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Content includes: Patient Safety: We’ve Come a Long Way National Patient Safety Consortium: Learning from Large-Scale CollaborationPatient Engagement in a Large-Scale Change Initiative: “As Safe as Possible, as Soon as Possible” Commentary: Three Ideas About “Post-Vention” Patient Safety Never Events: Cross-Canada Checkup Empowering Patients: 5 Questions to Ask About Your Medications Accelerating Post-Surgical Best Practices Using Enhanced Recovery After Surgery Patient Safety Culture Bundle for CEOs and Senior Leaders Commentary: We Must Look at Multiple Perspectives Homecare Safety Virtual Quality Improvement Collaboratives Commentary: Patient Safety in the Home Measuring and Monitoring Healthcare-Associated Infections: A Canadian Collaboration to Better Understand the Magnitude of the Problem Patient Safety: Patient Involvement Matters.

This report sets out to explore how antimicrobial stewardship (AMS) programmes are working to tackle antimicrobial resistance (AMR), by asking Clinical Commissioning Groups (CCGs) about their practice and experience of local stewardship. It is a follow-up to the Patients Association’s 2016 report on the same subject, and highlights some progress and areas for improvement in key areas. Using Freedom of Information Requests (FOIs), CCGs in England were asked a range of questions about their AMS programmes, relating to national guidance, toolkits and practice. The national policy and practice landscape puts AMS programmes at the heart of fighting AMR, and securing long-term quality healthcare for patients as a result. Primary care professionals are key to making these successful.

There is insufficient evidence that double versus single checking of medication administration is associated with lower rates of MAEs or reduced harm. Most comparative studies fail to define or investigate the level of adherence to independent double checking, further limiting conclusions regarding effectiveness in error prevention. Higher-quality studies are needed to determine if, and in what context (eg, drug type, setting), double checking produces sufficient benefits in patient safety to warrant the considerable resources required.

The results, published in BMJ Safety & Quality, found that fewer moderate-severe IMG-related errors occurred with the user-tested guidelines compared with current guidelines, but this difference was not statistically significant. Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines compared with current guidelines. Participants who used user-tested guidelines reported greater confidence. The authors conclude that user-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence.

Recommendations The Government should immediately issue a fulsome apology on behalf of the healthcare system to the families affected by Primodos, sodium valproate and pelvic mesh. The appointment of a Patient Safety Commissioner who would be an independent public leader with a statutory responsibility. The Commissioner would champion the value of listening to patients and promoting users’ perspectives in seeking improvements to patient safety around the use of medicines and medical devices. A new independent Redress Agency for those harmed by medicines and medical devices should be created based on models operating effectively in other countries. The Redress Agency will administer decisions using a non-adversarial process with determinations based on avoidable harm looking at systemic failings, rather than blaming individuals Separate schemes should be set up for each intervention – HPTs, valproate and pelvic mesh – to meet the cost of providing additional care and support to those who have experienced avoidable harm and are eligible to claim. Networks of specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh; and separately for those adversely affected by medications taken during pregnancy. The Medicines and Healthcare products Regulatory Agency (MHRA) needs substantial revision particularly in relation to adverse event reporting and medical device regulation. It needs to ensure that it engages more with patients and their outcomes. It needs to raise awareness of its public protection roles and to ensure that patients have an integral role in its work. A central patient-identifiable database should be created by collecting key details of the implantation of all devices at the time of the operation. This can then be linked to specifically created registers to research and audit the outcomes both in terms of the device safety and patient reported outcomes measures. Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors’ particular clinical interests and their recognised and accredited specialisms. In addition, there should be mandatory reporting for pharmaceutical and medical device industries of payments made to teaching hospitals, research institutions and individual clinicians. The Government should immediately set up a task force to implement this Review’s recommendations. Its first task should be to set out a timeline for their implementation. Response from Patient Safety Learning Patient Safety Learning welcomes the publication of the First Do No Harm report today from the Independent Medicines and Medical Devices Safety Review. The Chair of the review, Baroness Julia Cumberlege, highlighted in this that they found the healthcare system to be "disjointed, siloed, unresponsive and defensive" to the patients effected by these issues. She also noted that: ‘The system is not good enough at spotting trends in practice and outcomes that give rise to safety concerns. Listening to patients is pivotal to that’ The report highlighted some key themes consistent with other major patient safety failures: Patients not being engaged in their care: Lacking the information required to make informed choices, awareness of how to report problems and their experiences not being recognised. Ineffective reporting: Data not being utilised to identify and address patient safety issues. Existing reporting systems not being effective enough to capture this information and share learning widely. Blame culture: Persistent failure to acknowledge when things go wrong for fear of blame, reducing the ability to address threats to patient safety. Patient Safety Learning considers that patient safety is currently treated as one of many priorities to be weighed against each other. We think it is wrong that safety is negotiable. Patient safety must be core to the purpose of healthcare, reflected in everything that it does.

This is what the Transfers of Care Around Medicine (TCAM) project aims to address: When patients discharged from hospital are identified as needing extra support, they are referred through a safe and secure digital platform for advice from their local community pharmacist. Original work in the North East showed that patients who see their community pharmacist after they’ve been in hospital are less likely to be readmitted and, if they are, will experience a shorter stay. Many AHSNs, including Wessex and the West of England, have worked with trusts and Local Pharmaceutical Committees to help set up a secure electronic interface between the hospital IT systems and PharmOutcomes, the community pharmacy system used in their area. This has further enhanced TCAM by providing patient data quickly and seamlessly to their community pharmacist. Wessex AHSN developed an awareness campaign to encourage people to seek help with their medicines, featuring a character called Mo in a series of animated films and accompanying poster resources for pharmacies. The films have been viewed almost 64,000 times. Through the national implementation of TCAM in 2018-2020, each AHSN will support their local trusts to establish a TCAM pathway. This will enable all suitable patients to be referred to their community pharmacy or GP pharmacist where appropriate.

e-PAIN uniquely distills the knowledge of a range of professionals into 12 Modules made up of interactive sessions to meet the needs of a multidisciplinary audience. e-PAIN is current, up to date and presented in an interactive way to make both basic and specialist knowledge accessible. Any module can be completed stand alone and you can download a certificate upon completion of each module. Sessions take on average 30 minutes to complete and modules have on average 5 sessions. e-PAIN is a collaboration between the Faculty of Pain Medicine, the British Pain Society and e-Learning for Healthcare. It is provided by Health Education England.