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ECRI’s list of patient safety concerns for 2020: 1. Missed and delayed diagnoses—Diagnostic errors are very common. Missed and delayed diagnoses can result in patient suffering, adverse outcomes, and death. 2. Maternal health across the continuum—Approximately 700 women die from childbirth-related complications each year in the U.S. More than half of these deaths are preventable. 3. Early recognition of behavioural health needs—Stigmatisation, fear, and inadequate resources can lead to negative outcomes when working with behavioural health patients. 4. Responding to and learning from device problems—Incidents involving medical devices or equipment can occur in any setting where they might be found, including ageing services, physician and dental practices, and ambulatory surgery. 5. Device cleaning, disinfection, and sterilisation—Sterile processing failures can lead to surgical site infections, which have a 3% mortality rate and an associated annual cost of $3.3 billion. 6. Standardising safety across the system—Policies and education must align across care settings to ensure patient safety. 7. Patient matching in the EHR—Organisations should consistently use standard patient identifier conventions, attributes, and formats in all patient encounters. 8. Antimicrobial stewardship—Over prescribing of antibiotics throughout all care settings contributes to antimicrobial resistance. 9. Overrides of Automated Dispensing Cabinets (ADC)—Overrides to remove medications before pharmacist review and approval lead to dangerous and deadly consequences for patients. 10. Fragmentation across care settings—Communication breakdowns result in readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and dissatisfaction.

The guidelines offer updated guidance on the diagnosis, assessment, care and management of patients with PDOC. They support doctors, families and health service commissioners to ensure that everyone is aware of their legal and ethical responsibilities. The guidelines cover: Definitions and terminology of PDOC. Techniques for assessment, diagnosis and review. Care pathways from acute to long-term management. The ethical and medico-legal framework for decision-making. Practical decision-making regarding starting or continuing life-sustaining treatments, including CANH, and management of end-of-life care for PDOC patients. Service organisation and commissioning.

In the case that HSIB examined, 26-year old Abby presented at her emergency department (with a suspected urinary tract infection and unable to pass urine) on Saturday. Following a positive pregnancy test, she was referred to an EPU for scan on the same day and discharged home. Abby didn’t have a scan until Tuesday (after following up with the EPU over the weekend). By then, she was found to have a ruptured ectopic pregnancy requiring emergency surgery for significant blood loss. The report sets out four safety recommendations in response to the findings. They are focused on: Updating clinical information to include ectopic pregnancy as a possible alternative/serious diagnosis to lower urinary tract infection. Standardising the information that women receive on discharge from the emergency department. Providing expert guidance on the type and level of information that EPUs should collect to identify those at risk. Including assessment on early pregnancy services especially relating to potential complications in CQC inspections.

CARS estimates the risk of death following emergency admission to medical wards using routinely collected vital signs and blood test data. The aim of the study was to elicit the views of: Healthcare practitioners (staff) and service users and carers on the potential value, unintended consequences and concerns associated with CARS. Practitioner views on the issues to consider before embedding CARS into routine practice.

The report called for people to be given much greater choice over when and where they are screened. It recommends that women should be able to choose appointments at doctors’ surgeries, health centres or locations close to their work during lunchtime or other breaks rather than having to attend their own GP practice. Local screening services should put on extra evening and weekend appointments for breast, cervical and other cancer checks. As people lead increasingly busy lives, local NHS areas should look at ways that they can provide appointments at locations that are easier to access. These documents provide details, including the terms of reference, for the review of national cancer screening programmes in England.

In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.

“One small step for man ... “ 50 years on – we all recognise this phrase that accompanied one of the most famous descents in history: Neil Armstrong’s emergence from the lunar module toward his first step on the moon. The Apollo 11 moon landing represents an unparalleled accomplishment. Its characteristics resonate with patient safety professionals who look to space for inspiration. The Apollo programme experienced both triumphant achievement and catastrophic failure. The effort learned from mistakes, embraced teamwork, and considered human factors as part of its domain. Its workforce remained focused on a single goal. The effort embodied commitment, complicatedness and complexity. The 50th anniversary of these victories provides compelling parallels for error reduction efforts active today in healthcare in the US: Organisational learning systems NASA (National Aeronautics and Space Administration) is a learning system. Learning systems are developed and nurtured through common goals, leadership commitment and resource sustainability. They thrive through action generated by the application of data, evidence and knowledge. Likewise, the US Agency for Healthcare Research and Quality (AHRQ) has partnered with the US-based hospital and healthcare accreditation organisation, The Joint Commission, to disseminate analysed evidence compiled by the Evidence-based Practice Center (EPC) programme. These organisations are working together to transfer what is known into an actionable form through a series of articles to enhance the use of better practice and learning on the frontline. This programme and the article series are introduced in a recent commentary on the project. Coordinated action The Keystone Center represents the culmination of the work of patient safety’s own Neil Armstrong – Dr Peter Pronovost, known for his otherworldly (at the time) commitment to the checklist intervention. The Keystone Center initially coordinated and collected data to guide the implementation of the checklist concept in 70 intensive care units across the state of Michigan. Now the Center serves as the state’s mission control for hospital patient safety and quality. Leaders there raise awareness of success through the Speak-Up! award programme that acknowledges frontline healthcare staff for voicing their concerns and making care safer. The Center enables sharing of concerns that result in cost savings due to harm avoidance. A push in the right direction The Apollo programme applied technical sophistication, engineering and know-how to land a man on the moon and return safely to Earth within a decade. No small feat! Despite that imperative, both the module and the space programme needed a little boost now and again to get out of Earth’s orbit to complete its momentous undertaking. Patient safety has a similar call motivating its work – zero preventable harm. Some aim for ‘zero harm’ but is this achievable? Healthcare is very complex with multiple machine/human/machine interfaces. Clinicians, leadership and organisations still need a boost to design and use technology and data to support the workforce to improve care at the bedside. The mission-driven, Boston-based Betsy Lehman Center builds on a strong desire to prevent failures similar to those that took the life of its namesake – Betsy Lehman – the Boston Globe reporter who died in 1994 due to medication errors. The Center is a state agency that serves as mission control for its constituents. To help healthcare in Massachusetts move its safety work beyond the comfort of the status quo, they have recently convened a consortium to propel existing programmes towards new and aspirational achievement. On the dark side of the moon Of course, the Apollo programme suffered setback and tragedy. While I want to highlight successes in my Letter from America, I will also share stories of struggle to foster learning from what doesn’t work. News and narrative will often remind us of why continued work on safety improvement is fundamental. Diagnostic error is prevalent. A recent analysis of closed US medical malpractice claims found that delayed or missed diagnoses in three primary clinical areas – vascular events (such as strokes), infections (like sepsis) and cancer – substantially resulted in disability or death. You can take that to your mission control to motivate data collection, teamwork and effort to focus on diagnostic improvement in practice. Transparency is messy. The revelation of Neil Armstrong’s reported death in 2012 due to substandard medical care is sad for all kinds of reasons. It underscores persistent cultural influences that reduce the sharing of information related to poor care. This minimises our opportunity to learn from failure and support patients, families and clinicians involved in error. Organisational resistance to transparency about mistakes and the messiness of openness are challenges... even when the incident involves a patient with less name recognition. The Apollo programme and the 1969 lunar landing remains inspirational to this day. It behooves all of us who dream of contributing to something we once felt was impossible to engender the right spirit, resources and commitment to help get it done. The learning required for such accomplishment takes time, a culture that supports discussion and recognition of success. If we embrace contribution, collaboration and community, our small steps have the potential to contribute to the “giant leap” forward – to help us take off, realise achievement and return our patients safely home.

Findings Participants’ perceptions regarding their engagement as a patient safety strategy were expressed through three overarching themes: the word 'patient' obscures the message safety is a shared responsibility involvement in safety is a right. Themes were further defined by eight subthemes. Conclusions Using direct messaging, such as 'your safety' as opposed to 'patient safety' and teaching patients specific behaviours to maintain their safety appeared to facilitate patient engagement and increase awareness of safety issues. Patients may be willing to accept some responsibility for ensuring their safety by engaging in behaviours that are intuitive or that they are clearly instructed to do. However, they described their involvement in their safety as a right, not an obligation. Interpretation Clear, inviting communication appears to have the greatest potential to enhance patients’ engagement in their safety. Nurses’ ongoing assessment of patients’ ability to engage is critical insofar as it provides the opportunity to encourage engagement without placing undue burden on them. By employing communication techniques that consider patients’ perspectives, nurses can support patient engagement.

Key findings The investigation identified that there: are multiple opportunities for error in the processes used to communicate unexpected findings are many steps that have to be completed successfully before the patient is informed is variance in how clinicians receive findings and how they acknowledge receipt of them.

The following safety issues were identified during the HSIB’s initial investigation and will form the basis for the ongoing investigation: referral from the emergency department into early pregnancy services provision of early pregnancy assessment services that allow for the timely diagnosis and optimum management of ectopic pregnancies.

This case study outlines: Aims, objectives and scope Method and approach Measurement plan Learning points Plans to spread the learning and adoption