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Content ArticleDigital transformation across adult social care is occurring rapidly, however, uptake is not uniform, and the care sector is yet to fully harness digital tools to transform care delivery. With unprecedented service pressure and demand across health and care services, using digital tools in care settings has the potential to relieve some pressure by increasing efficiency and better supporting the workforce. This report by the think tank Public Policy Projects brings together the thoughts and ideas of many Adult Social Care experts regarding the future of the care sector, and the opportunities which digital advancements can bring. Chaired by Damian Green MP, it is intended as a thought-piece to guide action and further work on the area, as a guideline for future development.
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Content Article
Dr Freya Smith, a Specialty Trainee in General Practice, reflects on the sinister and toxic side of medicine, using the recent Paterson and vaginal mesh scandals to demonstrate how patients have been let down by the system. In an honest and personal account, she shares with us the horror and sadness she felt at learning of these scandals and how she aspires to keep her future patients safe. -
Content ArticleIn this interview for the Betsy Lehman Center in Massachusetts, Lee Kim Erickson, Senior Vice President and Chief Quality Officer at Wellforce, talks about maintaining a focus on patient safety during times of crisis, the impact of the Covid-19 pandemic on training for healthcare workers and the importance of maintaining a focus on care from the patient's point of view.
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Content ArticleThis study, published in The Organization of Primary Healthcare during the COVID-19 Pandemic, aims to investigate the effect of being a training practice on a number of different outcomes related to the safety culture of primary care practices. It found that: "Training young GPs has an important positive impact on the health system. It safeguards the health workforce of the future (and the present), while also being associated with higher quality and safety of the practices involved in training while lowering the risk of distress for qualified GPs participating in vocational training".
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Content ArticleThe Patient Safety Education Project (PSEP) uses a high impact, conference-based education program grounded in adult learning principles to teach systems-based patient safety methodology to healthcare professionals. This PSEP participants handbook covers: Gaps in patient safety: A call to action External influences: Law and other factors What is patient safety?: A conceptual framework Advancing patient safety: How to teach and implement Systems thinking: Moving beyond blame to safety Human Factors design: Application for healthcare Communication: Building understanding Teamwork: Being an effective team member Organization and culture: Essential to patient safety Technology: Impact on patient safety Patients as partners: Engaging patients and families Leadership: Everybody’s job
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Content Article
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Jenny Edwards died in February 2022 from pulmonary embolism, following misdiagnosis. In this blog, her son Tim introduces us to Jenny, illustrating the deep loss felt following her premature passing. He talks about the care she received and argues that there were multiple points at which pulmonary embolism should have been suspected. Tim found the investigation that followed Jenny’s death to be lacking in objectivity and assurance that any learning could be taken forward. He has since produced an independent report, drawing on existing data, freedom of information requests and his mother’s case, to highlight broader safety issues.- Posted
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Content ArticleThis paper asked healthcare workers who are considered to be theatre safety experts—theatre managers, matrons and clinical educators—to take part in the second round of a Delphi study. These individuals work at the coalface in operating theatres and deliver the surgical safety checklist daily. It addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the second Delphi study round was to establish the views of theatre users on the theatre checklist and local safety standards for invasive procedures. Likert scale responses and a combination of closed and open-ended questions solicited specific information about current practice and researched literature that generated ideas and allowed participants freedom in their responses of how the World Health Organisation’s (WHO's) Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. The paper is part of a literature review undertaken by the author towards a Doctor of Philosophy (PhD). Read the findings of round one of the Delphi study
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Content ArticleIn this blog, Louise Pye, Head of Family Engagement at the Healthcare Safety Investigation Branch (HSIB) highlights how the Patient Safety Incident Response Framework (PSIRF) can help NHS trusts involve patients and families in the face of extreme winter pressures. She highlights how the seven themes set out in the PSIRF guidance will help patient safety leaders ensure the involvement of patients and families is maintained even when services are dealing with extreme pressures.
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Content Article
Pulmonary embolism is the third most common cause of cardiovascular death worldwide after stroke and heart attack. Although life-threatening, when diagnosed promptly survival rates are good. This report, authored by risk expert Tim Edwards and published by Patient Safety Learning, highlights serious and widespread patient safety concerns relating to the misdiagnosis of pulmonary embolisms. Drawing on existing data, freedom of information requests and his mother’s case, he outlines nine calls for action to improve pulmonary embolism care. -
Content Article
NSW Government: Between the Flags
Patient Safety Learning posted an article in International patient safety
The Between the Flags (BTF) system is a 'deteriorating patient safety net system' for patients who are cared for in New South Wales (NSW) public health facilities in Australia. It is designed to assist clinicians to recognise when patients are deteriorating and to respond appropriately when they do. -
Content ArticleThis 15-minute training video by the Parkinson's Excellence Network pulls together the key symptoms and issues that can impact on a person with Parkinson's and their care when admitted to a hospital ward. it aims to help ward staff understand the key issues when caring for people with Parkinson's.
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Content ArticleThis article by Rebecca Rosen and Trisha Greenhalgh in the BMJ looks at the safety of remote GP consultations. It begins by looking at the case of student David Nash, who tragically died in 2020 after four telephone consultations with his GP; he was denied an in-person appointment for a painful ear infection that led to a fatal brain abscess. One coroner has raised concerns that this is not a one-off incident, noting that in five inquest reports they wrote during the pandemic, they question whether deaths could have been prevented by in-person consultations. The authors look at the recommendations of the ongoing 'Remote by Default 2' study, which is exploring how best to embed remote consulting in future GP services. They highlight better triage of appointment requests, active listening, checking back, increasing the use of video consulting and better training for clinicians as factors that could improve the safety of remote consultation.
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Content ArticleA culture of patient safety is essential for the continual improvement of service and reducing errors. This study in Risk Management and Healthcare Policy aimed to examine how the scores of patient safety culture items impact accreditation compliance percentages in primary care settings in Kuwait.
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Content ArticleThis letter from Dr Robert Farley, President of the Institute of Physics and Engineering in Medicine (IPEM) to Karen Reid, the Chief Executive Officer of NHS Education for Scotland (NES) highlights that lack of funding for Clinical Scientist training places is putting patient safety in Scotland at risk. Dr Farley says, "We understand NHS Education for Scotland are proposing funding that equates to less than a single training post in medical physics and clinical engineering in 2023. ‘This is despite the Scottish Government's Chief Healthcare Science Officer’s public acknowledgement of the importance of training. "Scotland currently has a 10 per cent Clinical Scientist vacancy rate across the medical physics specialisms. This equates to seven vacancies in radiotherapy, three in nuclear medicine, four in diagnostic radiology and radiation protection. These posts are critical to supporting diagnostics and cancer treatments."
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News Article
Oliver McGowan: NHS autism training mandatory after teen's death
Patient Safety Learning posted a news article in News
Mandatory training for treating people with autism and learning disabilities is being rolled out for NHS health and care staff after a patient died. It comes after Oliver McGowan, 18, from Bristol, died following an epileptic seizure. At the time, in November 2016, he had mild autism and was given a drug he was allergic to despite repeated warnings from his parents. His mother Paula lobbied for mandatory training to potentially "save lives". A spokesman for the NHS said the training had been developed with expertise from people with a learning disability and autistic people as well as their families and carers. The first part of the Oliver McGowan Mandatory Training is being rolled out following a two-year trial involving more than 8,300 health and care staff across England. Mark Radford, chief nurse at Health Education England said: "Following the tragedy of Oliver's death, Paula McGowan has tirelessly campaigned to ensure that Oliver's legacy is that all health and care staff receive this critical training. "Paula and many others have helped with the development of the training from the beginning. "Making Oliver's training mandatory will ensure that the skills and expertise needed to provide the best care for people with a learning disability and autistic people is available right across health and care." Read full story Source: BBC News, 2 November 2022 -
News Article
Record number of trainee doctors for ‘under pressure’ NHS
Patient Safety Learning posted a news article in News
The largest expansion of medical training posts has been announced the day after Scotland’s health secretary warned that the NHS was facing up to its most challenging winter. Humza Yousaf yesterday confirmed that 152 more places for trainee doctors would be created next year. He hailed it as the “most significant increase in medical training places to date” and an increase on the 139 places created last year. The announcement comes after ministers were urged to fund the creation of additional training places in key specialities including general practice, core psychiatry, oncology, emergency medicine, intensive care medicine and anaesthetics. “These additional training places highlight the Scottish government’s continued commitment to ensure that our health service is resilient and can continue delivering high quality care to those who need it,” Yousaf said. “This record expansion will support a wide range of medical specialties, many of which are under increased pressure as a result of growing demand. “We will continue to monitor the number of available training places in collaboration with NHS Education for Scotland to help make sure the NHS is equipped to meet the country’s current and future needs.” Read full story (paywalled) Source: The Times, 1 November 2022 -
News ArticleA new report published by the NHS AI Lab and Health Education England (HEE) has advocated for training and education for providers in how they deliver and develop AI guidance for staff. The report, entitled ‘Developing healthcare workers’ confidence in AI (Part 2)’, is the second of two reports in relation to this research and follows the 2019 Topol Review recommendation to develop a healthcare workforce “able and willing” to use AI and robotics. It is also part of HEE’s Digital, AI and Robotics Technologies in Education (DART-ED) programme, which aims to understand the impact of advances of these technologies on the workforce’s education and training requirements. In the previous report, the AI Lab and HEE found that many clinicians and staff were unaccustomed to the use of AI technologies, and without the suitable training patients would not be able to experience and share the advantages. The new report has set out recommendations for education and training providers in England to support them in planning, resourcing, developing and delivering new training packages in this area. It notes that specialist training will also be required depending on roles and responsibilities such as involvement in implementation, procurement or using AI in clinical practice. Brhmie Balaram, Head of AI Research and Ethics at the NHS AI Lab, added: “This important new research will support those organisations that train our health and care workers to develop their curriculums to ensure staff of the future receive the training in AI they will need. This project is only one in a series at the NHS AI Lab to help ensure the workforce and local NHS organisations are ready for the further spread of AI technologies that have been found to be safe, ethical and effective.” Read full story Source: Health Tech Newspaper, 25 October 2022
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News Article
Board to get anti-racism training as CQC orders cultural improvements
Patient Safety Learning posted a news article in News
Regulators have told the agency that supplies blood to the NHS to develop a more inclusive culture, after hearing multiple reports of ethnic minority staff being ‘disrespected’ and discriminated against. “Many staff” at NHS Blood and Transplant also expressed fear of reprisal for raising issues and concerns, the Care Quality Commission (CQC) said. The CQC carried out a “well-led” inspection of the agency over the summer, after receiving concerns about its culture and the behaviour of some senior leaders. Chief executive Betsy Bassis resigned after the inspection, although the CQC report does not refer to any specific allegations made against her. NHSBT has acknowledged it needs to improve its culture, particularly around diversity and inclusion issues. An internal memo sent to staff last week, seen by HSJ, said executives and board members would receive one-to-one training in “inclusive leadership and understanding racism”. Read full story (paywalled) Source: HSJ, 27 October 2022 -
Content ArticleWhether beginning a new effort or trying to keep people motivated to better prepare for future hazards, applying risk communication principles will lead to more effective results. This self-guided module introduces seven best practices, numerous techniques, and examples to help you improve your communication efforts. Please note that this training focuses on improving risk communication skills for coastal hazards planning and preparedness, however the principles can be adapted for any setting, including healthcare.
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Content ArticleThe Operating Room Black Box (OR Black Box) is a system that collects, stores and analyses a large amount of data from the operating room beyond just surgical video, such as video and audio of the operating room and patient physiology data. In this episode of the Behind the Knife podcast, Dr. Teodor Grantcharov, one of the creators of the OR Black Box, talks about how the technology can be used to enhance surgical training. Using the system for feedback through self-directed review, coaching and integrated AI analysis has changed the way we can learn and teach in surgery, and may have implications for the future of evaluation and assessing credentials.
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Content ArticleSimulation is traditionally used to reduce errors and their negative consequences. But according to modern safety theories, this focus overlooks the learning potential of the positive performance, which is much more common than errors. The authors of this article describe the learning from success (LFS) approach to simulation and debriefing. Drawing on several theoretical frameworks, they suggest supplementing the widespread deficit-oriented, corrective approach to simulation with an approach that focuses on systematically understanding how good performance is produced in frequent simulation scenarios.
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Content ArticleA doula, according to Doula UK (2022), provides ‘support in pregnancy, birth and in the postnatal period by providing information, advocacy, and practical and emotional support to the whole family’. This blog by the Healthcare Safety Investigation Branch (HSIB) maternity team outlines why HSIB decided to investigate the role of doulas in maternity safety and the results of their investigation. It highlights discrepancies in doula training and several cases where doulas stepped outside of the boundaries of their role. HSIB argues that there is a need for further work to understand how families view the role of doulas during pregnancy and birth.
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Content Article
Surgeon's News: Surgical safety update (March 2023)
Patient Safety Learning posted an article in Surgery
Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels. Two articles in this month's issue we want to highlight are the Surgical safety update (p.10) on cases from the Confidential Reporting System for Surgery (CORESS) and Safe passage (p.18) discussing the National Patient Safety Syllabus. -
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 Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line. The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream). This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.
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