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Community Post
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Community PostThis year's theme for World Patient Safety Day (17 September) is Health Worker Safety: A Priority for Patient Safety. We know that staff safety is intrinsically linked to patient safety but we need your insight to help us understand what matters most when it comes to feeling safe at work. So we're asking you to tell us: What is most needed for health and care staff to feel physically or mentally safe at work? In this short video, Claire Cox (Patient Safety Learning's Associate Director of Patient Safety and a Nurse) shares her top three. What do you think is most needed? Please join the conversation and help us speak up for health worker safety! Nb: You'll need to sign in to the hub to comment (click on the icon in the top right of your screen). If you're not a member yet, you can sign up here for free.
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Content ArticleDuring pregnancy, and up to one year after birth, one in five women will experience mental health issues, ranging from anxiety and depression to more severe illness. For those women experiencing mental ill-health, barriers often exist preventing them from accessing care, including variation in availability of service, care, and treatment. These are often worsened by cultural stigma, previous trauma, deprivation, and discrimination. This document by the Royal College of Midwives outlines recommendations to ensure that women are offered, and can access, the right support at the right time during their perinatal journey.
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Content ArticleIn June 2022, General Sir Gordon Messenger and Dame Linda Pollard published their final report on the review of leadership and management in the health and social care sector, as commissioned by the Secretary of State for Health and Social Care in October 2021. This briefing by NHS Providers summarises the key areas covered by the report, grouping recommendations under the following headings: Training Development Equality, diversity and inclusion Challenged trusts, regulation and oversight
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Content ArticleThis is the report of a review into how the executive leadership of the NHS could be better supported and empowered to ensure the best possible service is delivered for patients. Sir Ron Kerr was commissioned by the Department of Health and Social Care (DHSC) to conduct the review, which focused on three issues in particular: The expectations and support available for leaders - particularly those in challenging organisations and systems The scope for further alignment of performance management expectations at the organisational and system level The options for reducing the administrative burden placed on executive leaders The report describes the methodology of the review, outlines its findings and makes a number of recommendations around these issues.
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Content ArticleCalibration, defined as alignment between a person’s diagnostic accuracy and their confidence in that accuracy, is an essential component of diagnostic excellence. Miscalibration—the misalignment between a person’s diagnostic accuracy and their confidence in that accuracy—can manifest as either overconfidence or underconfidence and can have serious consequences for patient diagnosis. This resource about calibration from the US Agency for Healthcare Research and Quality (AHRQ) is primarily aimed at individual clinicians whose scope of practice includes diagnosis. It focuses on processes involved in making a diagnosis and the outcome of giving an explanatory label to patients after these processes unfold.
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Content ArticleThis guide published by NHS England & Improvement describes the validation rules relating to the LFPSE project, specifically around submitting an Adverse Event via the Adverse Event Application Programming Interface (API). It covers several types of validation rules, which have been split into three sections. Bespoke business validation rules which have been implemented based on the dependencies between responses and extensions that cannot be captured by the FHIR resource validation. FHIR validation responses which may be returned from the API when native FHIR validation checks the submission body against the LFPSE FHIR profiles defined for an adverse event. Invalid operations and similar responses which are external to validation of the submission, including responses pertaining to permissions, personal information and any other responses that do not fit into the two categories above.
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Eating disorders training for health and care staff
Patient-Safety-Learning posted an article in Eating disorders
This series of training programmes was collaboratively developed by eating disorder charity Beat, Health Education England and NHSE. It was developed in response to the 2017 PHSO investigation into avoidable deaths from eating disorders, as outlined in recommendations from the report Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients. It is designed to ensure that healthcare staff are trained to understand, identify and respond appropriately when faced with a patient with a possible eating disorder. It includes sessions relevant for different healthcare professionals and includes: Medical students and foundation doctors programme Nursing workforce sessions GP and Primary care workforce sessions Medical Monitoring in eating disorders Understanding Eating Disorders Webinar resource for dietitians, oral health teams and community pharmacy teams -
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Friends of African Nursing
Patient_Safety_Learning posted an article in International patient safety
Friends of African Nursing (FoAN) was started as an organisation by Lesley and Kate, who had family contacts in Africa and due to their professional nursing backgrounds, had taken an interest in the health systems in African countries which they had visited whilst on holiday. It was apparent to them both separately, that the privilege of the healthcare environment in which they both worked in the UK - which offered continuing education, ready access to journals, speciality (perioperative) education and a professional association (in which they were closely involved, at home) as a ready made network was indeed a huge privilege which should be shared. Their primary interest is in supporting nurses and nursing in Africa. FOAN specialises in supporting nurses who work in Operating Theatres particularly and work with the surgical teams. Surgery is often high risk in Africa and their key interest is to update practice, educate on risk management and patient safety as well as infection prevention measures. They have also delivered programmes for ward leaders and other bespoke courses. Visit the FoAN website to find out more via the link below. -
Content ArticleThe UK government’s long-awaited NHS workforce plan for England outlines a vision to increase the number of nursing staff in England over the next 15 years, with a promise of 170,000 more nurses by 2036/37. This article from the Royal College of Nursing (RCN) outlines how the detail of the plan will affect nurses. It argues that the plan fails to acknowledge the financial investment needed if its objectives are to be fulfilled, and expresses the RCN's concern that it does not address financial support for student nurses.
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Duty of Candour for Wales
Gethin posted an article in NHS Wales (Gig Cymru)
The Duty of Candour for Wales statutory guidance. -
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This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the Independent Investigation into East Kent Maternity services. -
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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Community PostCan any one share? The trust I work in delivers patient safety training as part of the mandatory training. I was wondering if any other trust does this, if so would they mind sharing Thier slides as I'm not sure what it should include. Thanks!
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Community Post
How can we encourage students to become active leaders in patient safety?
PatientSafetyLearning Team posted a topic in Leadership for patient safety
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A question posed by a delegate at our Patient Safety Learning Conference 2019: 'As invaluable sources of fresh intelligence, how can we encourage students/learners to become active leaders in patient safety?' What are your thoughts?- Posted
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Community PostHi I have been working in a presentation we are giving at ASPiH in November around the work we have done using simulation to test systems and processes. we have done this in two ways. Firstly as a by-product of an educational in situ simulation in s clinical environment where a latent threat has been identified. In this case we will work with the area in looking at just what contributes to the threat and ways that may help. The second way (and with my HF head on, more exciting) has been setting out to test a process. We have done this several times now and have had some real successes in demonstrating the work as done v work as imagined theory. has anyone else used simulation in this way? looking forward to your replies. Phil
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Community Post
Teaching RCAs to teams: a checklist
lzipperer posted a topic in Investigations, risk management and legal issues
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Root case analysis has its detractors but can still bring value to understanding deep-seated problems that affect the safety of care. Does anyone have a checklist of elements of an effective TRAINING strategy to bring staff on board with the process? Not how to do an RCA, but to bring a team to the skill competencies they need to do RCA? I'd appreciate hearing your experiences. Please tell your tales! -
Community Post
Patient Safety Managers - is there a defined role? Help for a newly appointed PSM
HelenH posted a topic in Patient safety standards
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I met at a recent conference a newly appointed Patient Safety Manager. She’d been working in a supporting role in another organisation and was delighted with her obviously well deserved promotion to a more senior role of patient safety manager in another Trust. But 6 days in, she’s had no induction, there is no patient safety strategy or plan in the Trust, there isn’t any guidance as how she should do her job other than just ‘get on with doing RCAs. ‘ She doesn’t know who she can turn to for advice or support either in her Trust or elsewhere. Are there networks of PSMs she can turn to? Surely there is a model framework for patient safety that is produced as a guide? How can we help her and other PSMs?- Posted
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Content ArticleAn independent review of how effectively the test prevents unsuitable staff from being redeployed or re-employed in health and social care settings.
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Content ArticleNHS Resolution has launched its first eLearning module that focuses on learning from the significant avoidable harm that can occur during antenatal and postnatal care and is seen in the cases notified to its Early Notification Scheme. This free resource is designed to support clinicians working in maternity services. The module uses three illustrative case stories to immerse learners into the antenatal, intrapartum and postnatal care provided to mothers and the neonatal care provided to their babies. It aims to deepen learners' understanding of NHS Resolution’s role within the healthcare system, develop their understanding of the law of negligence as applied to clinical claims and explore how clinical decisions and actions can lead to avoidable harm. The module takes approximately two-and-a-half hours to complete and can be used as evidence of CPD hours undertaken for revalidation.
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Content ArticleThe Patient Safety Movement Foundation offers a unique educational opportunity for healthcare professionals around the world to expand their knowledge in the theory and practice of patient safety. Please apply to this fellowship programme from the link if you are interested in joining the 2024 cohort of fellows. Application deadline is 1 August 2023.
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NHS Long Term Workforce Plan (30 June 2023)
Patient Safety Learning posted an article in NHS England
The first comprehensive workforce plan for the NHS, putting staffing on a sustainable footing and improving patient care. It focuses on retaining existing talent and making the best use of new technology alongside the biggest recruitment drive in health service history. -
Content ArticleThe state of medical education and practice in the UK 2023 is published at a time when the UK health systems face extensive challenges. This report from the General Medical Council (GMC) shares concerning data about the experiences of doctors and the challenges to providing adequate care to patients. In this context, careful and constructive exploration of the practical, evidence-based steps that can be taken to improve the situation is critical – to protect both patients and the doctors who care for them.
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Content ArticleSickle cell disease is the name for a group of inherited red blood cell disorders that affect haemoglobin, which is a protein in red blood cells that carries oxygen through a person’s body. It mainly affects people from African or Caribbean backgrounds, though it can affect anyone. It affects approximately 15,000 people in the UK. In November 2021, the All-Party Parliamentary Group for Sickle Cell and Thalassaemia published a report detailing the issues that people with sickle cell disease experience in relation to their care. The report made 31 recommendations to organisations across the healthcare system to help address these issues. The Healthcare Safety Investigation Branch (HSIB) launched two investigations (see also: Invasive procedures for people with sickle cell disease) to find out what additional learning or knowledge could be added in this area and to provide further insights into the practical challenges patients with sickle cell disease may face when receiving NHS care. HSIB used a real patient safety incident, referred to as ‘the reference event’, to explore how sickle cell crises are managed within hospital settings. In particular, the investigation considered: the knowledge nursing staff may have about the care of patients in sickle cell crisis how patient-controlled analgesia (PCA) – where a patient can use a device to give themself doses of pain relief medication – is considered holistically, such as monitoring the patient and staff workload.
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In 2022, an illustration of a Black foetus in the womb by Nigerian medical illustrator and medical student Chidiebere Ibe, went viral. The image sparked an important conversation around representation in medical imagery and the impact this has on health outcomes for patients who are Black, Indigenous and people of colour (BIPOC). Research showed that only 5% of medical images show dark skin and only 8% of medical illustrators identified as BIPOC. A collaboration between Chidiebere Ibe, Deloitte and Johnson & Johnson, Illustrate Change aims to build the world's largest library of BIPOC medical illustrations for use in medical education and training. So far, the library contains images relevant to the following specialties: Dermatology Eye disease General health Haematology Maternal health Oncology Orthopaedics
