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Content ArticleHere is a real example from the US of why embedding patient safety can be so difficult. We assume that patient safety is something everyone cares about. But what happens when it goes up against cost imperatives? Patient safety is easiest to move forward, particularly with the Centers for Medicare & Medicaid Services (CMS) Transforming Episode Accountability Model (TEAM) initiative, when improved outcomes and safety equal cost reductions. However, even this is not a guarantee. For example: in one provider, a trial on an AI analytics package was done on a hospital and results showed, according to their own cost estimates (not the vendor's), a potential 10-20 million US dollars savings that would recur if they remained 'under control'. A 'no brainer' right? Clinicians liked it. A patient safety genius there (I'm labelling his abilities correctly) loved it. So why didn't it happen? There is no line item in the accounts for cost reduction. The finance team refused to believe it. They were under huge pressure and did not want to put their heads above the parapet so an accounting quirk led to no savings. This was potentially hundreds of millions of dollars of saving, demonstrable improvements in outcomes and protection against outside scrutiny and criticism... It still didn't happen. I'd like to say there is a happy ending. There isn't. There is a lesson. Engage all stakeholders in discussions and then, perhaps, you might make a bit more progress. However, institutional issues are going to continue to create havoc until outcomes are aligned. If revenue versus cost is the main metric (and it is in some provider systems), you'll continue to get strange decisions driven by potentially perverse incentives.
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Content Article
NHS England case study: Inpatient falls and brain injury (23 July 2024)
Sam posted an article in Patient management
This NHS England case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. Through its core work to review recorded patient safety events, the National Patient Safety Team identified issues with the assessment and management of brain injury following an inpatient fall, leading to delays in diagnosis and treatment. A targeted review of falls reported to the National Reporting and Learning System (NRLS) over a one-year period identified deviation from NICE guidance on ‘Head injury: assessment and early management’ and variation in clinical assessment. This included differences in how neurological observations were taken, and delays in diagnostic interventions, including computerised tomography scans. Subsequent treatment and management were also impacted by these delays. Reports also suggested significant deviation from NICE guidance on ‘Falls in older people’ regarding safe retrieval of patients from the floor, exacerbating patient discomfort and risk of further injury. As a result of the review, it was highlighted that management of suspected traumatic brain injury following an inpatient fall should be an area of improvement focus for frontline clinical staff. NHS England worked with the Royal College of Physicians to successful apply to the Healthcare Quality Improvement Partnership (HQIP) to extend the scope of the National Audit of Inpatient Falls to include traumatic brain injury assessment and early management. This will help organisations to ensure they are meeting national best practice standards and allow the national programme to develop targeted resources. -
Content ArticleThis case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. The National Patient Safety Team identified a risk of harm from locked community public access defibrillator (CPAD) cabinets. CPADs are stored in numerous locations to allow members of the public to provide lifesaving defibrillation in the event of an out of hospital cardiac arrest. Most CPADs are kept in locked cabinets and require a 4-digit code to unlock the cabinet and release the CPAD. The code is usually provided by the ambulance service during a 999 telephone call. Several reports were reviewed where members of the public, who had been guided to a CPAD, could not get the unlock code or the incorrect code was held by the ambulance control centre. Working with NHS England cardiology colleagues, the National Patient Safety Team liaised with relevant stakeholders including the ambulance services in England, the Resuscitation Council (RCUK) and the British Heart Foundation (BHF), who maintain detailed mapping of CPADs and have researched their use. Discussions centred on the issues raised by our initial findings, such as why some cabinets are kept locked, how best to maintain data on CPAD access and use and how best to standardise an approach which would reduce delays in access. The outcome of these discussions highlighted the establishment of a National Defibrillator Network (The Circuit) and evidence from The Circuit showed that less than 1% of unlocked cabinets are vandalised, which is less than for locked cabinets. Whilst work on this issue is ongoing, a consensus statement has been issued by key stakeholders (NHS England, BHF, RCUK, St John Ambulance and the Association of Ambulance Chief Executives) which recommends “public access defibrillators should be placed in unlocked cabinets allowing immediate access in an emergency”.
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NHS Resolution Case Stories
Patient_Safety_Learning posted an article in Patient engagement
NHS Resolution share a number of Case Stories on their website. These are illustrative based on a range of examples of real events. NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. You can access the case stories via the link below. -
Content ArticleThis case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. The Incident Reporting and Investigation Centre (IRIC) in Scotland contacted NHS England to share an incident where a patient’s body-worn continuous insulin patch pump device was incorrectly identified by their healthcare team as a glucose sensor, when admitted to hospital with a severe hypoglycaemic event and loss of consciousness. As a result, the pump continued to infuse insulin during treatment therefore prolonging, rather than correcting, the hypoglycaemia. Insulin pumps can be identified by on-device marking and NHS England's review of the National Reporting and Learning System (NRLS) did not indicate this to be a widespread safety issue. However, they used this case to signpost Medical Device Safety Officers, Medication Safety Officers and the National Association of Medical Device Educators and Trainers (NAMDET) networks to guidance available from the Association of British Clinical Diabetologists to raise awareness of the potential for this error. In addition, the Royal College of Emergency Medicine highlighted this issue in a Safety Flash to ensure healthcare staff were aware of the risk.
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Content ArticleThis case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. Through its core work to review recorded patient safety events, the National Patient Safety Team identified an incident related to a surgical procedure to the eye which resulted in patient harm from 100% alcohol being applied to the cornea without the solution being diluted to the desired lower strength. Patients undergoing collagen cross-linking procedures to the eye, require removal of a section of corneal epithelium by applying 18% or 20% alcohol to the cornea. When unable to procure a pre-diluted solution, practice was to dilute 100% alcohol to achieve the desired strength. In the reported cases the dilution process was inadvertently omitted, resulting in 100% alcohol being applied to the cornea, causing damage to the ocular surface. NHS England worked with The Royal College of Ophthalmologists (RCOphth) Quality and Safety Committee who used the findings to publish a Safety Alert.The Safety Alert asked members to evaluate the use of alcohol during corneal cross-linking surgery and whether suitable 18% or 20% alcohol preparations could be sourced from a specials manufacturer. The recommendations made by RCOphth were communicated to the Medicines Safety Officers network across NHS providers.
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Content ArticleThis NHS England case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm. Through its core work to review recorded patient safety events the National Patient Safety Team identified a risk of inadvertent exposure to anaesthetic agent. An incident report described a patient being given an unintended dose of the inhaled anaesthetic agent isoflurane, after the vaporiser (a device attached to an anaesthetic machine which delivers the anaesthetic) had been left on. The patient was being given oxygen via an anaesthetic machine during their immediate post operative recovery period. The patient recovered. A search of the National Reporting and Learning System (NRLS) over a two-year period identified nine similar incidents in which patients were inadvertently administered a dose of anaesthetic agent due to a vaporiser being left on. The issue was shared with the Medicines and Healthcare products Regulatory Agency (MHRA) and the Safe Anaesthesia Liaison Group (SALG), so they could promptly review the design of vaporisers used to deliver anaesthetics, to make it clearer to staff if they are on or off. SALG agreed to this issue being considered by the Association of Anaesthetists ‘Anaesthesia Equipment Standards Committee’. The issue was also communicated to the network of Medical Device Safety Officers across NHS providers, to encourage them to report any similar incidents to the MHRA’s Yellow Card reporting system to support further learning around the issue.
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Content ArticleThis WHO report includes six case studies from 12 individuals with lived experience of diverse health conditions. These case studies explore the topics of power dynamics and power reorientation towards individuals with lived experience; informed decision-making and health literacy; community engagement across broader health networks and health systems; lived experience as evidence and expertise; exclusion and the importance of involving groups that are marginalized; and advocacy and human rights. It is the first publication in the WHO Intention to action series, which aims to enhance the limited evidence base on the impact of meaningful engagement and address the lack of standardized approaches on how to operationalise meaningful engagement. The Intention to action series aims to do this by providing a platform from which individuals with lived experience, and organisational and institutional champions, can share solutions, challenges and promising practices related to this cross-cutting agenda.
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Content ArticleAHRQ PSNet is looking for interesting, provocative cases that illustrate key issues in patient safety such as medication errors, diagnostic errors, and adverse events that either had the potential for or resulted in patient harm. Cases from outpatient, ambulatory surgery, home health, long-term care, and rehabilitation settings are of particular interest. When a case is selected, the editorial team invites an expert author to write a commentary based on the case. Please note that case submitters do not receive any “authorship” because case submissions are anonymous. However, submitters of selected cases will receive a $300 honorarium. The AHRQ Patient Safety Network (PSNet) is a national web-based resource featuring the latest news and essential resources on patient safety. Case submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above, describe how the error was recognized) Recommendations (describe your suggestions for how providers or systems might prevent similar errors from happening in the future) Responses to each of the above areas are limited to 250 words. Please note that submissions may be extensively edited for consistency with PSNet’s style, without changing important clinical details. Case selection criteria The editorial team reviews submitted cases regularly and judges cases using the following criteria: How interesting is the case from a medical error/patient safety standpoint? Is the case an important example of a common error, or is it unique but nevertheless raises some key issues of general interest? Does the case have sufficient clinical detail to inform practicing clinicians? Does the case have significant educational value? Does the case highlight important systems issues? If you are interested in submitted a case, please visit: https://psnet.ahrq.gov/webmm/submit-case. You may be contacted if further information is needed to judge your case submission.
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Content ArticleThis National Guardians Office report analyses the themes and learning from their review of the speaking up culture at Blackpool Teaching Hospitals which was undertaken 2020. The National Guardians Office received information indicating that a speaking up case may not have been handled following good practice. The information received also suggested black and minority ethnic workers had comparatively worse experiences when speaking up. Based on focus groups and interviews with Trust workers, and analysis of internal processes and data, the report reviews information about the trust’s speaking up culture and arrangements and the trust’s support for its workers to speak up. The review found that work was underway to improve the organisation’s speaking up culture, but there were long-standing issues with the trust’s speaking up culture. There was a perception among some workers that speaking up was futile. Black and minority ethnic workers – and other groups – also reported facing barriers to speaking up. The review also found that some workers who had spoken up to national bodies had variable experiences. The report makes recommendations for actions which national bodies and the healthcare system as whole can take to support organisations, including bringing national guidance into line with good practice and make that guidance universally applicable.
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Content Article
Delay in recognising placental abruption (30 June 2021)
Patient-Safety-Learning posted an article in Maternity
This case story about placental abruption, published by NHS Resolution, highlights the importance of regular risk assessments throughout labour to help prevent harm to mother and baby. It provides learning points and considerations that can be applied across all maternity units. -
Content ArticleEast Lancashire Hospitals NHS Trust (ELHT) is a healthcare provider treating over half a million patients a year in the North West. Back in 2013, they were investigated as part of the Keogh Review and as a result were categorised as an organisation in “special measures”. Morale amongst the staff consequently hit rock bottom, against a backdrop of negative media articles. Staff engagement was identified as a fundamental driver to improve staff and patient experience. However, it was appreciated that the cultural change required would take time to achieve. To gain regular feedback from their staff, they used the Staff Friends and Family Test (Staff FFT), to which they added several local questions. Based on this feedback and information from the NHS Staff Survey, they set about rebuilding ELHT with the clear intention to create a culture where staff felt they belonged. Read their case study.
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NICE: Shared learning case studies
Sam posted an article in Suggest a useful website
The National Institute for Health and Care Excellence (NICE) have over 800 examples of shared learning, showing how NICE guidance and standards have been put into practice by a range of health, local government and social care organisations. -
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Alison – the emotional impact of dementia on relationships
Claire Cox posted an article in Learning disabilities
This is Alison’s Story. The charity MacIntyre supports Alison. She has Down’s Syndrome and a diagnosis of dementia. Her story is one of relationships and the emotional impact that dementia can have on friendship. Alison has a really close relationship with Rachel, her best friend who she also lives with. In this case study you will hear: who Alison is how she received her diagnosis of dementia a reflection on Alison's diagnosis by her support manager. -
Content ArticleThe Marmot Review into health inequalities in England was published on 11 February 2010. It proposes an evidence based strategy to address the social determinants of health, the conditions in which people are born, grow, live, work and age and which can lead to health inequalities. Summary of findings and recommendations People living in the poorest neighbourhoods in England will on average die seven years earlier than people living in the richest neighbourhoods. People living in poorer areas not only die sooner, but spend more of their lives with disability – an average total difference of 17 years. The Review highlights the social gradient of health inequalities - put simply, the lower one's social and economic status, the poorer one's health is likely to be. Health inequalities arise from a complex interaction of many factors – housing, income, education, social isolation, disability - all of which are strongly affected by one's economic and social status. Health inequalities are largely preventable. Not only is there a strong social justice case for addressing health inequalities, there is also a pressing economic case. It is estimated that the annual cost of health inequalities is between £36 billion to £40 billion through lost taxes, welfare payments and costs to the NHS. Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community.
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Content ArticleThe Care Quality Commission (CQC) is the independent regulator of health and social care in England. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve. In this series of case studies, CQC highlight what providers have done to take a flexible approach to staffing. The case studies show different ways of organising services. They focus on the quality of care, patient safety, and efficiency, rather than just numbers and ratios of staff. They illustrate how providers have redesigned services to make the best use of the available range of skills and discipline or they found new ways to work with others in the local health and care system. Safe, effective staffing is about having enough people with the right skills, in the right place, at the right time. It's about team work, not silo working. It's about developing staff to support each other in new roles - making sure patients follow the smoothest possible journey on their care pathway.
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Content ArticleDue to the high morbidity and disability level among diabetes patients in nursing homes, the conditions for caregivers are exceedingly complex and challenging. The patient safety culture in nursing homes should be evaluated in order to improve patient safety and the quality of care. Thus, the aim of this study was to examine the perceptions of patient safety culture of nursing personnel in nursing homes, and its associations with the participants’ (i) profession, (ii) education, (iii) specific knowledge related to their own residents with diabetes, and (iv) familiarity with clinical diabetes guidelines for older people. The findings from this study, published in BMC Nursing show that advanced education and familiarity with current diabetes guidelines was related to adequate evaluations on essential areas of patient safety culture in nursing homes.
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Content ArticleThe use of artificial intelligence (AI) in patient care currently is one of the most exciting and controversial topics. It is set to become one of the fastest growing industries, and politicians are putting their weight behind this, as much to improve patient care as to exploit new economic opportunities. In 2018, the then UK Prime Minister pledged that the UK would become one of the global leaders in the development of AI in healthcare and its widespread use in the NHS. The Secretary for Health and Social Care, Matt Hancock, is a self-professed patient registered with Babylon Health’s GP at Hand system, which offers an AI-driven symptom checker coupled with online general practice (GP) consultations replacing visits at regular GP clinics. The use of artificial intelligence (AI) in patient care can offer significant benefits. However, there is a lack of independent evaluation considering AI in use. This paper from Sujan et al., published in BMJ Health & Care Informatics, argues that consideration should be given to how AI will be incorporated into clinical processes and services. Human factors challenges that are likely to arise at this level include cognitive aspects (automation bias and human performance), handover and communication between clinicians and AI systems, situation awareness and the impact on the interaction with patients. Human factors research should accompany the development of AI from the outset.
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Content ArticleThe Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) is a process supported by the Resuscitation Council (UK) and UK Royal Colleges to create personalised anticipatory care plans for patients. Hampshire Hospitals NHS Foundation Trust has been an early adopter of this process with variability in engagement with this process across our trust. Published in Progress in Palliative Care, this paper describes a quality improvement project was performed to improvement engagement with ReSPECT as well as consistency and quality of documentation.
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Content Article
Patient Safety Journal
Claire Cox posted an article in Suggest a useful website
The latest issue of the Patient Safety Journal is now out. US patient safety journal brought to you by the Patient Safety Authority, an independent agency of the Commonwealth of Pennsylvania. Each issue publishes original, peer-reviewed research and data analyses and also gives patients a voice. It's mission is to give clinicians, administrators and patients the information they need to prevent harm and improve safety. Patient Safety - June 2023 Patient Safety - March 2023 Patient Safety - December 2022 Patient Safety - September 2022 Patient Safety - June 2022 Patient Safety - March 2022 Patient Safety - January 2022 Special Issue: Pharmacy Education and Practice Patient Safety - December 2021 Patient Safety - September 2021 Patient Safety - June 2021 Patient Safety - March 2021 Patient Safety-December 2020 Patient Safety - September 2020 Patient Safety Journal - June 2020 Patient Safety March 2020 Patient Safety - December 2019 Patient Safety - September 2019 -
Content Article"It’s time to halt, take a break, and redraw the relationship between patient care and self-care. Self-care isn’t an optional luxury. It must sit at the heart of what we do, to ensure our teams can continue to rise to the challenges of working in the 21st century NHS, to give our patients the best of both ourselves, and the organisation so many of us are proud to be a part of." This editorial by Dr Michael Farquhar, published in Anaesthesia, explains the importance of taking breaks while on shift and ensuring a good sleep between shifts and the inextricable link between sleep and patient safety.
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Content ArticleThis case story is based on real events; NHS Resolution is sharing the experience of those involved to help prevent a similar occurrence happening to patients, families and staff. Key learning points An abnormal antenatal cardiotocograph (CTG) may represent chronic fetal hypoxia. Consideration should be given to the use of an antenatal CTG classification system (see example CTG sticker) and/or computerised cCTG. Intrapartum CTG classification may not be appropriate in women who are not in established labour. Where there are CTG concerns and fetal well-being cannot be further assessed, obtain senior review and consider expediting the birth. Clear communication with the woman giving birth, birth partner(s) and maternity team is an essential part of good clinical care.
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Whistleblowing disclosures joint report 2019
Patient Safety Learning posted an article in Whistle blowing
On April 1 2017, a new legal duty came into force which required all prescribed bodies to publish an annual report on the whistleblowing disclosures made to them by workers. The Nursing and Midwifery Council has published a a joint whistleblowing disclosures report with other healthcare regulators. The aim in this report is to be transparent about how we handle disclosures, highlight the action taken about these issues, and to improve collaboration across the health sector. As each regulator has different statutory responsibilities and operating models, a list of actions has been devised that can accurately describe the handling of disclosures in each organisation. -
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Impact of the new medical examiner role on patient safety
Claire Cox posted an article in Organisational
In an analysis published in the BMJ, Alan Fletcher and colleagues outline how the new medical examiner system could create a world leading mortality review system if implemented appropriately. -
Content ArticleFollowing the investigation into the Mid Staffordshire Hospital (United Kingdom) and the subsequent Francis reports (2013 and 2015), all healthcare staff, including students, are called upon to raise concerns if they are concerned about patient safety. Despite this advice, it is evident that some individuals are reluctant to do so and the reasons for this are not always well understood. This research study from Fisher and Kiernan, published in Nurse Education Today, provides an insight into the factors that influence student nurses to speak up or remain silent when witnessing sub-optimal care. Four key themes were identified in the study: context of exposure fear of punitive action team culture hierarchy. On the one hand, students recognised there was a professional obligation bestowed upon them to raise concerns if they witnessed sub-optimal practice; however, their willingness to do so was influenced by intrinsic and extrinsic factors. Students have to navigate their moral compass, taking cognisance of their own social identity and the identity of the organisations in which they are placed.
