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One year ago, on 2 October 2019, we officially launched the hub at our annual conference. To celebrate this special occasion, we want to update you on how the hub has grown and the impact it’s having, both on the people using it directly and on patient safety more broadly. To date, the hub has over 1,000 members from 450 organisations and from over 40 countries. It’s home to over 3,000 pieces of content, has had 45,000 unique visitors and has been accessed 70,000 times. Although we are delighted with these numbers and continued growth of the hub, we are most proud of the relationships the hub is facilitating and the good work that is happening as a result. We launched the hub so that all members of the public – from patients to clinicians – could share their insight and experiences of patient safety. By working together with users of the hub, we aim to highlight patient safety concerns and take action so that real change can happen as we journey towards the patient-safe future.   Wonderfully, we are beginning to achieve these aims. Here are some of the ways the hub has been making an impact. Impact of the hub on patient safety Sharing successes to improve patient safety We are delighted to see on the hub that trusts are sharing new initiatives and good practices they have successfully implemented. Homerton University Hospital NHS Trust has shared innovative solutions that improve patient safety, and these have been picked up by other patient safety leads who want to try them in their own organisations. A blog series about a ‘second victim’ support initiative at Chase Farm Hospital has led to another hospital initiating a conversation with Chase Farm so they could create something similar. We’ve had great feedback about how the hub is helping members: Kirsty Wood, Senior Critical Care Outreach Practitioner, says: “The hub is an essential platform that allows collaboration and communication across the country. The diversity of the experiences and ideas that are shared enables others to improve current practices and keep up-to date. Through networking, we are able to learn from each other, provide invaluable support and energy to strive for patient safety.” Gethin Bateman of the NHS Wales Informatics Service says that the hub has supported his development and learning and has also helped him to achieve targets at work: “If it didn’t exist, I wouldn’t have that valuable repository of information. I could go online and Google for policy documents, etc. But you don’t get the conversation around them, which may be more important than the actual document.” Dr Rachel Grimaldi, Creator of CARDMEDIC, comments: “The hub is such a useful, creative resource and really the only place to go now, I think, to share patient safety initiative stories so people can learn from each other.” Campaigning for safer care Using member feedback and evidence, the hub is helping us to highlight patient safety issues and promote safer care. In February, we connected with the Campaign Against Painful Hysteroscopy patient group and began a new Community discussion on the hub titled ‘Painful hysteroscopy’. We have seen a significant amount of interest in this issue, with many patients sharing their experiences. Another issue we’ve been highlighting on the hub is the lack of support for thousands of patients with ‘Long COVID’ (patients with confirmed or suspected COVID-19 who continue to struggle with prolonged, debilitating and sometimes severe symptoms months later). We are using the hub as a forum for people living with Long COVID to share their stories and experiences, such as intensive care doctor Jake Suett, who wrote a blog about his own experience of suspected Long COVID. In his blog, Jake sets out a number of recommendations to improve support for people living with Long COVID and includes a template others can use to call on their MPs to raise awareness. His blog has been the hub’s most visited page yet, with over 8,000 views. Highlighting frontline staff concerns One of the most popular types of content on the hub has been the candid stories from frontline staff, often posted anonymously. One example is a theatre nurse’s story of speaking up when a surgeon dropped an instrument, washed it and immediately re-used it. We highlighted this specific incident of unsafe care – along with the wider safety concerns it raises around private practice – with the CQC, NHS England and NHS Improvement, NMC, GMC and National Guardian for the NHS, calling for action be taken. The nurse was willing to be identified to the CQC and work with them to initiate an investigation. Hopefully, this will help to prevent this type of situation from occurring again. The challenges we face Encouraging people to be confident enough to create original material themselves is challenging. Time is a factor; frontline staff are very busy. They can also be afraid of the repercussions if they share examples of unsafe practice, even when done anonymously. “Hello, I read your tweets and often would love to comment but don’t feel safe to do so. I was a senior nurse for patient safety but left. Organisational reputation in my experience trumps learning, openness and honesty in managing complaints and patient safety incidents…Carry on the good work.” (Anonymous) Others, particularly patients, are often worried that their experience or voice is not deserving of wider dissemination. Even when members are keen to share good practice and their trust’s new initiatives, they are often uncertain as to whether they are allowed to share; organisations’ cultural barriers can be hard to overcome. Our plans for the hub Over the year ahead, we are looking to collaborate further with other organisations and grow our networks, in both the UK and internationally, so we can share patient safety ideas and initiatives globally. We will expand internationally through links with the Patient Safety Movement Foundation, collaboration with WHO and new knowledge-sharing networks in Africa. Following feedback from user workshops with members, we will continue to develop the hub to meet the needs of our users and actively encourage new members to make the best use of the hub. We will continue to raise awareness of patient safety issues. This month, we are launching our error traps gallery. An error trap is a situation that could lead to avoidable harm unless action is taken to address this issue, and they can be found throughout health and social care. We want to raise awareness of these on the hub and will be asking you to send us your photos of error traps and any ideas you have to address them. We will also be continuing our harmed care patient pathway blog series with Joanne Hughes, one of the hub’s topic leads, to develop our understanding of the needs of patients, families and staff when things go wrong, and look at how these needs may be best met and by whom. Work with us towards the patient-safe future Every voice is important. If you’re a patient, clinician, researcher, student, patient safety professional… whoever you are, you’ll have an experience of patient safety. If you’ve got something to share, whether a patient or staff experience or a successful patient safety or staff safety initiative, please do share it with the hub community. If you’re already a member of the hub, you can share your content or join a Community discussion. If you’re not yet a member, please register and get involved. We would love for your voice to be a part of our growing network, as we speak up, take action and work together towards the patient-safe future.

The rate at which nursing and ambulance staff are leaving the NHS is increasing. The number of nurse vacancies has risen to over 40,000 – a record high. The ambulance service has recorded an 80% per cent increase in staff leaving the profession since 2010. These rates are unequally distributed across professions, specialties and geographical regions, introducing inevitable inequalities in patient care. This Efficiency Research project aims to use this variation to detect underlying contributory factors for better or worse nurse and ambulance staff retention, and determine its effect on patient outcomes. A research team from Staffordshire University will use their experience of applying ‘big data’ analytics and unifying large datasets from three previous studies on the effect of nurse staffing on patient safety. Projects began in 2019 and will run until December 2023. There are three work programmes to explore workforce retention and configuration in healthcare. The first programme will combine and align multiple large datasets from 20 NHS trusts across secondary care and mental health and 10 ambulance trusts. This will enable the analysis of multiple variables and their effect on workforce retention, and how these variables, in combination with workforce retention, subsequently impact patient outcomes. The second work programme will involve designing and testing an infrastructure for the routine extraction, combination and analysis of these large datasets. This will enable the adoption of these techniques across the NHS. The nursing element (NuRS) will start first, with the ambulance staff (AmReS) element following approximately six months later. A third programme will examine the effect of the COVID-19 pandemic on patient safety in terms of reporting behaviours, for example; and will explore how nursing and ambulance workforce configuration in response to a pandemic affects patient safety and quality of care. This project is a unique opportunity to unlock the key underlying drivers of nurse and ambulance retention and determine their impact on care quality, helping to tackle the challenge of supply in the NHS and ensure that high quality, sustainable care is available to all.

Anna Erhard, Quality and Outcomes Manager at the Schoen Clinic, presented at the recent Bevan Brittan Patient Safety Seminar. Attached are the presentation slides.

Mindful organising is a key integrating concept in resolving the organisational accident. Mindful organising is both the unique source of critical information about the normal operation, as well as the key recipient of intelligence about the operation, ensuring that operational actions are always informed by the most current, relevant information about potential risks no matter how remote. Highlights of the paper: Principles of mindful organising are operationalised in a Mindful Governance model. The model is grounded in two cases studies in contrasting aviation organisations. The case studies led to the development of three prototype web applications.

Resilient Health Care (RHC) is predicated on the idea that health care systems constantly adjust to changing circumstances. RHC has become increasingly popular as a new way to improve patient safety, but to date there is no agreed way of using RHC as the basis for teaching patient safety. A key resource for patient safety educators is the World Health Organisation (WHO) patient safety curriculum, released ten years ago. However, it is well established that patient safety thinking in healthcare has been driven largely by Safety-I principles, and this is reflected in the WHO curriculum. The aim of this paper is by Sujan et al., published in Safety Science, was to review and to provide a critique of the WHO patient safety curriculum from a Safety-II perspective, in order to assess to what extent RHC principles are already incorporated, and to identify areas where RHC might make contributions to the WHO curriculum. Based on this analysis, we argue that RHC thinking could be added in modular fashion to the WHO curriculum, but that in the future a broader curriculum should be developed that integrates RHC thinking throughout.

In 2013, the Centers for Medicare and Medicaid Services announced that it would begin levying penalties against hospitals with the highest rates of hospital-acquired conditions through the Hospital-Acquired Condition Reduction Program. Whether the programme has been successful in improving patient safety has not been independently evaluated. Sheetz et al. used clinical registry data on rates of hospital-acquired conditions in 2010–18 from a large surgical collaborative in Michigan to estimate the impact of the policy. They concluded that the programme did not improve patient safety in Michigan beyond existing trends. These findings, published in Health Affairs, raise questions about whether the program will lead to improvements in patient safety as intended.

The 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.

The University of Missouri Health Care (MUHC), an academic healthcare system located in Columbia, Missouri, USA, deployed an evidence-based emotional support structure for second victims based on research with recovering second victims. MUHC is a six-hospital healthcare system with 52 ambulatory clinics and approximately 6,500 employees. The second victim support structure, known as the forYOU Team, was designed to increase awareness of the second victim phenomenon, “normalise” the psychological and physical impacts, provide real-time surveillance for possible second victims within clinical settings, and render immediate peer-to-peer emotional support when a potential second victim is identified. This article published in Patient Safety & Quality analyses the success of the programme. The forYOU Team’s five-year experience in providing clinician support has yielded many valuable insights into this aspect of MUHC’s patient safety culture. Organisational awareness of the second victim phenomenon and an institutional response plan are critical steps in minimising the suffering of the institution’s healthcare clinicians. From this experience, the authors strongly encourage healthcare facilities to develop a comprehensive plan and provide accessible, effective support for all clinicians experiencing the second victim phenomenon.

The Health Foundation’s Report, Untapped potential: Investing in health and care data analytics, highlights nine key reasons why there should be more investment in analytical capability. Nine key reasons why there should be more investment in analytical capability: Clinicians can use the insights generated by skilled analysts to improve diagnosis and disease management. National and local NHS leaders can evaluate innovations and new models of care to find out if expected changes and benefits were realised. Board members of local NHS organisations and systems can use analysis to inform changes to service delivery in complex organisations and care systems. Local NHS leaders can improve the way they manage, monitor and improve care quality day-to-day. Senior NHS decision makers can better measure and evaluate improvements and respond effectively to national incentives and regulation. Managers can make complex decisions about allocating limited resources and setting priorities for care. Local NHS leaders will gain a better understanding of how patients flow through the system. New digital tools can be developed and new data interpreted so clinicians and managers can better collaborate and use their insights to improve care. Patients and the public will be able to better use and understand health care data. Action and investment is needed across the system so the NHS has the right people with the right tools to interpret and create value from its data. This could result in an NHS that can make faster progress on improving outcomes for patients.

Reducing emergency admissions from care homes has the potential to reduce pressure on hospitals. This is a significant national policy focus, as demonstrated by a strong commitment to improve support in care homes in the NHS Long Term Plan.  Key points: Analysis of a national linked dataset identifying permanent care home residents aged 65 and older and their hospital found that on average during 2016/17 care home residents went to A&E 0.98 times and were admitted as an emergency 0.70 times. Emergency admissions were found to be particularly high in residential care homes compared with nursing care homes. A large number of these emergency admissions may be avoidable: 41% were for conditions that are potentially manageable, treatable or preventable outside of a hospital setting, or that could have been caused by poor care or neglect. Four evaluations of initiatives to improve health and care in care homes carried out by the Improvement Analytics Unit (IAU) in Rushcliffe, Sutton, Wakefield and Nottingham City show reductions in some measures of emergency hospital use for residents who received enhanced support. There are key learnings from these IAU evaluations, including a greater potential to reduce the need for emergency admissions and A&E attendance in residential care homes and the benefit of coproduction between health care professionals and care homes.

The lack of funding in social care doesn’t only mean that services are unable to meet demand – there is also under-investment in data and analytics. Laura Schlepper explains why social care data matters and what would help to increase its potential.

As we study the numbers on the coronavirus cases and the deaths related to COVID-19, a similar question comes up again and again: Why is the coronavirus causing so many more deaths in Italy than in other countries? In this article, published in Medium, Andreas Backhaus, an Economist, discusses the demographics and why they are a warning to other countries.

In an interesting paper by Brazil and colleagues in the July edition of BMJ Quality and Safety, the authors explore the positioning of simulation-based methods within QI programmes, the role of trained simulation experts as part of QI-focused teams and the directions for future scholarly enquiry that supports integration of these fields. The paper summarises the literature on the use of simulation with many examples of application in the field of patient safety. It explores the evidence on the impact of simulation. It goes on to suggest four areas where QI and simulation practitioners interested in closer integration of their fields might focused: Read - add articles found in quality/safety or simulation journals that integrate both fields onto your reading list. Study - seek out professional development opportunities: courses, workshops, conferences in QI methodology or simulation/debriefing. Collaborate - identify individuals in your local institution and find ways to work (and research) together. Engage - connect with the larger community of practice working on these topics via in-person meetings or platforms such as Twitter and LinkedIn.

Guy's and St Thomas' NHS Foundation Trust share their Quality Impact Assessment (QIA) policy. The QIA policy has been developed to ensure that the Trust has the appropriate steps in place to safeguard quality whilst delivering changes to service delivery. This process is used to assess the impact that the Cost Improvement Plan (CIP) may have on the quality of care provided to patients at Guys and St Thomas’ NHS Foundation Trust.

This study aims to present two system models widely used in Human Factors and Ergonomics (HF/E) and evaluate whether the models are adoptable to England’s national patient safety team in improving the exploration and understanding of multiple incident reports of an active patient safety issue and the development of the remedial actions for a potential National Patient Safety Alert. The existing process of examining multiple incidents is based on inductive thematic analysis and forming the remedial actions is based on barrier analysis of intelligence on potential solutions. However, no formal systems models evaluated in this study have been used. AcciMap and Systems Engineering Initiative for Patient Safety (SEIPS) were selected, applied and evaluated to the analysis of two different sets of patient safety incidents: (i) incidents concerning ingestion of superabsorbent polymer granules and (ii) incidents concerning the interruption in use of High Nasal Flow Oxygen.

The variety of alarms from all types of medical devices has increased from 6 to 40 in the last three decades, with today’s most critically ill patients experiencing as many as 45 alarms per hour. Alarm fatigue has been identified as a critical safety issue for clinical staff that can lead to potentially dangerous delays or non-response to actionable alarms, resulting in serious patient injury and death. To date, most research on medical device alarms has focused on the nonactionable alarms of physiological monitoring devices. While there have been some reports in the literature related to drug library alerts during the infusion pump programming sequence, research related to the types and frequencies of actionable infusion pump alarms remains largely unexplored. The objectives of this study protocol is to establish baseline data related to the types and frequency of infusion pump alarms from the B. Braun Outlook 400ES Safety Infusion System with the accompanying DoseTrac Infusion Management Software. This exploratory study will analyse the aggregate alarm data for each hospital by care area, drug infused, time of day, and day of week, including overall infusion pump alarm frequency (number of alarms per active infusion), duration of alarms (average, range, median), and type and frequency of alarms distributed by care area. Infusion pump alarm data collected and analyzed in this study will be used to help establish a baseline of infusion pump alarm types and relative frequencies. Understanding the incidences and characteristics of infusion pump alarms will result in more informed quality improvement recommendations to decrease and/or modify infusion

Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. This paper from Almaberti et al. Implementation Science published  attempts to reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today. Previous methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.