The STROBE study, published in BMC Pregnancy and Childbirth, will help establish understanding of the effectiveness of locally-delivered simulation training for operative vaginal birth. Robust evidence supporting the effectiveness of such an approach would add weight to the argument supporting regular, local training for junior obstetricians in operative vaginal birth.
Building an organisation-wide approach to improvement is a journey that can take several years. It requires corporate investment in infrastructure, staff capability and culture over the long-term.
An essential early step is securing the support and commitment of the board for a long-term programme, including their willingness to finance the skills and infrastructure development needed to implement it.
The report includes case studies of three English NHS trusts with an outstanding CQC rating that have implemented an organisational approach to improvement.
The Curriculum Guide is comprised of two parts. Part A is a teachers’ guide designed to introduce patient safety concepts to educators. It relates to building capacity for patient safety education, programme planning and design of the courses. Part B provides all-inclusive, ready-to-teach, topic-based patient safety courses that can be used as a whole, or on a per topic basis. There are 11 patient safety topics, each designed to feature a variety of ideas and methods for patient safety learning. Universities are encouraged to start with Part A which provides comprehensive advice on how to introduce and build patient safety courses.
The associated resources include teaching slides on the following topics:
What is Patient Safety?
Why applying human factors is important for patient safety
Understanding systems and the effect of complexity on patient care
Being an effective team player
Learning from errors to prevent harm
Understanding and managing clinical risk
Using quality-improvement methods to improve care
Engaging with patients and carers
Infection prevention and control
Patient safety and invasive procedures
Improving medication safety.
What Human Factors isn’t: 1. Common Sense
What Human Factors isn’t: 2. Courtesy and Civility at Work
What Human Factors isn’t: 3. Off-the-shelf Behaviour Modification Training
What Human Factors isn’t: 4. A cause of accidents.
The MaPSaF can be used to:
facilitate reflection on patient safety culture
stimulate discussion about the strengths and weaknesses of the patient safety culture
reveal any differences in perception between staff groups
help understand how a more mature safety culture might look
help evaluate any specific intervention needed to change the patient safety culture.
In this report the CQC have seen much good and outstanding care, in particular around:
staff interactions with patients
leadership and engagement with staff and patients.
However, there were a number of areas where services needed to make substantial improvements:
There are two types of training – Foundation and Community of Interest (previously known as Revalidation).
Originally the foundation training spanned over two days but we recognised that this took up a lot of time and resource, especially given a large proportion of our delegates are practising clinicians. With this in mind, we condensed one of the days learning objectives into an e-learning session, followed up with the one-day classroom course.
There are a number of ‘open’ foundation courses. Usually located in Leeds and London. Anyone can sign on to these courses once they have completed the e-learning. Open courses allow for a good mix of colleagues from both the health organisations and the manufacturing companies. Venues are decided and hosted by NHS Digital and the course fee is £475 for NHS colleagues and £625 for others. Completion of the e-learning and the classroom course are worth a total of 14 Continuing Professional Development (CPD) points.
For those with more than one colleague wishing to participate on the course, we can arrange a ‘closed’ course at your venue. Price is negotiable but we ask for a minimum of 12 delegates.
The foundation course covers all the principles of Clinical Risk Management and helps put the theory and technique learned on the e-learning, into practise.
The Clinical Safety Community of Interest Course (CSCOI), previously known as the Revalidation Course, contains:
a stronger emphasis on sharing best practice and networking
case studies presented by members of the clinical safety community
recent developments in health IT, including a key speaker where possible.
There will also be a recap of the key requirements outlined in DCB0129 and DCB0160.
This course is for both clinicians and non-clinicians. Clinicians attending this course will be issued with 6.5 CPD points. Cost for CSCOI is £225 for NHS and £325 for others.
Booking can be made online
This is a slide set from Rebecca Lawton (Yorkshire and Humber Patient Safety Translational Research Centre) for the National Institute for Health Research and Yorkshire and Humber Improvement Academy, explaining what second victim is and how we can do better to support staff.
What can I learn?
Introducing power of the patient
Tricky conditions: understanding disease, diagnosis and decisions
What everyone should know about getting the best care
The patient's side of the call for better
The aim of the UK-wide survey was to obtain a snapshot of the structure of, and role-specific training and CPD provision for, the non medical, non-midwifery maternity workforce. The objectives were to:
determine the ratio of unregistered staff to registered midwives in the maternity services
determine the number of maternity services where nursing associates were employed
determine the number of maternity services where registered nurses were employed in areas other than neonatal care
determine the areas of work for registered nurses in maternity care
gather information about the role-specific training offered to non-midwives at induction and as CPD during employment.
This survey is intended to add to the conversation on some aspects of the workforce and skill mix in maternity services. As a result of the findings the following recommendations are made:
the opportunity should be created for a stakeholder engagement event to disseminate findings and consider aspects requiring further exploration, which may include:
future training needs analysis work to explore role-specific training for non-midwifery staff (registered or unregistered) in maternity services, to clarify what should be provided.
to look at utilising these findings in the wider work being carried out within the RCN safe and effective staffing campaign (RCN 2019). Although the RCN campaign is focused on nursing, these survey results may inform work on both midwifery and nursing staffing.
Hellaby hopes that the time is right for NHS national organisations to clearly articulate the potential of simulation as a tool for organisational learning and patient safety so the activities become mainstream and available across all organisations.
What can I learn?
Practical guidance and examples of best practice in the design of infusion devices
How design can be used to change and make safer the use of infusion devices in practice.
Principles that can be widely applied to the design of other technologies