Search the hub

The pandemic’s effect on non COVID-19 care and treatment While the healthcare system has rightly focused its attention on the deadly effects of COVID-19, we made the case this year that we need to pay attention to patient safety now more than ever; the pandemic has both magnified existing patient safety issues and created new challenges. One major area of our focus has been the pandemic’s impact on non COVID-19 care and treatment, and the consequences for patient safety. To develop our understanding of this issue, in March we launched our #safetystories campaign, asking for patients with issues not related to COVID-19 – and yet facing new challenges because of it – to share their stories with us on the hub. Our aim was to find common themes and report to healthcare leaders with our insights, so we could help close emerging patient safety gaps as the health and care system prioritised COVID-19. Later that month, we published our first blog on the potential impact of COVID-19 on patient safety, outlining where we thought the pandemic would have the biggest impact on patient safety. The pandemic continues: identifying and addressing further risks to patient safety As the year progressed and we identified different risks to patient safety that were exposed by the pandemic, we urged: For patient safety considerations to be placed at the heart of the design and development of new ventilators for the NHS (March). At the time, the Government was focusing on the fast delivery of additional ventilators to meet increasing demand. This included development of ventilators, not just by established manufacturers, but also by companies who hadn’t previously produced them. For the Government to tackle patient and staff safety concerns arising from the increased pressure on social care (April). Social care was already under immense pressure well before the spread of COVID-19 but, as the pandemic took hold, the sector had to respond to additional risks, such as short supplies of PPE and the increased number of rapid hospital discharges. For trusts to address patient safety concerns impacting maternity services, particularly in relation to women choosing to have home births (April). This came after evidence suggested that more women were requesting to birth at home to reduce the risk of contracting COVID-19 while in hospital. For clarity around the large number of false negative COVID-19 test results (April). A high rate of false negative COVID-19 test results means that a significant number of people could be carrying the virus, wrongly assured they are not infectious. For the NHS to put in place a clear strategy to address the backlog of cases for elective surgery (June). We stressed the importance of this being done in a systemic way, with a published strategy that would help to ensure decisions regarding the priority of cases are made transparently and with patient safety at the forefront. Ensuring the voices of patients and staff are central to our work As our work in this area progressed, in May, we held a webinar with HealthPlusCare, titled ‘Patient safety: Time for questions? Non COVID-19 care and treatment’. Over 500 participants, including clinicians and patients, joined our discussion on the impact of the pandemic on non COVID-19 care and treatment. We used feedback from the discussion to inform our submission to the Health and Social Care Select Committee’s Inquiry, ‘Delivering Core NHS and Care Services during the Pandemic and Beyond’. Many issues we raised were highlighted in their report, published at the start of October. Looking forward As 2020 comes to a close and we move into the new year, the pandemic continues to hugely impact health and social care. We remain an independent voice for patient safety in this area, bringing attention to patient safety issues the pandemic exposes or creates, and engaging with partners to call for the NHS and Government to act urgently and reduce avoidable harm.

This 5 minute video, from MedStar Health, focuses on the human cost to our healthcare workforce when we fail to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events. This story has inspired conversation and can be used widely as a teaching tool. When patient harm occurs, caregivers involved are often devastated along with the patient and family, yet many have had to navigate this storm alone. A systems approach in our healthcare workplace, along with the just culture, cultivates the sharing of knowledge and helps prevent patient harm from occurring altogether. If you'd like to share your thoughts on Annie's Story, the systems approach and building a just culture, please comment below or join the conversation in our forum – Analysing events without blame or shame.

This paper from ABHI details the role of surgical instruments and how they bring value to the NHS. It highlights the vast range and number of instruments that are needed in the NHS at any one time and, to ensure that these instruments continue to be safe and fit for purpose, makes the following recommendations: Investment in the replacement of aged surgical instrument inventory should be considered as a priority for NHS spending. The procurement of surgical instruments should be based on overall quality and value, with the demonstration of strong ethical and resilient supply chains recognised and rewarded in purchasing decisions. There should be a focused, sustained and appropriately accredited programme of education into the management and maintenance of surgical instruments. Such a programme could be delivered in conjunction with industry.

Actions required Primary actions to be completed by 7 October 2020: Identify and locate affected devices in your organisation. Identify alternative ventilators available on site. If no suitable alternative available, and capacity is an issue currently or expected imminently, follow protocol for resource shortage escalation set out by your local governance. Train all relevant staff on alternative ventilators and ensure training records are up to date. When actions 1–4 are complete, remove affected V60s from use and quarantine until repaired by the manufacturer. Place the alternative devices into service in place of the affected V60s. You may continue to use affected V60s if there is a risk of severe patient harm due to lack of ventilator availability. A thorough risk assessment must be completed, and additional monitoring must be used. A backup form of ventilation must be available at all times. Secondary action to be completed by 23 December 2020: 8. Review procurement and stock policies to ensure you are not reliant on one manufacturer or model of ventilator.

During the debate on the second reading of the Bill there were contributions from a range of parliamentarians, reflecting on how it related to the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). Some points of interest from the debate included: Baroness Cumberlege noting concerns that "rumours are absolutely rife of a ritual burial" of the First Do No Harm report. She noted plans to create a parliamentary group called First Do No Harm to ensure the recommendations of the report were implemented. She stated her intention to put down an amendment to the Bill to include a proposal to appoint a patient safety commissioner, one of the key recommendations of the report. In his closing comments Lord Bethell, Parliamentary Under-Secretary of State (Department of Health and Social Care), noted that this amendment had support from a number of members of the House of Lords and that they had sent "a clear message to the Government and the public that patient safety must be paramount in how we regulate medicines and medical devices". Follow the link below for the full transcript.

Among the results reported by the Scan4Safety demonstrator sites, were: the release of 140,000 hours of clinical time back to patient care non-recurrent inventory reductions of £9m recurrent inventory savings worth nearly £5m across the six trusts.