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Found 47 results
  1. Content Article
    Implementation challenges The investigation highlighted the main implementation challenges. This includes: National consistency in drug libraries – smart infusion pumps have an inbuilt dose error reduction system (DERS) which requires the use of a drug library. The investigation found that drug libraries were developed ‘locally’ and that there is no agreed national drug library for use in NHS. They also found that there is no national guidelines or standards on how to implement the libraries. Significant changes in processes – introducing the technology requires significant changes to prescribing and administration processes in trusts. The investigation found that procedure and guidance documents often needed updating, and variations in medication practice were ‘locally managed’ and were rarely shared within and between hospitals. Provision of specialist IT support and infrastructure – substantial IT infrastructure is needed to support the integration of smart pump technology. Software is needed to upload the drug library to smart pumps, download data logs (including any errors detected) and monitor the status of each smart pump. The investigation highlighted that maintaining the required IT infrastructure required specialist staff roles and often a new skill set. The investigation found that the implementation of smart pump functionality would benefit from the use of risk management practices, as requirements are complex and similar to the introduction of a new IT system. Existing NHS Clinical risk standards could provide a basis for both manufacturers and trusts to work together to manage risks.
  2. News Article
    A Tory peer has attacked the Department of Health and Social Care’s ‘woeful’ response to the patient safety review she authored and has revealed she intends to create a cross-party group to force action. Baroness Julia Cumberlege - who led the “First Do No Harm” report on device and medicine safety– has said she has “not had a whisper” from the department over the report’s key recommendations since it was published in July. She told HSJ’s Patient Safety Congress she is setting up a cross-party parliamentary group to “pressure” the department to adopt the report’s recommendations. The report arose from The Independent Medicines and Medical Devices Safety Review, which spoke to more than 700 people, mostly women, who suffered avoidable harm from surgical mesh implants, pregnancy tests and the anti-epileptic drug sodium valproate. The report discovered “a culture of dismissive and arrogant attitudes” including the unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. It concluded that the NHS has “either lost sight of the interests of all those it was set up to serve or does not know how best to do this.” Health and social care secretary Matt Hancock and minister Nadine Dorries have apologised to the women who were harmed but the department has so far not responded to the report’s other eight recommendations in detail. Baroness Cumberlege said the cross party group would “[try] to open up a firmly shut departmental door. A department that doesn’t seem to get it.” She said: “We have been disappointed [in the department’s response] because we hoped by now we would have some sort of inclination about what’s going on." “The response from the department on the other key recommendations has been woeful. The reason they give is ‘there is a terrible amount of work to do’”. Read full story (paywalled) Source: HSJ, 11 November 2020
  3. News Article
    An NHS hospital where a woman bled to death in childbirth has been given an "urgent" deadline to keep patients at its maternity unit safe. A letter seen by the BBC reveals the Care Quality Commission (CQC) found unsafe staffing levels at the unit at Basildon Hospital throughout August. The CQC said the trust that runs it had until next Monday to implement appropriate measures. The trust said it had a "robust improvement plan in place". The seven-page document, sent by the CQC on 7 October, puts the Mid and South Essex NHS Foundation Trust on notice that it has to "implement an effective governance system", among other measures. Consequences for missing the deadline were not stated, but the CQC said it was using its powers under the Health and Social Care Act to impose conditions on the trust's registration. The Act does allow the CQC to temporarily close health services. Read full story Source: BBC News, 3 November 2020
  4. Content Article
    Developing the FRAS In January 2017, I read a tragic story in Outpatient Surgery involving an elderly patient in the US who suffered multiple burns following the use of chlorohexidine bottled alcoholic prep. I'd also read that in the US there are over 600 surgical fires every year. As the Practice Development Lead for my theatre department at the time, I decided to design a Fire Risk Assessment Score (FRAS). I discussed the FRAS with my manager and my suggestion to add the FRAS to the 'Time Out' of our WHO Surgical Safety Checklist. To further develop my ideas, I attended one of the Association for Perioperative Practice (AFPP) study days. All the delegates were asked to discuss and write a plan to make an immediate change in practice on return to their theatre department. I planned the FRAS. My manager who had originally agreed to my idea in January left in March, but I persevered with the idea and in July 2017 I made copies of the FRAS, discussed the score with senior staff, laminated the copies and placed one in each theatre. It was used as part of the WHO Surgical Safety Checklist Time Out. One month later I moved on and started bank shifts as a scrub practitioner in theatres. Fast forward 3 years Imagine my delight on a bank shift in August 2020 to see the FRAS as part of the patient profile on the hospital computer system – which meant it was in all six hospitals! So have fires decreased in theatres? Research shows that fires are still occurring in some UK theatres, and around the world, where a score is not part of the 'Time Out'; where bottled alcoholic prep is still used and not allowed to dry for 3 minutes before draping; and where lighted cables are sometimes allowed to rest on paper drapes. All perioperative staff need to have an awareness of surgical fires – where each flammable item used for the procedure is counted as 1 risk, and the score highlighted to the team and also documented before the start of the surgery. In doing this we can be reassured that we have taken all the necessary fire safety precautions for patients in our care, for the perioperative surgical team and also the preservation and the reputation of the hospital. Further reading The FRAS tool Kathy implemented Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. The Surgeon 2010; 8(2):87-92. Alani H et al. Prevention of surgical fires in facial plastic surgery. Australas J Plast Surg 2019; 28:40-9. Vogel L. Surgical fires: nightmarish “never events” persist. CMAJ 2018;190(4): E120. Cowles Jr CE, Culp Jr WC. Prevention of and response to surgical fires. BJA 2019; 8:261-266.
  5. News Article
    The government has been told it is ‘not sustainable’ to continue to delay its response to a major review on patient safety as ‘babies are still being damaged’. The Independent Medicines and Medical Devices Safety Review spoke to more than 700 people, mostly women who suffered avoidable harm from surgical mesh implants, pregnancy tests and an anti-epileptic drug, and criticised “a culture of dismissive and arrogant attitudes” including the “unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. The review’s author Baroness Julia Cumberlege told HSJ that “time is marching on” for the Department of Health and Social Care to implement the recommendations of her July report, which include setting up a new independent patient safety commissioner. The Conservative peer said pressure was building on government to adopt the findings of the review, since it had been endorsed by Royal Colleges and has already been adopted by the Scottish government. She said the government had given “evasive” answers in parliament on the issue. In an exclusive interview with HSJ, Baroness Cumberlege said: There is a crowded field of regulators but “there’s a void” for a service that listens and responds to patients’ safety concerns. She feels “diminished” that women’s concerns are still being dismissed by clinicians, but said young doctors are a cause for hope. She is “very optimistic” report will be implemented – but the NHS has to have the will to make changes. Read full story (paywalled) Source: HSJ, 13 October 2020
  6. News Article
    An NHS hospital which has faced repeated criticism by regulators for poor standards of care has been fined £4,000 for failing to assess A&E patients quickly enough. The Shrewsbury and Telford Hospitals Trust has been fined by the Care Quality Commission (CQC) after patients were not triaged within 15 mimutes of arrival in A&E – in breach of conditions set by the regulator last year and a national target. The care of emergency patients at the hospital trust, which is also facing an inquiry into poor maternity care, has been a long running concern for the watchdog which has rated the trust inadequate and put it in special measures in 2018. Earlier this year the CQC’s chief inspector of hospitals, Professor Ted Baker, wrote to NHS England warning of a “worsening picture" at the Midlands hospital and demanding action be taken. The CQC said it had issued the fixed penalty notice to the trust because it failed to comply with national clinical guidance that all children and adults must be assessed within 15 minutes of arrival. It also failed to implement a system that ensured all children who left the emergency department without being seen were followed up. After inspections in April 2019 and November 29 the CQC imposed seven conditions on the hospital over emergency care. The regulator said it was now clear the trust had not stuck to the conditions and had breached them both at Royal Shrewsbury Hospital and Princess Royal Hospital. Professor Baker said: "The trust has not responded satisfactorily to previous enforcement action regarding how quickly patients are assessed upon entering the urgent and emergency department." “We have issued a penalty notice due to the severity of the situation and to ensure the necessary, urgent improvements are made. It is essential that patients are seen in a timely way when they arrive at an emergency department; failure to do so could result in deteriorating health, harm, or even death, which is why national guidelines exist and must be followed." Read full story Source: The Independent, 12 October 2020
  7. News Article
    Too many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned. Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.” Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said. He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies. “Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.” Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.” Read full story Source: The Guardian, 29 September 2020
  8. Content Article
    In July, the PHSO submitted a report to the Public Administration and Constitutional Affairs Select Committee exploring the state of local complaints handling across the NHS and UK Government Departments. Drawing on evidence from a wide range of individuals and organisations, Making Complaints Count identified three core weaknesses in the existing complaints system: There is no single vision for how staff are expected to handle and resolve complaints. Staff do not get consistent access to complaints handling training. Public bodies too often see complaints negatively, not as a learning tool that can be used to improve service.[1] The PHSO stated in this report its intention to consult on a new Complaint Standards Framework for the NHS, aiming to “help create a stronger culture in which complaints are genuinely learned from”.[2] Patient Safety Learning believes that having an effective complaints process in healthcare is vital to improving patient safety, and in this blog we will set out our response to the consultation on this new Framework. Complaints: an untapped patient safety resource Too often complaints processes in healthcare are viewed in a negative light and patients and their families are not recognised as being a “primary source of learning for safety”.[3] Having an effective complaints system provides an important opportunity to learn from incidents of unsafe care. Patients experiences can be used to help identify patient safety problems, ascertain the causes of these issues and put in place remedial measures to prevent them from recurring. The absence of an effective system has often been cited in patient safety scandals as contributing towards the persistence of unsafe care. Robert Francis identified this in the Public Inquiry into the Mid Staffordshire NHS Foundation Trust, noting that complaints “were not given a high enough priority in identifying issues and learning lessons”.[4] More recently, the Independent Medicines and Medical Devices Safety Review stated that the current complaints system is “both too complex and too diffuse” to promptly identify safety issues arising from a medication or device.[5] It has also been long acknowledged that the complaints system in the NHS requires significant improvements, in terms of both the processes and finding an effective way of learning from complaints to bring about improvements. In the wake of the Mid Staffordshire Inquiry, a review of NHS hospital complaints, co-chaired by Ann Clwyd MP and Tricia Hart, made a number of recommendations for change in complaints handling and procedures.[6] More recently, a report from Healthwatch England which focused on how hospitals report on and communicate their work on complaints highlighted concerns about inconsistency in reporting and a focus on counting complaints rather than learning from them.[7] The consultation process for the PHSO’s Complaint Standards Framework was composed of a survey with several questions and a section in which to add any additional comments. Below is the response provided by Patient Safety Learning in the additional comments section. Consultation response Patient Safety Learning welcomes the PHSO’s Complaint Standards Framework and its recognition of the need to reform the NHS complaints system. From a perspective of making improvements for patient safety, we welcome: The statement that organisations should “have clear processes in place to show how they capture learning from complaints, report on it, and use it to improve services”. Its acknowledgement of the importance of sharing learning and complaints widely with other organisations in healthcare. The identification of the need for clear complaints governance structures, ensuring the feedback is regularly reviewed by staff at a senior level. Its recognition that an effective complaints system is intrinsically linked with promoting a Just Culture in healthcare, one that is less focused on blame and encourages transparency and accountability when mistakes occur. Implementation We note that this Framework is focused on providing “a shared vision for NHS complaints handling” rather than looking in more detail at how this would be put into practice.[8] While we welcome many of the aspirations set out in this, its implementation will ultimately determine its effectiveness in reforming the NHS complaints system. Too often, there exists a gap between learning and implementation in healthcare. We may know what improves patient safety, but in practice such measures can often remain siloed in specific organisations, resulting in patients continuing to experience harm from problems that have already been addressed. If this Framework is to create a more effective complaints process, one which contributes to improving patient safety, we feel that there are several issues that will need to be addressed prior to its implementation: It will need to be clear how organisations report on their progress in implementing the Framework. There will need to be guidance on how organisations report on their implementation of the Framework and a level of transparency and consistency to allow for monitoring and comparison. It needs to be made clear who is responsible for ensuring that organisations will design this approach to complaints into their governance structures. There is also the question of how this change will be monitored. In the consultation survey, the PHSO pose a question related to this, asking whether they “should be given legislative powers to set and enforce national complaint standards for the organisations it investigates”. At Patient Safety Learning, we think that it is vital that this process is monitored. However, we question whether the PHSO, specifically, can do this, in terms of whether it has both the legislative remit and the resources for this undertaking. In practice, we suggest that this role would sit better within the remit of the Care Quality Commission and its existing inspections regime. We feel this issue needs further consideration. Public reporting As mentioned previously, we believe a key question that needs to be addressed before implementing the Framework is how it will be reported on by organisations, and whether reporting will be consistent to allow for monitoring and comparison. A recent report from Healthwatch earlier this year looking at hospital complaints highlighted the difficulties around this. It noted significant variations amongst different hospitals regarding how they reported on complaints (in terms of the data provided publicly) and, in some cases, whether they did actually report on these complaints.[7] It stated “because the regulations don’t require trusts to publish their annual complaint reports, we can’t know for sure how many of them are fully compliant with the regulations”.[9] Achieving the goals of the Framework may encounter similar challenges, not providing clear indications of how its suggestions should be implemented. For example, the Framework states that organisations should “report on the feedback they have received and how they have used that feedback to improve their services”.[10] We believe that this needs to be accompanied by clear guidance, for instance, stating that feedback should be publicly reported on a quarterly basis. Sharing good practice We welcome the strong emphasis that the Framework places on the need to learn from complaints, and to share this learning widely. We believe that complaints too often remain an untapped resource for making patient safety improvements; a negative view of these processes present a barrier to effectively utilising the insights they can provide. In our report, A Blueprint For Action, we note that “healthcare is systematically poor at learning from harm”.[3] This has also been recognised in the CQC’s report, Opening the door to change, stating that “there is no clear system for staff to learn from each other at a national level. Local reporting systems are often poor quality and do not support staff well”.[11] How we achieve this ambition of sharing learning from patient complaints widely between NHS organisations requires further consideration. Organisations need the means to be able to share learning from complaints widely and effectively with other organisations in the NHS, without this getting lost in “the avalanche of other information that bombards organisations daily”.[3] Patient Safety Learning welcomes the opportunity to collaborate with PHSO on this issue and to promote and share good practice on the hub. References PHSO, Making Complaints Count: Supporting complaints handling in the NHS and UK Government Departments, July 2020. Ibid. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. Robert Francis QC, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013. The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020; Patient Safety Learning, Findings of the Cumberlege Review: patient complaints, 30 July 2020. Rt Hon. Ann Clwyd MP and Professor Tricia Hart, A Review of the NHS Complaints System: Putting Patients Back in the Picture, October 2013. Healthwatch, Shifting the mindset: A closer look at hospital complains, January 2020; You can find further reading on complaints in healthcare on the hub. PHSO, Have your say in shaping the future of NHS complaints handling, Last Accessed 18 September 2020. Ibid. PHSO, Complaint Standards Framework: Summary of core expectations for NHS organisations and staff, July 2020. CQC, Opening the door to change: NHS safety culture and the need for transformation, 2018.
  9. Content Article
    In this book the authors set out two key areas for attention if audit is to play a part in bringing about real improvements in quality of care. First, efforts must be made to ensure that the NHS creates the local environment for audit. Second, the NHS needs to make sure that it uses audit methods that are most likely to lead to audit projects that result in real improvements.
  10. News Article
    Ministers have been accused of trying to cover up the findings from investigations into hundreds of health and social care worker deaths linked to coronavirus after it emerged the results will not be made public. The Independent revealed on Tuesday that medical examiners across England and Wales have been asked by ministers to investigate more than 620 deaths of frontline staff that occurred during the pandemic. The senior doctors will review the circumstances and medical cause of death in each case and attempt to determine whether the worker may have caught the virus during the course of their duties. But now the Department of Health and Social Care (DHSC) said the results will be kept secret with the aim of helping local hospitals to learn and improve protection for staff. Separately, trade unions and NHS Providers, which represents hospital trusts, have urged the government to ensure full investigations into every death and to be transparent about findings to reassure health and social care staff ahead of any second wave. Sir Ed Davey, acting leader of the Liberal Democrats, said: “We currently have one of the highest number of deaths of health and care workers in Europe. The government has utterly failed to protect staff in both hospitals and care homes. The fact that now they are trying to cover up how and why each tragic death occurs is a disgrace." Read full story Source: The Independent, 15 August 2020
  11. News Article
    MPs are to launch a new system for evaluating whether key health targets are being met in England. A panel of experts reporting to the Commons health committee will assess progress made on policy commitments, starting with maternity services. They will rate performance from "outstanding" to "inadequate" and seek to drive improvements where needed. Panel chair Dame Jane Dacre said it would be "fair and impartial" in its findings. She said she was keen to ask recent patients and users of NHS services to contribute to the panel's work as well as specialists in chosen fields, all of whom would have no political affiliation. "It will be challenging, but I am committed to using available evidence to evaluate pledges, with the aim of improving patient care," she added. The panel will scrutinise, on behalf of the health committee, major commitments made by the Department of Health, NHS England, NHS Improvement and other public bodies. It will base its approach on the Care Quality Commission, which evaluates care homes, hospitals, GP practices and other health services. Read full story Source: BBC News, 5 August 2020
  12. News Article
    The list is a dismal and shameful one - Mid-Staffordshire, Morecambe Bay, the rogue surgeon Ian Paterson, maternity care at the Shrewsbury and Telford. All are patient safety scandals involving tragic stories of life-changing mistreatment of patients and, in some cases, the loss of loved ones. Pledges have been made that patient safety will be put front and centre of health policy. New regulators have been put in place. But now yet another review has found the health system in England to be "disjointed, siloised and defensive" and that the culture needs a shake-up. It has called for a new patient safety champion with legal powers to be put in place. The plan is to have an individual with "real standing" outside and independent of the system, accountable to the parliamentary Health and Social Care Select Committee. The Commissioner would be expected to take up and investigate patient complaints where appropriate, and hold organisations to account - the review had stated that the failure of health authorities to respond to concerns was a recurrent theme. Read full story Source: BBC News, 8 July 2020
  13. News Article
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
  14. Content Article
    A simple visual display that outlines and logically connects: An improvement aim that quantifies what better will look like, for who and by when. A small number of Primary drivers that focus on the key components of the system/main areas of influence that need to change to achieve the aim. These are often associated with process, infrastructure, norms (culture) and people. Secondary drivers that break primary drivers down in to natural subsections or processes. They provide more detail on where interventions to positively influence the primary drivers are required. Change ideas – these are the specific ideas that teams can test to see if they influence the secondary drivers and ultimately the aim.
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