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Found 25 results
  1. Event
    This online event is an important update for prescribers, and for those who take prescribed medicines, on the RPS Prescribing Competency Framework. This framework was originally produced in by the National Prescribing Centre as a competency framework for all prescribers, and updated by the Royal Pharmaceutical Society (RPS) in 2016. Join this event to: Hear about the changes to the RPS competency framework for all prescribers. Hear how others in pharmacy and other healthcare professions are using the framework. Ask questions to colleagues who were involved in updating the framework. Register
  2. Content Article
    Medical Examiners of Deaths Proposed Change: We propose to include a new requirement for acute providers (NHS Trusts and Foundation Trusts only) to establish a Medical Examiner’s Office, in accordance with guidance published by the National Medical Examiner. The Office will, initially, review those deaths occurring on the Trust’s premises and not referred to the coroner, ensuring that the certification of death is accurate and scrutinising the care received by the patient before death. Patient Safety Learning supports this proposal. We welcome the decision to make the establishment of a Medical Examiner’s Office a requirement for acute providers. This proposal was first recommended following the Shipman Inquiry (2002-2005) and recent media coverage has revealed that a significant number of NHS trusts have still yet have appoint a Medical Examiner. Medical Examiners can play a key role in improving patient safety in cases where the patient’s death was the result of avoidable harm. They can provide vital insights into these cases and help to identify effective remedial actions to prevent their recurrence, as well as sharing this information for wider learning beyond their specific trusts. Patient Safety Incident Response Framework Proposed Change: The NHS Patient Safety Strategy indicates that the current NHS Serious Incident Framework and Never Events Policy Framework will be replaced, over the next two years, by a new single Patient Safety Incident Response Framework. To accommodate and signpost this planned change, we propose adding a specific reference to “successor frameworks” to the existing requirements relating to the current Frameworks. Patient Safety Learning supports the proposal to update requirements. We welcome the review of these frameworks and the development of a new Patient Safety Incident Response Framework (PSIRF). However, we have concerns about the delay in its release, which was initially expected towards the end of 2019 and now instead subject to a limited release this year with pilot organisations, rather than being shared more widely. We are also concerned about the lack of stakeholder engagement in this process, particularly for patients and families. Despite providing a valuable source of information when incidents occur, they are often not included in investigation processes. The failure to include and listen to patients and families in investigations can often result in more harm and increasing the likelihood of complaints and litigation. In updating these processes therefore it is vital their views are taken into account. National Patient Safety Alerts Proposed Change: The National Patient Safety Alerting Committee is establishing new, co-ordinated and accredited arrangements for the issuing of National Patient Safety Alerts to providers. We propose to include a new requirement for providers to ensure that they can receive each relevant National Patient Safety Alert, identify appropriate staff to coordinate and implement actions required within the timescale the Alert prescribes, and confirm and record when those actions have been completed. Patient Safety Learning supports this proposal. We welcome steps to ensure providers have appropriate arrangements in place to coordinate and implement actions required by national patient safety alerts and record when these have been completed. A recent report by Action Against Medical Accidents, An organisation losing its memory?, has indicated that a number of trusts have experienced significant delays in introducing safer practices highlighted by national patient safety alerts. They found in many cases that the trusts experiencing delays ‘indicated that they were in the process of improving internal systems for overseeing the implementation of patient safety alerts’. It is a positive step to see this is now being added to the NHS Standard Contract as a formal requirement for them to do so. However, we have concerns beyond the scope of these contractual obligations that this process does not appear to be monitored at a national level. While these measures place specific responsibilities on providers, we are not clear on what, if any, oversight arrangements will be put in place to accompany these. We think such national monitoring and public reporting is essential and would look for this to be implemented as a priority. Patient Safety Specialists Proposed Change: The NHS Patient Safety Strategy envisages the establishment of a network of patient safety specialists, one in each provider, to lead safety improvement across the system. We therefore propose to include a requirement on each provider to designate an existing staff member as its Patient Safety Specialist. Patient Safety Learning supports this proposal. We support this proposal in principle but have reservations about how this will be implemented in practice. The requirement to appoint a Patient Safety Specialist, as set out in the NHS Patient Safety Strategy, currently lacks detail about the nature of this role. What do we mean by a ‘Safety Specialist’? What knowledge and training should they have? Will the appropriate governance arrangements be in place to make sure their voice is heard by the organisation’s leadership? We think these arrangements should be specified, resourced, monitored and transparently reported. We will be responding to the separate consultation on this which opened on the 30 January 2020 in more detail. Common sources of harm to patients in hospital/Safety Thermometer Proposed Change: Feedback suggests that the existing Contract requirements on use of the Safety Thermometer are creating too great a bureaucratic burden, and not facilitating learning. We therefore propose to remove the specific requirements relating to use of the Safety Thermometer and, instead, introduce a higher-level obligation on acute providers to ensure and monitor standards of care in the four clinical areas which the Safety Thermometer addresses – venous thromboembolism, catheter-acquired urinary tract infections, falls and pressure ulcers. At Patient Safety Learning we believe that the health and social care system should develop models for measuring, reporting and assessing patient safety performance. This data should be gathered centrally and then used for learning and to implement actions that improve care. With regards to the removal of Safety Thermometer requirement, while we recognise that it has been noted that this has not been effective in facilitating learning, we would expect the newly proposed measures to follow these principles. We would also expect patient safety measurement to apply to all NHS organisations, rather than being an obligation limited to acute providers.
  3. Content Article
    This White Paper: describes the framework's two foundational domains, culture and the learning system, outlining what is involved with each and how they interact provides definitions and implementation strategies for nine interrelated components (leadership, psychological safety, accountability, teamwork and communication, negotiation, transparency, reliability, improvement and measurement and continuous learning) discusses engagement of patients and their families, the core of the framework, the engine that drives the focus of the work to create safe, reliable, and effective care. Healthcare organisations and systems may use the framework as a roadmap to guide them in applying the principles, and as a diagnostic tool to assess their work to date. Although initially focused on the acute care setting, the framework has evolved to be more broadly applicable in any setting, in acute care, ambulatory care, home care, long-term care and in the community.
  4. Content Article
    There have been many advancements in medical education over the past 20 years, including how outcomes such as competencies are defined and used to guide teaching and learning. To support this positive change, the AAMC has launched the New and Emerging Areas in Medicine series. This first report in the series focuses on quality improvement and patient safety (QIPS) competencies across the continuum of medical education. It presents a roadmap for curricular and professional development, performance assessment, and improvement of healthcare services and outcomes. The competencies can help educators design and deliver curricula and help learners develop professionally. The competencies are for use in: engaging diverse health care professionals in collaborative patient-safety-improvement discussions, including cross-continuum and cross-discipline colleagues conducting gap analyses of local curricula and training programmes planning individual professional development developing curricular learning objectives developing assessment tools furthering research and scholarship in medical education and quality improvement guiding the strategic integration of QIPS into the curricula and the clinical learning environment.
  5. Content Article
    Shared learning for patient safety Organisations should set and deliver goals for learning from patient safety, report on progress and share their insights widely. We have created the hub, an online platform and community for people to share learning about patient safety problems, experiences and solutions. We research and report on the effectiveness of investigations into unsafe care. Leadership for patient safety We call for overarching leadership for patient safety across the health and social care system. We propose a Leadership Forum for Patient Safety that will lead the design and co-ordination of safe care and emphasise a systems approach and human factors. We recommend that all health and social care organisations publish annually their goals and outcomes for safer care. We recommend that integrated care systems set standards for patient safety in service commissioning, care delivery and care pathway design. We will work with the health and social care system to support strengthening leadership for patient safety. Professionalising patient safety Standards and accreditation for patient safety need to be developed and implemented. These need to be used by regulators to inform their assessment of safe care. We will work with the health and social care system to support the development of these standards. A competency framework for patient safety is needed to ensure that all staff are ‘suitably qualified and experienced’. We propose to work with Health Education England and others to develop this. Health and social care organisations need specialist patient safety and human factors experts with leadership support, resources and governance. hese roles must be clearly defined, with reporting lines to the board (both Executive and Non-Executive). These specialists will help lead re-design for safety, as well as learning from unsafe care, patient engagement, complaints, near misses, clinical reviews and audits. Guidance, resources and toolkits need to be developed and implemented with the support of specialist expertise in patient safety and human factors. We will promote and share these through the hub. Patient engagement for patient safety We will work with the health and social care system to encourage and support the actions necessary to ensure patients are valued and engaged in patient safety. We will initiate development of ‘harmed patient care pathways’ for patients, families and staff following a serious incident. We will help develop and support effective patient advocacy and governance for patient safety. Data and insight for patient safety Models for measuring, reporting and assessing patient safety performance are needed that include quantitative as well as qualitative data. We will convene a panel of experts to identify the critical data and insight needed to measure and monitor patient safety. We will work to ensure that patient safety is designed into digital health initiatives as a core principle, rather than an add-on. Just Culture All health and social care organisations should develop programmes and publish goals to eliminate blame and fear, introduce or deepen a Just Culture and measure and report their progress. We will celebrate great work and innovation for patient safety through our Patient Safety Learning Awards and the hub.
  6. Content Article
    This website links with some of the work that the BMA do: Trade union representation. Individual support and advice. Lobbying. Legal and financial services. Patient information - signposting on how the NHS works.
  7. Content Article
    Key points of the paper: Suggests national safety standards for invasive procedures (NatSSIPs) should be read and acted on by all invasive procedure teams, including dentists. Highlights that involvement of all staff in development of a local safety standard for invasive procedures is important to ensure a policy that is successful in improving patient safety in your workplace. Suggests the whole dental team should take responsibility for continually improving patient safety.
  8. Content Article
    The Framework identifies the competencies and areas necessary for organisational leadership and management of health services, acknowledging there should be a balance between three domains: Personal attributes. Core functions of leadership: competencies relating to a leader’s ability to set direction and know how to prepare an organisation for safe and effective service delivery. Ability to ‘Execute’/Mise-en-place: competencies relating to a leader’s ability to create enabling environments, systems, processes and mechanisms, and to empower people for delivering patient-centered, quality and safe services.
  9. Content Article
    This article includes: a comprehensive search of standards. aims to improve the quality of health apps, and is a critical ’stepping stone’ to producing actionable guidelines for developers and adopters.
  10. Content Article
    A Blueprint for Action identifies two core issues that underpin the persistence of avoidable harm. The first is that by treating patient safety as a ‘priority,’ healthcare organisations make the safety of patients open to compromise. A Blueprint for Action makes the case that patient safety it is more than a ‘priority’ – it is part of the core purpose of healthcare. The second core issue identified in A Blueprint for Action is that unlike, for example, fire safety, no person or body sets patient safety standards for healthcare organisations. As a result, the health and social care systems have no way to ensure that patients everywhere receive the same high standards of safe care. A Blueprint for Action identifies six foundations of safe care. These include shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture. A Blueprint for Action proposes a range of actions to address these foundations. These include the development of the hub for clinicians, researchers and patients to share learning and solutions for patient safety with communities of peers; establishing a forum of leaders to set standards and good practice for leadership of patient safety; developing a competency framework for patient safety; creating harmed patient care pathways to better support patients and staff following incidents of patient safety; convening a symposium of experts to develop better ways to measure and manage patient safety; and advocacy for adoption of what Professor Sydney Dekker has termed a Just Culture. Download A Blueprint for Action in full. Alternatively, you can download the Executive Summary. In addition, we have created a visual summary of A Blueprint for Action, primarily for print purposes but also available to download. We would love to hear your thoughts on our Blueprint for Action and work with you to explore pushing these actions forward. If you would like to be part of this work, please contact info@patientsafetylearning.org We’ve already received strong support from patient, clinical and patient safety thought leaders and campaigners, including the following statements. Dr Ted Baker, Chief Inspector of Hospitals, Care Quality Commission, said, “In our recent report “Opening the Door to Change” I called for a new era of leadership, focused on safety culture, engaging staff and involving patients. I strongly welcome “A Blueprint for Action” as it lays out how everyone involved in healthcare, including patients, can work together to bring about the change in culture that is needed to make our healthcare as safe as it can be.” Dr Annie Hunningher, Barts Health, said, “This paper sets out the vision that we can change the way we structure, describe the processes and measure outcomes for true safety. It is leading the charge to understand and support a culture, a system, the multidisciplinary education and ‘metrics that matter’ to deliver safer care. Safety has been the Cinderella of healthcare management, not a priority and under-resourced. We now have an opportunity to collaborate and commit to genuine safety improvement. By setting standards, professionalising safety with ward to board safety understanding, and involving our patients we can collaboratively find the path to transform the future. Thank you Patient Safety Learning!” Rachel Power, Chief Executive of the Patients Association, said, “Patient Safety Learning’s blueprint offers a convincing analysis and a coherent set of solutions – we support their approach, and their aim to bring patient safety into the mainstream. We agree that the solution must involve recognising patients as active partners in their care, ensuring that they are able to raise concerns when things are going wrong, and engaging them fully in all aspects of patient safety. It must be an over-riding priority for the NHS that patients are safe when they are in its care.” Tom Kark QC, author of the 2019 Kark Review of the Fit and Proper Person Test, said, “The Patient Safety Learning Blueprint for Action is an important paper and could make a significant change to patient safety if… its proposals are put into effect.” Professor Albert Wu of Johns Hopkins Bloomberg Center for Public Health, said, “Knowledge and know-how are crucial to improving the safety of health care. This first entails awareness, and then actual learning, on the part of clinicians, leaders and managers, and patient and families. Patient Safety Learning is dedicated to engaging the hearts and minds of all of these essential players. I foresee that they will play an important role in helping us learn together. Their publication, A Blueprint for Action, lays out a way forward.” For the Academic Health Sciences Network (AHSN), Dr Cheryl Crocker, Network Patient Safety Lead and Natasha Swinscoe, Network Lead MD Patient Safety, said, “We welcome the Blueprint for Action report and fully support the call to co-ordinate improvement programmes better across systems. This encapsulates the focus of our patient safety work through The AHSN Network. We are delighted to be supporting Patient Safety Learning and are well-placed to make an active contribution in both health and care to all six recommended actions.” Peter Walsh, Chief Executive, Action against Medical Accidents (AvMA), said, “This report is a welcome and sensible reminder of the sort of approach that I believe most people agree is needed to breathe new life into work on patient safety. We must not allow patient safety to be put in the ‘too difficult box’. It is far from fixed and it is vital that we have an approach which is fair and sensitive to the needs and contributions of both patients and staff.” Andrew Corbett-Nolan, Chief Executive (Partner), Good Governance Institute, said: "This Blueprint for Action provides a crucial contribution to improving patient safety in health and social care. The report is a practical resource to support and sustain safe care. It is a must read for Board members of health and care organisations." Peter Homa, Chair, NHS Leadership Academy, said, “A Blueprint for Action” is a magisterial summary of how we can, together, create a safer, more humane environment for patients, their loved ones and staff. International evidence is drawn upon to describe the preconditions for success including the requirement to learn from errors. We should ensure that the positive impact of learning from an error is far greater than the negative impact of the original error. This report and its authors, Patient Safety Learning, are powerful positive forces that will help us create a healthcare that is “patient safe”
  11. Community Post
    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
  12. Community Post
    I met at a recent conference a newly appointed Patient Safety Manager. She’d been working in a supporting role in another organisation and was delighted with her obviously well deserved promotion to a more senior role of patient safety manager in another Trust. But 6 days in, she’s had no induction, there is no patient safety strategy or plan in the Trust, there isn’t any guidance as how she should do her job other than just ‘get on with doing RCAs. ‘ She doesn’t know who she can turn to for advice or support either in her Trust or elsewhere. Are there networks of PSMs she can turn to? Surely there is a model framework for patient safety that is produced as a guide? How can we help her and other PSMs?
  13. Content Article
    'To support all prescribers in prescribing safely and effectively, a single prescribing competency framework was originally published by the National Prescribing Centre/National Institute for Health and Care Excellence (NICE) in 2012. NICE and Health Education England approached the Royal Pharmaceutical Society (RPS) to manage the update of the framework on behalf of all the prescribing professions in the UK. A Competency Framework for all Prescribers was first published by the RPS in July 2016. Going forward, the RPS will continue to maintain and publish this framework in collaboration with a multi-disciplinary group with representatives from professional regulators, professional organisations, prescribers from all prescribing professions, lay representatives and other relevant and interested stakeholder groups from across the UK. ' Since the 2016 framework, there have been various changes that needed to be included in the update of the framework, these include: Legislation changes introducing paramedic prescribers in April 2018. Current prescribing topics, such as remote prescribing, social prescribing, psychosocial assessment and eco-directed sustainable prescribing. Publication of the RPS Competency Framework for Designated Prescribing Practitioners in December 2019; for further information, please see 'A competency framework for designated prescribing practitioners'. Supporting tools
  14. Content Article
    The Prescribing Competency Framework covers 10 areas, all of which are essential to medication safety (the version in this blog was updated in May 2022). In plain language they are: The consultation Assessment of the patient’s presenting complaint and medical history and other areas such as medicines history, adherence[3] and Safeguarding. Prescribing options (including stopping / reducing medicines). Always Involving the patient, including reaching a ‘shared decision’ on the treatment, or respecting the patient’s right to refuse.[3] Writing legible / legal prescriptions, with full & unambiguous directions. Providing information on medicines & following this up with the patient. Monitoring and reviewing the effect of medicines and acting on this. Prescribing governance Safe prescribing, including ensuring that allergies, sensitivities, adverse reactions, and interactions are acted on appropriately. Prescribing professionally, including record keeping, staying up to date on guidance and following all related laws (e.g. the Mental Capacity Act)[4]. Improving prescribing practice through audit, clinical supervision, clinical governance, meaningful patient involvement and continuing professional development. Prescribing as part of a multi-disciplinary team, and as part of wider inter-disciplinary care plan(s), in all settings Since the advent of ‘non-medical prescribing’ (i.e. prescribing by healthcare professionals other than doctors) over 15 years ago, prescribing has been a subject that is taught and assessed at Universities. Only experienced and specifically qualified registered healthcare professionals can prescribe medicines. Becoming a non-medical prescriber involves an in-depth course of both written and oral (scenario based) assessment, and not all who undertake it pass. The bedrock of this course is the Prescribing Competency Framework. Embedding the framework In view of the obvious benefits of following a competency framework for prescribing, here are some questions for reflection: 1. Do the prescribers in your team use the competency framework? 2. Is the competency framework part of the prescribing CPD in your organisation? 3. Is the competency framework used as part of prescribers’ annual appraisals? 4. How is prescribing competency monitored in your organisation, and is the competency framework included in clinical supervision? 5. Does your organisation use the prescribing competency framework in clinical governance sessions? 6. Is the prescribing competency framework referred to in incident investigation reports? The framework is missing from the narrative of major investigations I can find great examples of the implementation and the resulting patient safety benefits of points 1 to 5 above. Although I am saddened to see references to the prescribing competency framework missing in major investigations, inquests, and related commentaries. Elizabeth Dixon Major examples of failings where prescribing competency was a contributory factor include the death of Elizabeth Dixon[5]. It appears that a failure to review opiate prescribing, and failings in inter-disciplinary communication and monitoring of medicines may have contributed to her death. ‘…the daily dose of morphine was increased over fivefold. While this may be an appropriate pattern in a child with progressive and painful malignant disease nearing the end of life, there was no evidence that this was the case for Elizabeth. The repeated increases in morphine administration are likely to have contributed further to the tendency for secretions to accumulate in the tracheostomy tube and require frequent suctioning.’[5] Oliver McGowan Another case where the competency in prescribing is relevant is that of Oliver McGowan, a teenager with autism and mild learning disability. He died in 2016 following experiencing neuroleptic malignant syndrome after administration of an antipsychotic medicine that he had previously reacted adversely to. Oliver did not have a mental illness, psychosis or a history of challenging behaviour. He was prescribed an antipsychotic medicine despite a number of prescribing 'red flags' being present. This medicine was listed in the ‘allergies’ column of his drug chart and in his ‘Hospital Passport’, his parents and Oliver himself had asked not to be given the medicine, an alternative non-drug related option had been recommended, and an email had been sent by A&E doctors warning of Oliver’s sensitivity to antipsychotics. I recommend prescribers study this case and look the available information, which I attempted to summarise in a presentation in 2019. At the inquest into Oliver’s death the coroner concluded that his care was ‘appropriate’[6] and was reported as saying that Oliver’s medicines were ‘properly prescribed’. There followed a Learning from Deaths Review [LeDeR] into Oliver’s death. This made no recommendations. This review was met with incredulity by Oliver’s parents, and by some clinicians. As a result, there was a review into the LeDeR process for Oliver McGowan[7]. This review, which covered the process of the first review only, was highly critical. It found that the author of the first LeDeR review felt bullied into toning down the initial report, and subsequently left her job: ‘The interviewer asked what would have happened if she had not done this. Ms A replied: I would have been sacked, no doubt about it, they never said this, but I knew’ ‘…I could never work there again’ As far as I am aware there have been no specific recommendations in relation to prescribing because of Oliver McGowan’s death, and the prescribing competency framework has not been mentioned in any related NHS report or commentary. Richard Handley Other cases where prescribing competency is a factor include that of Richard Handley, who died from complications because of constipation. Richard was a 33-year-old adult with Down’s syndrome and a moderate learning disability who was also diagnosed with a mental illness and hypothyroidism and had lifelong problems with constipation. I also understand, for reading about this tragic case that Richard was prescribed medicines which had a side-effect of constipation. A serious case review[8] in 2015 identified multiple failings, however prescribing is not specifically listed. I believe this is a missed opportunity for learning and include discussion of Richard’s case in my teaching on medicines and prescribing. In writing this piece I was surprised to discover that the prescribing competency framework does not appear to have been referenced in any of the reports mentioned above. Final thoughts Given the annual expenditure on medicines with the benefits and risks involved in their use, it seems surprising to me that the art and science of prescribing medicines receives so little attention in investigation reports, and from public bodies. I believe patients, the public and healthcare practitioners need to be aware of the Prescribing Competency Framework and why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out if we believe it is not being followed. At present it appears that, since the demise of the National Prescribing Centre, no national body is picking up on this need for more awareness, training and education specifically related to prescribing. I believe that patients are being harmed and lives may be being lost as a direct result of this gap in learning. May 2022 update: The Oliver McGowan Mandatory Training in Learning Disability and Autism has now been launched after passing into law as part of the Health and Care Act 2022. The training aims to ensure that staff working in health and social care receive learning disability and autism training, at the right level for their role. In an interview for Woman's Hour, Oliver's mum Paula talks about Oliver and the events that led to his death, as well as discussing the new mandatory training. References University of Sheffield, More than 200 million medication errors occur in NHS per year, say researchers, 23 February 2018. Royal Pharmaceutical Society, Prescribing Competency Framework for all Prescribers, September 2021. National Institute for Health and Care Excellence, Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. NICE Clinical Guideline CG76, 28 January 2009. UK Government, How to make decisions under the Mental Capacity Act 2005, 30 September 2014. Dr Bill Kirkup CBE, The life and death of Elizabeth Dixon: a catalyst for change, November 2020. INQUEST, Coroner concludes care of Oliver McGowan was ‘appropriate’ despite parents’ pleas not to use medication which led to the teenager’s death, 20 April 2018. Fiona Ritchie OBE, Independent Review into Thomas Oliver McGowan’s LeDeR Process Phase two, (8, 7, 12. & 7.19), October 2020. Flynn Margaret and Eley Ruth, A serious case review: James’ Suffolk Safeguarding Adults Board (restricted access), Social Care Institute for Excellence, 2015.