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The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’. A key action associated with this aim is the creation of a system-wide patient safety syllabus which is capable of ‘producing the best informed and safety-focused workforce in the world’. The Academy of Medical Royal Colleges (AOMRC) has been commissioned by Health Education England (HEE) to develop a new National patient safety syllabus. The Academy has now published its first version of this for review and feedback. At Patient Safety Learning, we’ve been working with the AOMRC and HEE in the initial stage of development to share our thoughts on the initial proposals in this syllabus. Now that this has been formally published for consultation, we want to share our draft submission with hub members for comment and contributions, ahead of submitting this by Friday 28 February 2020. The consultation process provides the option to feed back as part of an online survey, however we felt that the 500-word character limit was too limited to provide comments on such an important topic. Our draft submission document will be submitted by email. We hope that many others committed to improving patient safety also do so. It’s very important that the syllabus acts as a key driver for achieving a step change in patient safety across the NHS. NationalPatientSafetySyllabus_DraftConsultationSubmission.pdf

I used to work for the World Health Organization (WHO) helping to establish its patient safety programme over 20 years ago. So it’s a real privilege to be invited back to a three day meeting at WHO to help contribute to the development of its 2020-2030 Global Patient Safety Action Plan. Going into this meeting the key questions in my mind are: What have we learned about patient safety in the last 20 years? Why harm is so persistent? What impact has the global commitment to patient safety had in reducing harm? What approaches to patient safety are having the most impact? How can we be more effective share learning for safer care? My aims in attending this are to: Contribute to the meeting, pressing the importance of patient safety being considered as a core purpose of health and social care. Highlight the role of the six foundations of safer care that we have identified in A Blueprint For Action, especially the promotion of shared learning via the hub and the need for standards for patient safety. Promote Patient Safety Learning’s ambition for a patient-safe future and the actions we have identified to address the major causes of unsafe care. Identify opportunities for future collaboration. Support the G20 focus on patient safety as a social movement and drawing more attention to the economic impact of unsafe care. Meet up with international leaders in patient safety and WHO experts and staff. I’ll be tweeting and blogging across the three days so we can all #share4safety. Best wishes, Helen @helenh49

This video gives a summary of the PRAISe project - a QI project about antibiotic stewardship, based on Learning from Excellence philosophy. Funded by the Health Foundation.

On January 2020, Patient Safety will be on the G20 agenda (amongst other five health key priorities). One would ask: What is Patient Safety doing on an economic forum like the G20? Another cynic might even add: What is Healthcare doing on the G20? The G20 was established in the late 1990s with the objective of its members working together to achieve economic and financial stability. It is comprised of 19 countries and the European Union (EU). The G20 collectively represent more than 85 % of the world’s Gross Domestic Product (GDP), and more than two- thirds of the world’s population. Healthcare was only introduced in 2017 during the German presidency. WHY PUT PATIENT SAFETY ON THE G20 AGENDA? Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both U.S. and Canada, Patient Safety Adverse Events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the U.S. alone: 440 thousand patients die annually from healthcare associated infections (HAIS). In Canada: there are more than 28 thousand deaths a year due to Patient Safety Adverse Events. In Low – Middle Income Countries (LMIC), every year 134 million adverse events take place resulting in 2.6 million deaths annually. Having said all that, up to 70 % of harm is . (OECD, 2017) In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development (OECD) countries is attributed to patient safety failures each year (OECD 2017) But if we add the indirect and opportunity cost Economic & Social), the cost of harm could amount to trillions of dollars globally (OECD 2017). According to a report by Frost & Sullivan in 2018, Patient Safety Adverse Events cost the US alone 146.1 billion dollars annually. When you compare the cost of prevention to the cost of harm, the return on investment (ROI) becomes a “no brainer”. In a study that looked at patient safety ROI for Pressure Injuries, the cost of prevention was € 291.33 million compared to the cost of harm of € 2.59 billion (almost 1,000 times higher). (Demmarre et al 2015) Over the past 20 years, numerous efforts were made to improve patient safety in individual G20 countries as well as globally under the World Health Organization leadership. Despite all those efforts, the level of harm to patients persists and 20-40% of health resources are being wasted (WHO). Many healthcare structural causes are responsible for the ongoing harm: Healthcare Workforce Factors: In addition to the quality and quantity, the wellbeing and safety of health workforce are foundational to patient safety. A substantial body of research now points to link nurse staffing with patient outcomes. A business case by Needleman (2006) demonstrated cost saving from reduced complications and shorter length of stay associated with higher nurse staffing levels. This relationship is articulated clearly in the Jeddah Declaration on Patient Safety in 2019. Dall (2009) estimated the impact of increased nurse staffing on medical cost, lives saved and national productivity. Their research suggests that adding 133,000 nurses to U.S. hospitals would save 5900 lives per year, increase productivity by $1.3 billion, or about $9900 per year per additional nurse. Decrease in length of stay resulting from this additional nurse staffing would translate into medical savings of $6.1 billion and increased in productivity attributed to decreased length of stay was estimated at $231 million per year. Addressing and ensuring guidelines that are consistent with research findings for nursing staffing in acute settings is a viable key solution to prevent medical errors, improve patient safety and decrease cost of healthcare delivery. Healthcare Education Causes: Even though healthcare is provided by multi-disciplinary teams, healthcare education (undergraduate – postgraduate) continues to be conducted in separate settings. This siloed approach results in many of the communication failures / safety failures that are experienced on a regular basis. According to Joint Commission communication failures were the leading root cause of the sentinel events reported to the Joint Commission from 1995 to 2004. Healthcare education requires a serious reevaluation of its current curricula and practices. Furthermore, the lack of patient safety components to the medical and allied health sciences curriculum does a disservice to have safe medical practices imbedded within the day-to-day implementation of the healthcare workforce. Patient – Provider Information Asymmetry: The information and communication gap between the healthcare providers and their patients has caused ongoing harm. With the information abundance, patients turned to the internet as a source of guidance, regardless of its accuracy, which is minimally provided by Healthcare teams. Healthcare providers need to be the trusted guidance for information and the empowering force for patients to make informed decisions. Unempowered patients may result in lack of transparence and noncompliance to the care plans that contribute patient harm. Major movement for patient empowerment and community engagement is warranted. In addition, engaging patients can reduce the burden of harm by about 15%, saving billions of dollars each year. (WHO) Poor Safety Culture: The Hospital Survey on patient safety culture has been implemented in many countries to gain insight on the employees’ perception of the hospital patient safety culture. It has been consistently found that employees perceive hospital cultures lack transparency and results in punitive consequences when adverse events are reported. ‘Shame and Blame’ culture is one of the major barriers to improving safety. It is imperative that healthcare systems adopt strategies enabling Just Culture. Lack of consideration of Human Factors: In the healthcare sector, and since the Institute of Medicine (IOM) report “To Err is Human”, have come a long way in improving our services with elimination of potential harm in mind. However, healthcare can learn much more from other industries that have improved safety through use of HFE in redesigning work process and flow to ensure they are error-proof. HFE is an important discipline that can embed resilience to healthcare systems and could, potentially, transform patient safety. Lack of sufficient sharing and learning: The different sectors within the healthcare industry have created silos based on profession, departments, type of organization and many more subcultures and entities within a facility and at the national levels. This results in fragmented systems working in isolation, creating piece meal solutions and multi-levels of communication gaps, let alone the opportunity to share and learn in a manner that prevents harm from being repeated. Learning (from within healthcare), through Reporting & Learning Systems, and (from other industries), e.g. aviation, nuclear, oil & gas, is essential to healthcare safety innovation and transformation. Furthermore, population ageing has significant implications for patient safety as older adults are at higher risk for medical errors and the rate of adverse events due to increases in frailty, comorbidities, and incidences of chronic conditions, falls, and dementia makes providing health care more complex and increases costs. Individuals 65 years and older are at a two-fold risk for developing adverse events when compared with individuals between the ages of 16 and 44 years. (Brennan TA, Leape LL, Laird N, et al.) Nations across the G20 will face this challenge, which necessities innovate safety interventions and new approaches in health care to design a safer health care system. When it comes to patient safety, doing more of the same will result in: More lives will be lost More preventable harm will take place like Healthcare Associated Infections, medication errors, Anti-microbial Resistance (AMR) …etc. More money will be wasted (not to mention indirect cost and opportunity cost). When a patient is harmed, the COUNTRY LOSES TWICE: The individual will be lost as a revenue generating source for society+ the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. OUR G20 PROPOSAL FOR PATIENT SAFETY Establishing a G20 Patient Safety Network (Group) that will combine two types of expertise: Safety experts from healthcare and other leading industries (like Aviation, Nuclear, Oil & Gas, other) Economy and Financial Experts This will function as a platform to prioritize and come up with innovative patient safety solutions to solve Global Challenges while highlighting the return on investment (ROI) aspects. This multidisciplinary group of experts can work with each state that adopts the addressed Global Challenge to ensure correct implementation of proposed solution. BENEFIT: Investment in Patient Safety – – > sustainability of healthcare systems – – > and overall economies In conclusion, patient safety is a global priority that goes beyond healthcare. It is a challenge that requires the collective wisdom of the G20 and the overall global community. It is not just an issue for health ministers, but it is an important issue that requires the attention of finance ministers and heads of states. The economic cost of failing patient safety could be risking the sustainability of healthcare systems and the overall global economies. WE NEED TO ACT NOW!

"There must be multidisciplinary teams working in all private hospitals – it’s standard in the NHS but almost non-existent in the private sector. And the Care Quality Commission must be provided with the same performance data, in the same format from the private sector as it demands of the NHS in order to create a clear and consistent picture of patient safety across the board.” [Linda Miliband, a lawyer at Thompsons representing 650 of Paterson's victims]. It makes me shudder to think that until now, there are surgeons who think they are above the law and the staff are just there to do their bidding and cover up their failings! In the Paterson case, we question why it took so long. If women are having a skin sparing mastectomy for breast cancer, why would they worry about their cleavage? Were they convinced that this was important by this rogue surgeon? Did the scrub practitioners and surgical assistants not query this? No organisation is perfect – it can always be improved. We are told to be proactive, yet when we are employers are reactive. At the end of the day, it's not about earning higher wages than our colleagues in the NHS hospitals, it is about patient advocacy, compassion, integrity and patient safety, and also being able to sleep peacefully at night with a clear conscience. Moving forward, we must hope and pray that swift changes are made by our government to the private sector, so patients do not suffer unduly and their safety once again compromised. I look back at the incident I experienced in theatre where a surgeon dropped an instrument, washed it under a tap and reused it without sterilising it. I keep wondering whether the anaesthetist applied Duty Of Candour and explained to the patient why he was giving her another 'big' dose of antibiotics the following morning due to dropping the instrument and not sterlising it. Did the surgeon inform the patient? I don't know. I was not part of the investigation. All I heard was that the surgeon was happily back to work and my shifts were blocked! As a follow up, I received a P45 in the post three months later with no explanation or email/ phone call. I've still heard nothing to this day. I know of three colleagues who also received P45 in the post after making a safety complaint. What is it about speaking up that employers do not like? As scrub practitioners we need to focus on doing the right thing and if we are always thinking that every patient is a member of our own family, we will do it correctly. My mother told me before I left my country to start nursing in the UK: "God gave you a tongue, always use it to ask questions and stand up for yourself and others!" In the future, I will ask these questions at my next interview: "Are staff allowed to Speak Up and report safety incidents?" "Are the reports followed up and lessons shared without victimising the person who reported it?" I may not get the job, but at least I can cast a small stone to create a few ripples. I will never stop Speaking Up for patient safety. I do not want to work in an environment where patient safety is compromised. What about you? What will you do? We all need to take action NOW.

NHS Improvement are asking NHS organisations to identify, by June 2020, at least one person from their existing employees as their patient safety specialist. Training for these specialists will be based on the national patient safety syllabus being developed with Health Education England. Working with representatives from a few NHS trusts, patient safety partners (patient and public voice representatives) and clinical commissioning groups, NHS Improvement have drafted the requirements for a patient safety specialist to help organisations identify the most appropriate person(s) for the role. You can download the draft requirements here. NHS Improvement are inviting comments and feedback on this through their survey which can be accesed via the link at the bottom of this page. Consultation closes 12 March 2020.

The authors of this paper, published by BMJ Quality & Safety, believe that although there are deep anxieties and many sources of resistance to change in health care, there are also individuals and organisations which are exhibiting creativity and leadership. To support these efforts, they offer concepts and practical examples drawn from several industries including healthcare. Three ideas underlie their argument: Healthcare organisations can improve quality and other outcomes by enhancing their capabilities for organisational learning. Organisational learning requires leadership from executives, line (middle) managers, and informal network leaders throughout organisations. Leaders are more effective when they take a broad view of the interdependencies among individuals, teams, task flows, systems, and cultural meanings.

Often, there are many perspectives that we need to consider before we have a complete picture. 'The Blind Men and the Elephant', and earlier versions of this parable, show us the limits of perception and the importance of complete context. This also applies when we are facing a difficult or complex issue in relation to patient safety. As part of the Patient First programme at Brighton and Sussex University Hospitals NHS Trust, we used A3 problem solving. Many others do too. It’s a structured problem-solving tool, first employed at Toyota and typically used by 'lean' manufacturing practitioners. Flexible and succinct, it captures everything you need on a single piece of paper – A3 in size, hence the name. It also brings together some widely used improvement tools – cause and effect diagrams (fishbone diagrams) the 5 whys and small change cycles (Plan, Do ,Study, Act). Most recently, I've had the pleasure of using it with teams wanting to improve elements of their services such as time to triage, discharge or wanting to minimise avoidable harm (e.g. patient falls). I have also used it with families and clinical teams wanting to take forward a key service change. Its’ real power is that, rather than jumping in with solutions in hand (which are, more often than not, shopping lists of resources required), you don’t move forward until you have absolute clarity on what the ‘problem’ is you are trying to solve. Plus, this is a team activity. It is rare we know everything about our issue and the power of an A3 derives not from the report itself, but from the development of the culture and mindset required for its successful implementation. There are several formats around – just google A3 problem solving. I have summarised the first 4 steps below: Step 1: Problem Statement Set out why this is important? A couple of sentences about the size of the issue, how long it has been going on, impact on patients, their families and staff. For example Over the last 4 months we've seen a reduction in patients triaged from X% to Y%. There was a near miss event last week that would have been averted had triage been in place on that shift and staff are concerned that there is no single process for them to follow. OR Our surveys over the last 6 months indicate that only X% of our clients are fully engaged in the development of their care plans. We need to address this urgently in order to ensure best outcomes for our clients and support family members and carers who are willing and able to participate. This is your call to action – if it isn’t making your staff and clients sit up and want to engage then it needs more work. Step 2: Current Situation What you know about the issues, what staff are saying, what patients and their families are saying (small surveys are great), what the data is telling you, any protocols or algorithms, and anything else that you need to know. Step 3: Vision & Goals Vision: A softer statement of quality AND Goal(s) : Measurable goal(s) and when you are aiming to deliver, for example: From June 2020: ‘X% of patients to be triaged within Y minutes of arrival‘ AND ‘Y % of patients triaged to the correct clinical pathway’ Step 4: Analysis: Top Contributors & Root Causes Use a cause and effect (fishbone) diagram to ensure you are capturing the many causes For example, the methods in place that may not be working quite so well, things to do with the environment, equipment and the people, both patients and staff. Once these are all out on the table then you can use root cause analysis to get underneath them. It’s only at steps five and six that you start to think about the actions that you will take forward and how you might fix some of these big issues. The full A3 is pasted below: And finally, it goes without saying that step nine, ‘insights’, is key. In my experience, people get best benefit if they complete this as they go along. There is always learning, for example people you might have engaged sooner, early identification of others who are already on top of the issue and able to share their work with you so you can adapt for your own use – we used to call it ‘assisted wheel re-invention’ when I worked for the NHS Modernisation Agency. Please leave a comment below or message me through the hub @Sally Howard if you want to know more. I'm very happy to talk further about this approach.

It can be easy to make assumptions about a person’s quality of life, which can colour our judgements about the support, care and treatment of individuals, and how and what they should receive. So it is vital that the person and those who know them best are involved in their care, so that a more complete picture of an individual’s life can emerge and their needs, likes and dislikes can be shared with those providing care and support. This should improve the quality of the care and treatment that a person receives. It was with this in mind that the hospital passport was developed, containing important information about the person, such as their health and health difficulties, likes and dislikes, and any medication that they may be on. The idea was adapted from one created by Gloucestershire NHS primary care trust and introduced at St George’s Hospital in south west London. It was created by people with learning disabilities and health professionals from Wandsworth and Merton community learning disability teams and the acute hospital to ensure a better experience and health outcome for people with learning disabilities and their families in St George’s.