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NHS England has commenced a review of digital clinical safety standards DCB0129 and DCB0160 to ensure they remain up-to-date, practical and aligned with the latest advancements in healthcare technology and clinical practice. Compliance with these standards is required under the Health and Social Care Act 2012. They provide essential requirements for manufacturers of health IT systems and healthcare providers in assessing and managing clinical risks to ensure the safety of digital solutions used across the NHS and adult social care services in England. NHS England are actively seeking input from a range of stakeholders, including NHS professionals, IT manufacturers and those involved in digital risk assessment. This will support us to review the standards and ensure they remain effective in safeguarding patient safety and practical in their application. To register your interest in participating in a DCB0129 focus group, please complete the expression of interest form by 10 January 2025.

This is a guide for designers, developers and users of AI in healthcare. It outlines general principles health and social care professionals should consider, a case study drawn from clinical practice and a directory of resources to find out more. It includes key questions that clinicians and AI developers need to answer together to ensure the best possible outcomes. It follows on from the CIEHF's White Paper, Human Factors in Healthcare AI, which sets out a human factors perspective on the use of AI applications in healthcare.

A hospital-acquired pressure ulcer (HAPU) is a localised lesion or injury to the underlying tissue (wound) that happens while a patient is staying in hospital. It occurs when standardised nursing care is not correctly followed in the presence of friction and shear, leading to skin or underlying tissue breakdown. Unfortunately, inadequate knowledge of nurses to assess and provide standardised care for pressure ulcers or manage HAPUs results in patient harm. This study shared lessons from a reported HAPU incident and aimed to address the knowledge gap in patient safety risk assessment, identification and wound management at Nyaho Medical Centre (Accra, Ghana). A review of HAPU incidents was conducted using quality improvement tools such as cause-and-effect analyses to identify contributing factors and root causes. Subsequently, plan-do-study-act (PDSA) cycles were used to test interventions to improve pressure ulcer assessments and wound management. A run chart was used to analyse and evaluate the interventions over time. Development of policies, SOPs and training for assessing and managing pressure ulcers and wounds reduced the number of HAPUs during the project period. This project demonstrated that the combined use of quality methods and tools can be suitable for improving processes and outcomes for patients at risk for HAPUs.

Diagnostic error is a significant category within preventable patient harm, and it takes many years of effort to develop proficiency in diagnostic reasoning. This article proposes a set of questions that prompts careful consideration, analysis, and signposting of decision-making processes, to assist students in transitioning from medical school to the real-world of work and achieving diagnostic excellence in clinical settings. One of the key challenges medical schools must address is preparing students for the complexity, uncertainty and clinical responsibility in going from student to doctor. Recognising the importance of both cognitive and systems-related factors in diagnostic accuracy, we designed the QUID Prompt (Questions to Use for Improving Diagnosis) for students to refer to at the bedside.

This NCEPOD report looks at the quality of care provided to patients with Parkinson’s disease (PD) aged 16 years and over who were admitted to hospital when acutely unwell. It highlights the findings of a review into the pathway of care for patients with Parkinson’s disease (PD) which explored multidisciplinary care and organisational factors in the process of identifying, screening, assessing, treating and monitoring their ability to swallow. You can view and download the following diagrams related to the report: Full report Summary report Summary sheet Recommendation checklist   Infographic Slide set Commissioners' guide Fishbone diagram Recommendations Audit toolkit Key messages Document the swallow status of all patients with PD at the point of referral to hospital Screen patients with PD for swallowing difficulties at admission Refer patients with PD who have swallowing difficulties (or who have problems with communication) to speech and language therapy Notify the specialist PD service (hospital and/or community) when a patient with PD is admitted, if there is any indication from the notes, or following discussion with the patient or their relatives/carers, that there has been a deterioration or progression of their clinical state Provide written information at discharge on how to manage swallowing difficulties

In this opinion piece in The BMJ, consultant radiologist Giles Maskell examines changes to the ways in which medical imaging is used in the health service. He states that imaging used to be ordered, when necessary, at the end of a diagnostic process, whereas now many doctors are asking for scans before they will see a patient for the first time. The article highlights some of the implications of this shift in practice, including on screening service capacity and on the interpretation of test results.

Many clinicians and managers struggle with the concept of waste in clinical processes. After hearing and reading about the transformation of healthcare at Virginia Mason Medical Center in Seattle, the Gordon Caldwell read Toyota Culture the Heart and Soul of the Toyota Way. This article discusses some of the concepts of waste in clinical processes, concentrating particularly on the waste and costs of over-investigation.

This policy paper from the Department of Health and Social Care sets out the Government’s response to the recommendations of the investigation into the death of Elizabeth Dixon in respect of the failures of care she received from the NHS. Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The investigation chaired by Dr Bill Kirkup looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS. The report which set out the findings and recommendations of this investigation, The life and death of Elizabeth Dixon: a catalyst for change, was published on the 26 November 2020. This policy paper details the UK Government’s response each of the report’s recommendations. It also highlights a number of areas where action is being taken by government departments, arm’s length bodies and other organisations in response to the investigations recommendations.

This national primary care clinical pathway for constipation in children guidance supports clinicians in the prevention and management of constipation in children and young people by providing a clear and standardised approach, based on guidelines from the National Institute for Health and Care Excellence (NICE), the British National Formulary for Children (BNFc) and clinical expert groups. The pathway promotes available resources for clinicians, families and other care providers and ensures they are easily accessible, as well as raises the profile of constipation in children and young people with a learning disability as a factor in adult mortality rates.

A young person with a heart transplant and steroid-induced diabetes came into our surgery. This was at a time of high circulating levels of influenza, Covid and strep A. They presented with chest infection symptoms and were given antibiotics for chest infection by an advanced care practitioner. Advice was given to monitor blood glucose levels and temperature. A few days later the patient's mum rang as the patient was still coughing. The doctor spoke to the patient who sounded well. They were given an extended antibiotic course. The patient sadly passed away the following day. Following our significant event meeting following the event, we had a number of clinical meetings to learn more about the care of transplant patients. Despite being a full-time GP for 30 years, much of the information was unknown to me and probably unknown to the majority of GPs so we feel it is really important that transplant teams and primary care awareness is raised around this. We would like to use the hub to do this and promote safety netting that can easily be put in place to mitigate the risk. Our action points following the event: For all patients, when any third party information is passed from a professional this should be recorded exactly as reported with name and contact details of the professional (the information given to the on-call doctor resulted in a speedy response thinking a face to face would be needed, the subsequent telephone conversation left the impression of an improving condition hence no face to face). We should strive to improve communication with transplant units, providing our professionals a bypass number direct to reception to avoid answer phone messages and queues, and also seeking their number to break down any logistical barriers to communication. We have added all potential significant drugs that could interact with transplant patient medications, such as ibuprofen, clarithromycin, erythromycin, allopurinol as sensitivities so they are not prescribed in error (no prescribing issues in this case, but would be very easy for this to occur and cause severe renal failure on account of interaction with tacrolimus). We are adding the adrenal suppression code to alert us to the long-term steroid consequence and have highlighted significant increase risk of steroid-induced diabetes. We have added pop-ups that advise of the above that appear when we enter a transplant patient's notes (as long as transplant is coded). There is also a pop-up to advise that the normal presentation for unwellness may not apply, such as tachycardia or high temperature, raised CRP or white blood count, and to highlight that vomiting is a big concern as could impact on suppression medication and could also ppt adrenal crisis, thus low threshold for admission for IV treatment should be considered.

Double checking is a standard practice intended to improve patient safety. It is used in different areas of health care, such as medication administration, radiotherapy and blood transfusion. Some studies have found double checking to be a useful practice, which has been endorsed by agencies and individuals. The confidence in double checking exists in spite of the lack of evidence substantiating its effectiveness. In this study, Hewitt et al. asks: ‘How do front line practitioners conceptualise double checking? What are the weaknesses of double checking? What alternate views of double checking could render it a more robust process?’ The authors conclude that double checking deserves more questioning, as there are limitations to the process. Practitioners could view double checking through alternate lenses, and thus help strengthen this ubiquitous practice that is rarely challenged.

Keeping patients and staff safe is a top priority for every healthcare organisation. Leaders must be vigilant in continually monitoring, measuring, and improving risk, as well as identifying processes, environments, cultures and other factors affecting patient safety and organisational performance. ECRI’s Risk Assessments provide an efficient web-based solution for conducting such evaluations. These assessments collect multidisciplinary safety perspectives—from front-line workers to the executive suite—with reporting and analysis dashboards to help identify opportunities for improvement.

Very preterm infants are at increased risk of adverse outcomes in early childhood. This study in The Lancet Child & Adolescent Health assessed whether delayed clamping of the umbilical cord reduces mortality or major disability at two years. The authors found that clamping the umbilical cord at least 60 seconds after birth reduced the risk of death or major disability at two years by 17%, reflecting a 30% reduction in relative mortality with no difference in major disability.

This article in the Journal of Diabetes Science and Technology reviews the literature from various geopolitical regions and describes how a substantial number of patients with diabetes improperly discard their sharps. Data support the need to develop multifaceted and innovative approaches to reduce the risks associated with improper disposal of medical sharps into local communities.

This webinar from the Faculty of Clinical Informatics looks at the problems individual clinicians have with reporting and fixing issues with clinical systems across the NHS. Panel members also discuss ideas for how processes can be improved. The panel was made up of: Dr Marcus Baw, GP and Emergency Physician, Chair of the RCGP Health Informatics Group, FCI Fellow and open source developer Dr Ian Thompson, Clinical Lead (Primary Care) in Digital Health and Care at The Scottish Government Dr Lesley Kay, Consultant Rheumatologist at Newcastle Hospitals and Deputy Medical Director at the Healthcare Safety Investigation Branch  Emma Melhuish, Principal Informatics Specialist at NHS Digital Neil Watson, Director of Pharmacy, Newcastle Hospitals NHS Foundation Trust

Many diagnostic mistakes are caused by reasoning errors, but lack of feedback makes it difficult for healthcare providers to make improvements in this area. This paper, published in BMJ Quality & Safety, describes the reason for and process of developing 'The Diagnosis Learning Cycle', a new model for feedback and improvement in diagnosis. The model is based on theory and knowledge from both outside and within the field of healthcare. It proposes a standardised feedback mechanism that includes concrete measures of factors such as reasoning and confidence.

The Comprehensive Unit-based Safety Program (CUSP) is a method that can help clinical teams make care safer by combining improved teamwork, clinical best practices, and the science of safety. The Core CUSP toolkit gives clinical teams the training resources and tools to apply the CUSP method and build their capacity to address safety issues. A number of toolkits are available to help clinical teams adopt the CUSP method to make care safer. Most teams will want to start with the Core CUSP Toolkit to learn key principles of the CUSP method. Once you’ve learned the basics, additional toolkits can help you target certain safety issues in specific settings of care. Created for clinicians by clinicians, the Core CUSP toolkit is modular and modifiable to meet individual unit needs. Each module includes teaching tools and resources to support change at the unit level, presented through facilitator notes that take you step by step through the module, presentation slides, tools, and videos. Learn about CUSP Assemble the Team Engage the Senior Executive Understand the Science of Safety Identify Defects Through Sensemaking Implement Teamwork and Communication Apply CUSP The Role of the Nurse Manager Spread Patient and Family Engagement Learn about CUSP Assemble the Team Engage the Senior Executive Understand the Science of Safety Identify Defects Through Sensemaking Implement Teamwork and Communication Apply CUSP The Role of the Nurse Manager Spread Patient and Family Engagement

A report on the investigation into the death of Elizabeth Dixon and a series of recommendations in respect of the failures in the care she received from the NHS. Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube she asphyxiated and was pronounced dead at Frimley Park hospital on 4 December 2001. The investigation chaired by Dr Bill Kirkup looked at the events surrounding the care of Elizabeth and makes a series of recommendations in respect of the failures in the care she received from the NHS. Recommendations Hypertension (high blood pressure) in infants is a problem that is under-recognised and inconsistently managed, leading to significant complications. Its profile should be raised with clinicians; there should be a single standard set of charts showing the acceptable range at different ages and gestations; and a single protocol to reduce blood pressure safely. Blood pressure should be incorporated into a single early warning score to alert clinicians to deterioration in children in hospital. Community care for patients with complex conditions or conditions requiring complex care must be properly planned, taking into account and specifying safety, effectiveness and patient experience. The presence of mental or physical disability must not be used to justify or excuse different standards of care. Commissioning of NHS services from private providers should not take for granted the existence of the same systems of clinical governance as are mandated for NHS providers. These must be specified explicitly. Communication between clinicians, particularly when care is handed over from one team or unit to another, must be clear, include all relevant facts and use unambiguous terms. Terms such as palliative care and terminal care may be misleading and should be avoided or clarified. Training in clinical error, reactions to error and responding with honesty, investigation and learning should become part of the core curriculum for clinicians. Although it is true that curricula are already crowded with essential technical and scientific knowledge, it cannot be the case that no room can be found for training in the third leading cause of death in western health systems. Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error. There should be a clear mechanism to hold individuals to account for giving false information or concealing information relating to public services, and for failing to assist investigations. The Public Authority (Accountability) Bill drawn up in the aftermath of the Hillsborough Independent Panel and Inquests sets out a commendable framework to put this in legislation. It should be re-examined. The existing haphazard system of generating clinical expert witnesses is not fit for purpose. It should be reviewed, taking onto account the clear need for transparent, formalised systems and clinical governance. Professional regulatory and criminal justice systems should contain an inbuilt ‘stop’ mechanism to be activated when an investigation reveals evidence of systematic or organisational failures and which will trigger an appropriate investigation into those wider systemic failures. Scrutiny of deaths should be robust enough to pick up instances of untoward death being passed off as expected. Despite changes to systems for child and adult deaths, concern remains that without independent review such cases may continue to occur. The introduction of medical examiners should be reviewed with a view to making them properly independent. Local health service complaints systems are currently subject to change as part of wider reform of public sector complaints. Implementation of a better system of responding to complaints must be done in such a way as to ensure the integration of complaints into NHS clinical governance as a valuable source of information on safety, effectiveness and patient experience. The approaches available to patients and families who have not been treated with openness and transparency are multiple and complex, and it is easy to embark inadvertently on a path that is ill-suited to deliver the answers that are being sought. There should be clear signposting to help families and the many organisations concerned. Ministerial Statement Patient Safety Learning's statement on the Dixon Inquiry report