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Content ArticleHelen is a Consultant Anaesthetist at the Oxford University Hospitals NHS Foundation Trust (OUHFT) and a Senior Clinical Research Fellow in the Nuffield Department of Clinical Neurosciences, University of Oxford. Here, Helen highlights the importance of support and training and gives an example of how the OxSTaR team are transforming staff teamworking skills and improving patient safety.
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News Article
Maternity safety campaigners head to Downing Street to demand action
Patient Safety Learning posted a news article in News
More than 20 leading NHS doctors and experts back Baby Lifeline demand for safety training for maternity staff to cut £7m a day negligence costs The Independent’s maternity safety campaign goes to Downing Street today as senior figures from across the health service deliver a letter demanding action from prime minister Boris Johnson. Charity Baby Lifeline will be joined by bereaved families, Royal Colleges and senior midwives and doctors in Downing Street to hand in a letter calling on the government to reinstate a national fund for maternity safety training. Baby Lifeline, which has also launched an online petition today, said the government needed to find £19m to support training of both midwives and doctors to prevent deaths and brain damage, which can cost the NHS millions of pounds for a single case. The letter to Mr Johnson has also been signed by Dr Bill Kirkup, who led the investigation into baby deaths at the Morecambe Bay NHS trust and is investigating poor care at the East Kent Hospitals University Trust. He said: “There have been real improvements in maternity services, but as recent events in Kent and Shropshire have shown only too clearly, much more remains to be done. The Maternity Safety Training Fund is badly needed.” Sir Robert Francis QC, Chairman of the public inquiry into poor care at Stafford Hospital, who also signed, said: “The cost in lost and broken lives, not to mention the unsustainable financial burden and the distress of staff caused by these avoidable mistakes, is indefensible.” Other signatories included former health secretary Jeremy Hunt, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and a number of senior maternity figures, charities and clinical associations. Read full story Source: The Independent, 6 March 2020 -
Content ArticleA research paper published by researchers from the Johannes Kepler Universität and the University of Applied Sciences, both in Austria, examined the process of developing what is termed as a ‘constructive error culture’ in organisations. This Research Brief from Oxford Review summarises the findings.
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Content ArticleThis lecture, presented to staff at Southport and Ormskirk Hospital NHS Trust on 26 March 2020, gives an overview of the coronavirus, transmission, symptoms and treatment of the virus. Martin Kiernan qualified as a Registered General Nurse in 1984, and obtained a Master in Public Health in 1997. He currently works as a Nurse Consultant where he is responsible for the infection prevention and control programme for an integrated healthcare provider NHS Trust covering acute and primary care. He manages a team of two specialist nurses, a surveillance nurse, a healthcare assistant and an information officer. A significant part of his clinical duties includes assessment and application of policies and guidelines to ensure optimal clinical practice.
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Content ArticlePatient Safety Learning has submitted the attached response to the consultation for the national patient safety syllabus. The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’. A key action associated with this aim is the creation of a system-wide patient safety syllabus which is capable of ‘producing the best informed and safety-focused workforce in the world’. The Academy of Medical Royal Colleges (AOMRC) has been commissioned by Health Education England (HEE) to develop a new National patient safety syllabus. The Academy has now published its first version of this for review and feedback. At Patient Safety Learning, we’ve been working with the AOMRC and HEE in the initial stage of development to share our thoughts on the initial proposals in this syllabus. Now that this has been formally published for consultation, we want to share our submission as part of the consultation process which closed on Friday 28 February 2020. We welcome the development of a National patient safety syllabus and believe that it’s very important that this acts as a key driver for achieving a step change in patient safety across the NHS. In our response to the consultation we identify several areas where there are significant gaps in the initial draft that need to be addressed and comment on the development process of the syllabus, inviting a more inclusive and transparent process that enables a wide range of stakeholders to engage and contribute.
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Content Article
COVID-19: guidance for health professionals (Coronavirus)
Claire Cox posted an article in Guidance
Information on COVID-19, including guidance on the assessment and management of suspected UK cases. -
Content ArticlePresentation from WHO's 'A Decade of Patient Safety 2020-2030: Formulating Global Patient Safety Action Plan' patient safety meeting in Geneva.
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News Article
Nurses to carry out surgery under NHS plans to slash waiting times
Patient Safety Learning posted a news article in News
Nurses will be trained to perform surgery under new NHS measures to cut waiting times. Nursing staff will be urged to undertake a two year course to become “surgical care practitioners” as part of the drive to slash waiting times but critics have warned it will worsen the nursing shortage. Nurses who qualify will be tasked with removing hernias, benign cysts and some skin cancers, according to the Daily Mail. They will also assist during major surgeries such as heart bypasses and hip and knee replacements. The re-trained nurses will be tasked with closing up incisions after operations. The proposals are contained within the NHS’s People Plan, due to be unveiled next month. Lib Dem health spokesman Munira Wilson said: "This is a sticking plaster solution to very serious staffing crisis across our NHS workforce.'" However the proposals were backed by Professor Michael Griffin, president of the Royal College of Surgeons of Edinburgh. He said: "We are totally supportive of this. We have very little anxiety about this.” Read full story Source: 24 February 2020 -
Content Article
Coroners, post-mortems and inquests
Claire Cox posted an article in Coroner reports
Coroners are independent judicial officers who investigate deaths reported to them. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest. -
News Article
"Patients are not empowered to prevent their own harm", says Sir Liam Donaldson
Patient Safety Learning posted a news article in News
Today, Sir Liam Donaldson is chairing a patient safety meeting at the World Health Organization (WHO) 'A Global Consultation – A decade of Patient Safety 2020–2030' to formulate a Global Patient Safety Action Plan. His introductory address this morning focused on the task ahead – to maintain the World Health Assembly resolution momentum and patient safety as a global movement. "Patients are not empowered to prevent their own harm", Donaldson said, as he highlighted patient stories of unsafe care and the alarming parallels of patient and family experiences across the world. So where is the power? Donaldson went on to to highlight how the six current power blocks are not doing enough to improve safety and that we need to engage and motivate these power blocks to achieve change: Designing of health systems – we have not seen much evidence of systems being designed for safety. Health leaders are not using their power to lead for reduced harm. Educational institutions – these have to happen faster to train staff in. Research community – has patient safety research led to sustainable reduction in risk? Data and information – how has this improved patient safety? Industry – pharma doing very little on medication packaging and labelling; medical devices industry also could do more. -
Content Article
AWARE – Well-being resources
Patient Safety Learning posted an article in Good practice
A suite of resources designed to promote well-being among US residents, fellows, faculty members, and others has been created by the Accreditation Council for Graduate Medical Education. This initial set of AWARE resources focuses on individual strategies for cognitive skill building, and includes a video workshop, podcasts, and the ACGME AWARE app. -
Content ArticleSafety and improvement efforts in healthcare education and practice are often limited by inadequate attention to human factors/ergonomics (HFE) principles and methods. Integration of HFE theory and approaches within undergraduate curricula, postgraduate training and healthcare improvement programmes will enhance both the performance of care systems (productivity, safety, efficiency, quality) and the well-being (experiences, joy, satisfaction, health and safety) of all the people (patients, staff, visitors) interacting with these systems. Patient safety and quality improvement education/training are embedded to some extent in most curricula, providing a potential conduit to integrate HFE concepts. To support this, Bowie et al. in this article published in Medical Teacher offer professional guidance as “tips” for educators on fundamental HFE systems and design approaches. The goal is to further enhance the effectiveness of safety and improvement work in frontline healthcare practice.
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Content ArticleThis was the first Chartered Institute of Ergonomics and Human Factors (CIEHF) Pharmaceutical Sector group organised event, where the systems and human factors challenges of labelling and packaging were discussed by a wide-ranging audience across the healthcare and pharmaceutical sectors.
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EventThis masterclass, facilitated by Barry Moult, a former Head of Information Governance for an NHS Trust, and his colleague Andrew Harvey, will focus on developing your role as a SIRO (Senior Information Risk Officer) in health and social care. Further information and to book your place or email kate@hc-uk.org.uk A discount is available to hub members by quoting reference hcuk20psl when booking (cannot be used in conjunction with any other offer; full T&Cs available upon request).
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News Article
Nurses to retrain as doctors ‘more quickly’ without EU red tape
Patient Safety Learning posted a news article in News
Leaving the EU means the UK has greater control over the training of healthcare professionals. The Department of Health and Social Care (DHSC) has announced that nurses and other allied healthcare professionals will be able to retrain as doctors ‘more quickly’ now the UK has left the EU. Under training standards set by the EU, existing healthcare professionals wishing to move into another area would have to complete a set standard of training, regardless of any existing health background or qualifications. Under the potential new system, a nurse who has been in the job for 10 years could benefit from training standards based upon experience and qualifications, rather than strict time-frames. Health Secretary Matt Hancock said: “Our incredible NHS is full of highly-qualified and dedicated professionals – and I want to do everything I can to help them fulfil their ambitions and provide the best possible care for patients. Without being bound by EU regulations, we can focus on ensuring our workforce has the necessary training which is best suited to them and their experience, without ever compromising on our high standards of care or on patient safety. The plans we are setting out today mean that we can retrain healthcare workers and get them back to the frontline faster. This is good for patients, and good for our NHS." Nursing leaders warn that the move needs to come without compromising patient care. Andrea Sutcliffe CBE, Chief Executive and Registrar at the Nursing and Midwifery Council (NMC) said: “Having enough health and care professionals with the right knowledge, skills and values is vital to meet the individual needs of people across all four countries of the UK now and in the future." “The NMC supports the wish to explore how education and training for registered nurses and midwives may be achieved in more flexible ways while ensuring our high standards are maintained and not compromised. Every nursing and midwifery professional must be safe and competent to provide the best care and support possible." Read full story Source: Nursing Notes, 9 February 2020 -
Content ArticleThis inquiry looked at the current and future scale of the shortfall of nursing staff and whether the Government and responsible bodies have effective plans to recruit, train and retain this vital workforce. It assessed the impact of new routes into nursing (including student funding reforms, the Apprenticeship Levy, Nurse First and nursing associates). In particular, the inquiry examined the effect of changes to funding arrangements for nurse training, including the withdrawal of bursaries, and consider alternative funding models and incentives.
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Event
RLDatix Palooza
Patient Safety Learning posted an event in Community Calendar
untilBringing together healthcare and patient safety changemakers from across the globe, RLDatix Palooza creates a unique learning environment. With immersive education sessions, enlightening keynotes, healthcare thought leadership panels, interactive hands-on training opportunities and lively evening network activities – this is a conference like no other. You’ll leave with the inspiration (and skills) you need to take your patient safety initiatives to the next level. Registration -
Content ArticlePresentation from Joanna Lloyd, Bevan Brittan, on incident investigations.
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Content Article
Improving cancer patient safety within the emergency department
Martin Hogan posted an article in Cancers
I'm Martin. In this blog I want to talk about my role as a Macmillan acute oncology clinical nurse specialist (CNS) and what our team has done to improve patient safety within the acute ward of our hospitals. Coming from a non-oncology background there was a lot to learn when I moved into acute oncology. My background was mainly acute cardiac and respiratory, but this allowed me to notice how powerful and time effective the presence of an acute oncology CNS could be in improving cancer patient safety within the emergency department. -
Content ArticleResilient Health Care (RHC) is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is by Sujan et al., published in Safety Science, was to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout.
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Content ArticleThe General Medical Council views resilience as a critical part of becoming a “professional”. All graduating medical students should have proved that they are resilient, and NHS job specifications expect it. They define resilience as “the capacity to recover quickly from difficulties.” It implies “toughness”, and an untiring effort to do more, to work faster, and to be better. The Medical Schools Council suggests screening for resilience in interviews, and now once admitted, medical students receive formal resilience training as part of the curriculum. The GMC’s “Professional Behaviour and Fitness to Practise” guidance underlines the importance of emotional resilience, which it defines as an “ability to adapt and be resourceful, mindful, and effective in complex, uncertain, or stressful situations.” This sounds impressive, but is resilience a trainable skill? Katherine Ripullone and Kate Womersley discuss this in this BMJ Opinion article.
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Content ArticleIn this book, you’ll learn the definitions behind the 4-point process of patient activation. It will also share how leading health care organisations and other clients have successfully used the model in a wide range of different initiatives. Along the way, you will gain specific techniques for applying patient activation in your own efforts. In this book, patient activation will refer to a fully integrated system to move from awareness to action.
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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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Content Article
Ten Thousand Feet: workshops and consultancy
Claire Cox posted an article in Suggest a useful website
Ten Thousand Feet UK is a Consultancy led by Rob Tomlinson in collaboration with the Association for Perioperative Practice. Rob is a clinical nurse in the NHS and is leading the way to improving patient safety through clinician-led culture change in the UK. Rob has already delivered workshops on a national scale with success for teams who have embraced the new procedure. 'Never Events' within the NHS are still on the rise with distraction and a loss of situational awareness still being cited as one of the main causes. Ten Thousand Feet aim to embed new patient safety culture into operating theatre teams nationwide, so at any time, anyone working in the theatre who needs to focus their attention at the task in hand can can use the language tool “Ten Thousand Feet” to improve team efficiency and most importantly patient safety. At the end of the workshop theatre staff will be educated and empowered to use this concept in a safe and effective manner. -
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!
