affects people of all ages. The National Wound Care Strategy Programme (NWCSP) is addressing the unwarranted variation in wound care services, not enough use of evidence-based practices and use of ineffective practices. The NWCSP’s goal is to reduce pain and suffering for patients, improve healing rates, prevent wounds from happening or coming back, and use healthcare resources more efficiently. PRSB’s wound care standard will help to support this goal by encouraging use of evidences-based practice and consistent recording of information which can be shared with all those involved in the person’s care. The standard defines the information record content for the management of wound care. It is designed to support the professionals and those providing care as well as the person themselves, and to support the national wound care strategy. -
News Article
Regulator withdraws midwifery programme accreditation
Patient Safety Learning posted a news article in News
The Nursing and Midwifery Council (NMC) has withdrawn its accreditation of the midwifery programme at a Kent university due to fears over quality and safety. The regulator highlighted concerns that Canterbury Christ Church University students were not gaining the expertise needed to deliver safe, effective and kind care. An NMC director said the decision was made in the “best interests of women, babies, and families”. The university said the decision had “devastating consequences” for their student midwives. “Our absolute priority is the wellbeing of our students and staff, and ensuring that our students can continue to complete their studies and begin their future careers, to be the high quality, much needed midwives that this region needs,” a university spokesperson said. Sam Foster, NMC executive director of professional practice, said while the decision would impact students and the local workforce, the regulator's role was to uphold the high standards that “women and families have the right to expect”. Read full story Source: BBC News, 4 May 2023 -
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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Content Article
In this blog, Steve Turner reflects on why genuine patient safety whistleblowers are so frequently ignored, side-lined or victimised. Why staff don't speak out, why measures to change this have not worked and, in some cases, have exacerbated the problems. Steve concludes with optimism that new legislation going through Parliament offers a way forward from which everyone will benefit.- Posted
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Content ArticleStandard operating procedures (SOPs) should improve safety in the operating theatre, but controlled studies evaluating the effect of staff-led implementation are needed. Morgan et al. evaluated three team process measures (compliance with WHO surgical safety checklist, non-technical skills and technical performance) and three clinical outcome measures (length of hospital stay, complications and readmissions) before and after a 3-month staff-led development of SOPs. They found that SOPs when developed and introduced by frontline staff do not necessarily improve operative processes or outcomes. The inherent tension in improvement work between giving staff ownership of improvement and maintaining control of direction needs to be managed, to ensure staff are engaged but invest energy in appropriate change.
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Content ArticleThis article explains Quality and Safety Education in Nursing (QSEN), a US initiative to align nursing education and nursing best practices in quality and safety standards. The six focus areas of QSEN are: Patient-centred care Evidence-based practice Teamwork and collaboration Safety Quality improvement Informatics
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Content ArticleThis NatSSIPs 8 flow chart illustrates the sequential standards in the National Safety Standards for Invasive Procedures 2 combined with the World Health Organization (WHO) surgical safety checklist.
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Content ArticleThis is Patient Safety Learning’s submission to the consultation on the Professional Standards Authority (PSA) draft strategic plan 2023-26. The PSA were seeking the views of patients, service users, regulators, Accredited Registers and other stakeholders on the work that they do, how they work and how their strategic plan can help them to have a meaningful impact on patient and service user safety and public protection. The consultation is now closed.
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Content ArticleThe Beryl Institute is seeking feedback on its proposed new global experience measure. The aim is to create a simple, clear experience measure set that ensures global accessibility and applicability, and supports tangible action. This survey aims to help the steering group assess the value and importance of their proposed set of questions. They would like to hear the perspectives of: patient, family members and care partners healthcare/experience leaders The survey should take less than five minutes to complete.
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Content ArticleThe NHS Patient Safety Incident Response Framework (PSIRF) was launched in 2022 and is intended for full implementation by Autumn 2023. PSIRF requires Integrated Care Board (ICB)’s to work collaboratively with providers to develop a Patient Safety Incident Response Plan (PSIRP) and Patient Safety Incident Response Policy. Within the PSIRP, each organisation must work with their ICB and other stakeholders to identify how it will respond proportionately to all incidents requiring investigation. Suffolk and North East Essex NHS Foundation Trust share their Standard Operating Procedure on PSIRF ICB sign off process.
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Content ArticleThe Centre for Perioperative Care (CPOC) has published new safety standards (NatSSIPs2) to enable all hospitals in the UK to improve patient safety by applying a consistent and proportionate set of safety checks for all invasive procedures. Listen to the podcast from the Royal College of Anaesthetists on the new standards.
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Content ArticleIn this BMJ opinion piece, Scarlett McNally discusses the revised National Safety Standards for Invasive Procedures (NatSSIP2). The original NatSSIPs were designed to prevent “never events”—yet more than 300 occurrences of wrong site surgery, retained objects after procedure, or wrong implant insertion still occur yearly in the UK. NatSSIP2 brings in safety science and human factors, with expectations for organisations including standardisation, harmonisation, training, and audit. "The biggest danger is if the new standards sit on the shelf. With their benefits for patient safety and teamworking, we must accept the repetitive elements and consistently apply these new standards, every time, in every department", writes Scarlett.
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Content Article
Lilian Chiwera is an independent surgical site infection (SSI) surveillance and prevention (SSISP) expert with experience setting up and coordinating a very successful SSI surveillance service at Guys & St Thomas’ NHS Foundation Trust from 2009–2022. Lilian shares the work she and her colleagues are doing around a surgical site infections patient safety initiative and explains why she wants to establish an annual Surgical Site Infections Prevention Day. -
News Article
Government delays regulation for non-surgical cosmetic procedures
Patient Safety Learning posted a news article in News
The government has rejected an urgent call by MPs to bring in a new licensing regime for non-surgical procedures such as Botox injections, chemical peels, microdermabrasion and non-surgical laser interventions. Ministers also rejected recommendations by the House of Commons Health and Social Care Committee to make dermal fillers available as prescription only substances—as Botox is—and to bring in specific standards for premises that provide non-surgical cosmetic procedures. The government also rejected several recommendations aimed at tackling obesity—including a dedicated eating disorder strategy, annual health and wellbeing checks for every child and young person, and restrictions on buy-one-get-one free deals for foods and drinks high in fat, salt, or sugar. Read full story Source: BMJ, 2 February 2023 -
Content ArticleThe purpose of this assessment is to ensure that all Theatre Practitioners are fully compliant with current Trust Policy with regard to swabs, instruments, sharps and disposables items. All Theatre staff must be assessed and deemed competent.
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Content ArticleThe original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. The Centre for Perioperative Care shares their slideset on the revised standards.
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Content Article
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Nicole McCarthy tells us about the Royal College of Psychiatrists' Quality Network for Inpatient Working Age Mental Health Services (QNWA), how it supports and engages mental health inpatient wards in a process of quality improvement, its accreditation and developmental processes and how you can become a member. -
Content ArticleThe original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.
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