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Content ArticleThis presentation was given at the WHO Global Conference: Engaging patients for patient safety that took place in September 2023. Maki Kajiwara, technical officer at the World Health Organization's (WHO's) Patient Safety Flagship and Sue Sheridan, a founding member of Patients for Patient Safety US (PFPS-US), gave the presentation to introduce the new WHO Patient Safety Storytelling toolkit. The presentation outlines the need for a storytelling toolkit and provides questions and guidance to help storytellers share their experience.
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Event
Investigation and Learning From Deaths
Patient Safety Learning posted an event in Community Calendar
This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner. By 2024, all deaths in the community or acute settings that do not required to be referred to the coroner (non-coronial deaths) will need to be scrutinised by a medical examiner. The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care. For further information and to book your place visit: https://www.healthcareconferencesuk.co.uk/virtual-online-courses/investigation-learning-deaths-hospital-mortality or email frida@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #LearningFromDeaths -
Content Article
From Autumn 2023, NHS organisations in England are changing the way they investigate patient safety incidents. NHS England has introduced this new approach, which is called the Patient Safety Incident Response Framework (PSIRF). NHS England has produced detailed resources for patient safety leaders and policy makers about the purpose of PSIRF and what organisations are expected to do to deliver this part of the NHS Patient Safety Strategy. However, discussions with frontline clinicians, patient safety managers, educators and Patient Safety Partners have highlighted the need for a simple guide that helps communicate PSIRF to a wide range of stakeholders, including those who do not work in healthcare. This guide provides some basic information about what PSIRF is and why it’s been introduced. It also outlines what patients, carers and family members can expect from an investigation if they are involved in a patient safety incident. -
Content ArticleThe Patient Safety Incident Response Framework (PSIRF) is a new approach to responding to patient safety incidents. NHS organisations in England have been implementing the framework since September 2023 and, as part of this, each trust is required to create and publish a Patient Safety Incident Response Plan (PSIRP). Patient Safety Learning is compiling PSIRPs from all NHS trusts in England in our PSIRP finder, available below. Making these documents accessible in one central place will make them easy to find, allow trusts to compare ways of working and highlight variation in how trusts are approaching PSIRF implementation. As well as sourcing PSIRPs that are easily accessible in the public domain, we submitted a Freedom of Information (FOI) request to all NHS trusts in England in November 2023. We will continue to add links to plans as they become available. If you are aware of a PSIRP that has been published that isn't yet featured, please get in touch and we will add it to the finder.
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Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. Homerton University Hospital have shared a presentation on how they are going to implement LFPSE into Datix, a quick reference guide and a screen saver they are using to introduce it to staff. Others may find the resources useful and can adopt/adapt them in their own organisations. They can be downloaded from the attachments below. Additional resources on the hub: CSH Surrey share their presentation slides on LFPSE and Datix.
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Content ArticlePatient experience is deteriorating across the NHS, so hearing from users should be of the utmost importance as the NHS looks to improve, yet too often those leading work on patient experience feel that it is not prioritised. The King’s Fund has been working with the Heads of Patient Experience (HOPE) network to design and develop projects to better understand how people and communities are experiencing health and care services. This article outlines learning and recommendations from this work.
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Content ArticleThis article in the British Journal of Anaesthesia argues that the criminalisation of medical accidents leaves clinicians scared to report systemic causes and contributors to bad outcomes, removing a foundational pillar of patient safety. Looking at the case of RaDonda Vaught, a nurse who was found guilty of criminally negligent homicide for a fatal medication accident, the authors highlight the need to move away from seeing adverse incidents in healthcare as being easily avoided through greater attention, trying harder or adherence to rules. They call on healthcare organisations to learn from the case and argue that healthcare systems need to be collaboratively redesigned with a systems perspective.
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Event
PSIRF embedding webinar 4
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register -
Event
PSIRF embedding webinar 3
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register -
Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. LFPSE introduces improved capabilities for the analysis of patient safety events occurring across healthcare, and enables better use of the latest technology, such as machine learning, to create outputs that offer a greater depth of insight and learning that are more relevant to the current NHS environment. LFPSE fields can now integrated into Datix incident form, and the information is uploaded to the national database upon the completion of an incident report. After the reviewing manager’s and Patient Safety Team review, any changes are automatically re-uploaded and the information updated in the national database. CSH Surrey share their presentation slides on LFPSE and Datix.
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Content ArticleHigh reliability organisations are organisations that work in situations that have the potential for large-scale risk and harm, but which manage to balance effectiveness, efficiency and safety. They also minimise errors through teamwork, awareness of potential risk and constant improvement. This evidence scan collates empirical evidence about the characteristics of high reliability organisations and how these organisations develop within and outside healthcare.
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Content ArticleThis report makes several recommendations to unlock the preventative potential of Prevention of Future Deaths (PFD) Reports. These reports should be viewed as an opportunity for organisations to improve, share good practice, and ultimately prevent custodial deaths – not as criticism to be avoided at all costs. PFD reports have an integral function in ensuring compliance with the state’s duties under Article 2 of the European Convention of Human Rights (ECHR), the right to life, both locally and nationally. This, as well as their immense importance to bereaved families, must be borne firmly in mind.
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Content ArticleInpatient falls are one of the most common patient safety incidents reported in rehabilitation wards in Australia and can result in serious adverse patient outcomes, including permanent physical disability and occasionally death. Camden Hospital in Australia implemented a multidisciplinary review meeting (Safety Huddle) following all inpatient falls and near miss falls, which developed strategies in consultation with the patient to prevent the incident from reoccurring.
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Event
SEIPS in learning disability, social care and mental health
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using Systems Engineering Initiative for Patient Safety (SEIPS) in Learning Disability, Social Care and Mental Health. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. Register -
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This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network. -
Content ArticleTrevor Stevens daughter, Tobi, took her own life in December 2020 whilst in the care of the Norfolk and Suffolk NHS Foundation Trust. Trevor recently attended the HSJ Patient Safety Congress. In this blog, he reflects on his experience at the Congress. Related reading on the hub: Time for a reset on safety? Highlights from day one of the HSJ Patient Safety Congress
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News Article
Sepsis killing too many as lessons not learned, warns NHS watchdog
Patient Safety Learning posted a news article in News
Sepsis is still killing too many patients due to the same hospital failings that occurred a decade ago, a damning report by the NHS ombudsman has warned. Avoidable mistakes include delays in spotting and treating the condition, poor communication between health staff, sub-standard record keeping and missed opportunities for follow-up care, according to Rob Behrens, the parliamentary and health service ombudsman (PHSO). Despite some progress since a previous report on sepsis by the ombudsman in 2013, lessons are not being learned and repeated mistakes are putting people at risk, Behrens said. Major improvements are urgently needed to avoid more fatalities, he added. “I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” said Behrens. “It is clear that lessons are not being learned. Losing a life through sepsis should not be an inevitability.” Melissa Mead, whose one-year-old son, William, died from sepsis in 2014 after concerns were dismissed by doctors, said: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.” Mead, who peer-reviewed the study, added: “Too many lives are being lost in preventable circumstances.” Read full story Source: The Guardian, 25 October 2023 Further reading on the hub: Top picks: Six resources about sepsis -
Content ArticleSepsis is a life-threatening reaction to an infection. It can affect anyone of any age. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs. Sepsis is sometimes called septicaemia or blood poisoning. According to the UK Sepsis Trust, 48,000 people in the UK die of sepsis every year. This number can and should be reduced. It is often treatable if caught quickly. This report from the Parliamentary and Health Service Ombudsman(PHSO) looks at some of the sepsis complaints people have brought to PHSO, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised Further reading on the hub: Top picks: Six resources about sepsis
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Content ArticleNHS England published the new Patient Safety Incident Response Framework (PSIRF) in August 2022 outlining how organisations providing NHS-funded care should respond to patient safety incidents to facilitate ongoing learning and improvement. From Autumn 2023, PSIRF will replace the current Serious Incident Framework. It will change the way all healthcare providers, which deliver NHS funded care, including independent healthcare organisations respond to patient safety incidents. Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how we’re supporting members to be ready.
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Content ArticleAs part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.
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Content Article
We have had quite an eventful few weeks in the NHS in England, much of it not very pretty. There have been reports of a consultant dismissed from a Trust for raising concerns about safety, and, following a well-reported series of events, an experienced and essential clinician leaving the workforce. Then there were the events in Manchester where a nurse has been convicted of murdering seven children and the attempted murder of another six children. This despite the raising of concerns by not one, not two but seven senior clinicians. They faced the now repeatedly seen series of actions where they were not believed, faced counteraccusations and threatened with being reported to their regulators. Now we have the inevitable fall out, an incoming inquiry and, no doubt, the same or very similar themes to the many inquiries that have happened in the past. There has been much discussion about these events on social media, mostly focused on Lucy Letby, about patient safety, the actions that people should have taken and reasons why they did not. However, in this blog, I am choosing to look at things from a slightly different perspective, that of the Patient Safety Incident Response Framework (PSIRF).- Posted
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Content ArticleExtravasation is the leakage of intravenously administered solution into surrounding tissues, which can cause serious damage to the patient. There are multiple guidelines and local policies relating to extravasation injuries but not a singular national uniform policy. NHS Resolution share their recent slides on what can be learned from extravasation claims, presented at the IV Therapy Summit.
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Content ArticleThe Covid-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. This study from Purchase et al. aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. The study found that PISA taxonomy can be successfully applied to patient safety incident reports to support the first stages in deriving learning and identifying areas for further enquiry. No incidents were identified that warranted new codes to be added to the PISA classification system, which may extend to other substantive public health crises, negating the need for additional, specific coding within such classification systems and related frameworks for similar system-wide constraints.
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Content ArticleWalkthrough analysis is a structured approach to collecting and analysing information about a task or process or a future development (for example, designing a new protocol). It is used to help understand how work is performed and aims to close the gap between work as imagined and work as done to better support human performance. Walkthrough analysis is one of the tools included in the Patient Safety Incident Response Framework (PSIRF). This guide by NHS England provides information on how to carry out walkthrough analysis. It covers: Getting started System considerations Task and tool matrix View further PSIRF content and resources on the hub.
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Content ArticleThe protests outside the Scottish Parliament took an alarming turn recently with people wearing hospital gowns spattered with blood. The demonstrators were former patients of neurosurgeon Sam Eljamel, many allegedly harmed by him and still suffering and searching for answers years later. A public inquiry has been announced by the First Minister. As the Patient Safety Commissioner for Scotland Bill makes its way into law, Alan Clamp, chief executive officer of the Professional Standards Authority for Health and Social Care, asks what this means for Scotland and the safety of its patients? See also: Working together to achieve safer care for all: a blog by Alan Clamp
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