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Found 144 results
  1. Content Article
    This study investigated burnout and sources of stress related to the Covid-19 pandemic among a group of healthcare risk managers and patient safety practitioners. An online survey asked the open question, "Since the start of the Covid-19 pandemic, what work or non-work-related issues have been causing you the most stress?" The results showed that burnout and pandemic-related stress were very common in the healthcare risk management and patient safety workforce. Stressors included: the impacts of social distancing. changing duties and workload. real and potential impacts of the virus (for example, fear of infection for self or others). financial concerns (personal and organisational). untrustworthy and constantly changing guidance. feeling abused by persons in power. positive comments about the experience of working during the pandemic.
  2. Content Article
    Digital clinical safety is becoming increasingly embedded into organisations, and along with it, compliance with the Data Coordination Board standards DCB0129 and DCB0160, which are mandated under the Health and Social Care Act 2012. However, there exists a number of challenges that are limiting the potential impact of the process. A Digital Health Networks CSO Council survey of clinical safety officers, conducted in 2024, highlighted key areas of concern, including a lack of understanding of the clinical safety process and importance of the CSO role, insufficient capacity for digital clinical risk management and lack of senior leadership buy-in. This white paper provides actionable insights to address these concerns, foster a culture of compliance with standards and improve digital clinical safety.
  3. Community Post
    Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh [email protected]
  4. Community Post
    As someone who works with NHS and actually as a Mental Health and Physical Health patient I've experienced discrimination and out right assault by the police whilst in hospital and ended up under S136 for no valid reason. Although I was assaulted with handcuffs being thrown over the bed rail, breaking my wrist I think. Still not had my mangled wrist xrayed 2 months on. Nothing worse than being in a vulnerable situation and bullies absolutely thrive on people in vulnerable positions. Their bosses think they're wonderful and so kind but they are in a position of power so of course the bully treats them differently or act differently when seniors are around. I recently put in a formal complaint to CEO I knew very well but instead of replying (after I told her I had recordings) she completely blanked me and now retired. Instead of "this is very serious Dominic, please send any evidence etc" I get told "how wonderful" my bully is! Interim CEO took over so I must inform him of Duty of Candour (Robbies Law) too. They don't seem to like that being pointed out but I shall do it anyway in hope we get a decent CEO who isn't just a pencil pusher waiting for band 9 pension. If as a volunteer I've experienced what I have, I dread to think what goes on as full members of staff. What struck me was the impunity these bullies operate with once in band 8 or above roles. You'd be very shocked if you heard what myself and four other service users went through. At the time my bullies refused to apologise (even though she received "disaplinary action") For me bulling and cronyism are both rotting the NHS from the inside out and needs sorting ASAP Please don't get me wrong, I support 99% of NHS staff but I cannot ignore the bullying, certainly at directorate or managerial level. The small percentage who do bullies seem to have no self awareness and those under them seem to think bullying behaviour is just "Leadership" Well no leader worth any salt will abuse you or tell you who you can and cannot speak too. Seeing service users slowly driven out by a particular bullie was extremely hard and not one manager wanted to know (bar one kind soul). Leadership means you MUST act whenever you even sniff the types of behaviours that signal a bully, however things are that bad that management cannot or won't recognise the controlling and mean behaviours Thanks for reading my first post
  5. Content Article
    This blog captures a recent discussion at a Patient Safety Management Network (PSMN) meeting, where members of the network raised a number of important questions and issues relating to the Patient Safety Incident Response Framework (PSIRF). PSIRF is currently being rolled out across all NHS trusts in England and takes a new approach to investigating patient safety incidents. Autumn marks the deadline for all NHS trusts in England to transition to PSIRF, so it was fitting that our PSMN meeting on 1st September dealt with some of the key issues the new framework is presenting. Patient safety colleagues from a wide range of organisations shared their reflections, concerns and questions about the complex and pressing issues they are facing as they seek to adopt PSIRF’s new approaches to patient safety incident responses. There were rich discussions about variation in how trusts are implementing the framework, the resource implications of meeting the expectations of NHSE regarding PSIRF, how patients engage with the process and who should work with them. Perhaps the most important question that was discussed was about the purpose of patient safety investigations—families may have very different ideas to managers or incident investigation teams about why a loved one’s death should be investigated, and that can hugely affect how they respond to and experience the process. What are the implications of increasing engagement with families and patients? PSIRF introduces a range of new approaches to incident investigation, aiming to make the process shorter and simpler, more collaborative and transparent, and easier to implement learning from. Trusts’ existing patient safety structures and teams will need to adapt to significantly different ways of working under PSIRF. One of the key topics was how to highlight and deal with the consequences of these changes, some of which have been predicted and some of which have possibly not yet been considered by NHS England and individual trusts. Here are some of the implications that members highlighted: There is a resourcing and capacity issue linked to the increased work involved in engaging with families. For example, some organisations are separating the role of engaging with patients and families from that of undertaking investigations, to reflect different staff positions, experiences and skill sets. Across some organisations there is a huge gap in family liaison and support, and that extends to PSIRF. This is a significant resourcing issue that needs to be addressed, as without adequate communication and support, investigations can be very distressing for patients. Different ways of working will require changes and updates to trusts’ technology. For example, some trusts are designing trackers to record and monitor engagement with patients and families by multiple staff members. While this should improve communications between staff and patients, trusts may need to invest in digital and other solutions to make sure systems are reliable and that staff know how and when to use them. Does the language and approach of PSIRF create barriers for patients? The discussion then moved on to the fact that how we engage with patients and families can compound the harm they have already experienced. Working with harmed patients isn’t easy and needs the right people, equipped with right skills and the right resources. Many members voiced the need for more guidance and training for all clinical staff, as PSIRF means that their role in investigations and patient engagement is changing. For example, some organisations are updating their Duty of Candour policy to reflect the requirements of PSIRF, and these changes will affect all clinical staff. During the discussion, several members pointed to incidents where families had found the approach and language of PSIRF difficult, or even offensive. There was some discussion about how the language used is a barrier to patient engagement, with names and descriptions in the framework laden with what is being seen as NHS jargon such as ‘learning leads’ and ‘patient safety partners’. Members pointed out that this language is inaccessible and doesn’t make it easy for patients to understand what’s going on in the investigation process. One member suggested learning from the way the Parliamentary and Health Service Ombudsman has used accessible language in its new NHS Complaints Standards. Several members reported instances where families had found the language of PSIRF insensitive. For example, one family member had told a member of staff, “my mother’s death is not a learning opportunity.” Perceptions that the investigation process is detached from the reality of a person’s lived experience can lead to difficulties in maintaining supportive and positive relationships with patients and families. It highlights a need to consider whether the language used in the implementation of PSIRF is adequately compassionate and respectful. We also talked about when the best time to involve patients in different PSIRF processes is. For example, one member pointed out that if you involve patients in an After Action Review (AAR) too early on, then you won’t have any answers for them, and this can be frustrating for everyone involved. On the other hand, conducting an AAR without the patient won’t include the patient's direct insight and might be seen as ‘rehearsing the truth’. This can undermine trust in the transparency of the investigation. We also looked at the resources and literature available for patients engaging with PSIRF, and the general feeling was that there is a big gap here. There is no guidance from families from NHS England, and while some excellent resources have been produced by the Learn Together collaboration, they are quite lengthy, which may put patients off. It was suggested that a summary version of the resources would be a helpful tool to offer patients. What’s the purpose of patient safety investigations? The issues we looked at around the language of PSIRF led on to a broader discussion about why we investigate, and whether PSIRF is aligned with patient views on this. PSIRF places a big emphasis on learning from patient safety incidents, which is clearly vitally important for improving patient safety. However, patients who have been harmed or people who have lost a loved one to avoidable harm are likely to have different reasons for wanting an investigation. The family member previously mentioned, who did not like their mother’s death being referred to as a ‘learning opportunity’, did not see organisational learning as the primary purpose. Patients and families may be looking for: a sense of justice and, in some cases, compensation. compassionate support and clear information on what happened to them or their relative. assurance that changes will be made to prevent future harm. This is a strong motivator for most patients, but it may not be the only reason they want to be involved in the process of investigation. It was also pointed out that the proportionate approach that PSIRF promotes presents us with a big gulf in the nature and approach we take to patient and family engagement. The level of engagement will depend on the severity and impact of avoidable harm, meaning patients involved in incidents that don’t reach the threshold for a patient safety incident investigation (PSII) may not receive the answers and support they need. Staff engagement and support for patient safety specialists As well as the challenges PSIRF presents in terms of patient engagement, the new framework will also require buy-in from staff right across the organisation. Some members shared concerns about attitudes they had encountered in front line clinicians and patient safety leads. For example, it was reported that some doctors are taking the view that if no AAR is submitted, they don’t need to have a Duty of Candour discussion with patients or families. One very important question we discussed was what additional support might be needed for staff who conduct investigations or work in patient safety roles. Exposure to traumatic events and awful harm, day in and day out, is painful and causes harm in itself. There is a clear gap here; dealing with patient safety incidents can be emotionally draining, and we talked about the need for clinical supervision and psychological support for staff. At past PSMN meetings we have discussed at length the need to provide support and resources for harmed patients and their families. It is an important area that we will return to at future meetings. Variation between trusts The key theme that ran throughout the session was variation in how different organisations are implementing PSIRF. Each organisation’s culture and commitment to patients and family involvement will be an important factor in how PSIRF is implemented. While some organisations have a strong base on which to implement PSIRF patient engagement recommendations, others don’t. Some of the key variations discussed include: different practical approaches to engagement. Some trusts will have informal discussions with families, while others undertake more formal reviews and investigations. a wide range of structures across patient safety teams, with roles carrying different responsibilities from trust to trust. differences in how tools are applied. For example, some trusts are using AARs to assess how effective the investigation process is, while others are using them as a learning response directly. Some trusts are involving patients directly in AARs, while others are using their Patient Engagement Leads as the patient representative in the process. Patient Safety Partners have different levels of involvement in learning responses. PSIRF was deliberately designed to allow trusts to adapt their approaches according to their own contexts, which means that variation is an inevitable part of PSIRF implementation. However, members of the PSMN are expressing concern about how this will exacerbate inequities for patients based on where they happen to live—an incident that qualifies for an AAR in one trust may not qualify in others. Reflections on the way forward These wide-ranging issues feel like a lot to try and deal with while doing the day-to-day work of patient safety management. But as one colleague pointed out, there has been little funding or training on these complex issues, and members shouldn’t be too hard on themselves. There is a long way to go before PSIRF makes tangible improvements to the methods and outcomes of learning responses and incident investigations, for both patients and staff. It was highlighted that research and evaluation funding to consider dissemination and implementation is available for another year and members should consider how they might access and use this to look at tackling some of these key issues. Joining the Patient Safety Management Network Do you work in patient safety and want to join the Patient Safety Management Network? You can join by signing up to the hub today. If you are already a member of the hub, please email [email protected].
  6. Content Article
    When many people think about NHS services they often think about clinical staff, such as doctors or nurses, and how they deliver care and interact with patients and families. However, in the context of patient safety, there is often more to see ‘behind-the-scenes’ in non-patient facing services. These services may be less visible, but they play a vital part in ensuring patient safety. Understanding the importance of these services, and how they are crucial to the ability of the NHS to operate effectively, is often underestimated. In this blog for the Healthcare Safety Investigation Branch (HSIB), National Investigators Russ Evans and Craig Hadley highlight how 'behind-the-scenes' services are crucial to help the NHS operate effectively and safely.
  7. Event
    The eyewatering cost of clinical negligence claims to the NHS have dominated the headlines over the years, with spending increasing on average by 13% each year since 2010/11. Should costs continue to rise at the same rate, we could see the NHS paying out £4.4 billion a year by 2023/24, constituting a major threat to the sustainability and viability of the NHS. We need to tackle the problem at the source – by making improvements in quality and patient safety so that both patient harm and subsequent litigation are reduced. According to NHS England, by 2024, continuous improvements in patient safety could save an extra 1,000 lives and up to £100m in care costs each year. So how can this threat be reversed and where does technology come into play? The role of technology in enabling staff to shift from a reactive to a proactive approach to deliver patient care, subsequently preventing avoidable harm Investing in the right infrastructure to support staff identify risks, ultimately reducing litigation costs Really committing to learning and having a system in place which instils that learning Enabling and supporting system-wide safety improvements To register, please click here.
  8. Community Post
    I met at a recent conference a newly appointed Patient Safety Manager. She’d been working in a supporting role in another organisation and was delighted with her obviously well deserved promotion to a more senior role of patient safety manager in another Trust. But 6 days in, she’s had no induction, there is no patient safety strategy or plan in the Trust, there isn’t any guidance as how she should do her job other than just ‘get on with doing RCAs. ‘ She doesn’t know who she can turn to for advice or support either in her Trust or elsewhere. Are there networks of PSMs she can turn to? Surely there is a model framework for patient safety that is produced as a guide? How can we help her and other PSMs?
  9. News Article
    The Care Quality Commission's chief executive Ian Trenholm has said he is sceptical about the need to appoint an NHS patient safety commissioner, one of the key recommendations of the recently published Cumberlege review. In a wide-ranging interview with HSJ, Mr Trenholm also revealed that he wants the Care Quality Commission to review the collaboration of every health system in England. Mr Trenholm told HSJ he is “not sure” a patient safety commissioner was needed and that it would need to perform a “role that was different from what’s already in place” for it to add value. He said: “If you look at the work we’re doing on patient safety, the work that HSIB are doing on patient safety, and then we’ve got people within the NHS itself doing work on patient safety, I think there are enough people playing. The question is, are we all working together as effectively as we possibly could be. “If another player helps that work [then] great, but I’m not sure that’s something that is necessary.” Read full story (paywalled) Source: HSJ, 24 August 2020
  10. Content Article
    This document defines the investigation framework in the event of a patient safety Serous Incident (SI) related to NHS Wales Informatics Service (NWIS) delivered or supported services, which affects one or more health body in Wales. National guidance for the investigation of any patient safety incidents identified as either a Serious Incident (SI) or No Surprises/Sensitive Issue relating to the provision of digital health care services in Wales
  11. Content Article
    This article discusses endometriosis and how the common treatment of performing laparoscopic surgery to remove damaged tissue may not be as effective as once thought. Lucia Osborne-Crowley writes about how experts have found that women who have the surgery don't always get better and if they do, it only lasts a short while. The article also describes what endometriosis is and how it is important not to continue encouraging women to undergo repeat surgeries as it may not improve the condition.
  12. Content Article
    This article discusses a new consultation that has been launched by Robert Francis QC regarding the terms of reference for an independent study into the infected blood scandal. The article covers the suggested scope, the approach and the rationale behind the research and what it won't do, such as run through evidence already heard by the Inquiry.
  13. Content Article
    This article focuses on common general surgical Never Events (NEs). The researchers analysed data from the National Health Service (NHS) in England and found a total of 797 general surgical NEs identified under three main categories: wrong-site surgery, retained items post-procedure and wrong implant/prosthesis. With this research, the authors aimed to raise awareness of these common themes with the hope it may help create better safety standards and safeguards and reduce the incidence of NEs.
  14. Content Article
    This article describes how Never Events (NE) are serious clinical incidents that cause harm to patients. The authors analysed data from NHS England to categorise themes and identify common NE. Their results revealed 51 common NE themes in four main categories out of a total of 3247 between 2012 and 2020, identifying wrong-site surgery as the most common category. The authors conclude that with this research, awareness may help to reduce the amount of incidences in the future.
  15. Content Article
    This article discusses patient safety clinical incidents in relation to bariatric surgery with an aim to identify bariatric surgery-related learning points from the incidents. After analysing reports from the National Reporting and Learning System (NRLS) database in England and Wales, the authors found 541 bariatric surgery-related clinical incidents with 58 themes, including failure of thromboprophylaxis and medication errors. The authors hope that their research can raise awareness of these clinical incidents and propose a safety checklist and specific recommendations to help improve patient safety.
  16. Content Article
    This article describes the "July effect" and why July is considered a concerning time for patient safety in hospitals due to the new influx of medical students graduating and starting their internships. The authors discuss how it may be avoided, effects from the pandemic on resources and educating new doctors.
  17. Content Article
    In this article, Brian Edwards, MD, discusses pharmacovigilance, society's changing approach to benefit and risk, confusion between compliance and ethics within pharmacovigilance and how ethical business practice is the basis of good business practice.
  18. Content Article
    Durrand et al. look at ways patients may be able to better prepare for major surgery, including targeting behaviours and lifestyle choices such as smoking and excessive drinking. The authors review evidence that physical inactivity and poor fitness, among other behaviours, has an impact on a patient's outcome. They also explore evidence for possible interventions at the perioperative stage.
  19. Content Article
    This article describes how the Care Quality Commission has charged The Dudley Group Foundation Trust with the deaths of Kaysie-Jane Robinson (14) and Natalie Billingham (33) who were found to have died as a result of safety failures. The Dudley Group Foundation Trust pleaded guilty to the charges in court on 2 July 2021, however, only the death of Ms Robinson was accepted by the trust as a result of their care failures.
  20. Content Article
    National Guardian news discussing current events, annual reports, and guidance.
  21. Content Article
    The study aims to describe patients' experiences of acquiring a deep SSI and it's negative impact. The authors propose that as many safety measures should be taken as possible to avoid and prevent infection.
  22. Content Article
    After Rosie Bartel went for knee replacement surgery, she was told she had contracted the MRSA infection. In this video, Mrs. Bartel describes how she is now in a wheelchair after three years and 11 surgeries.
  23. Content Article
    Six news stories relating to studies on surgical site infections and reducing their incidence. Free registration is required to view this content.
  24. News Article
    More than 20 leading NHS doctors and experts back Baby Lifeline demand for safety training for maternity staff to cut £7m a day negligence costs The Independent’s maternity safety campaign goes to Downing Street today as senior figures from across the health service deliver a letter demanding action from prime minister Boris Johnson. Charity Baby Lifeline will be joined by bereaved families, Royal Colleges and senior midwives and doctors in Downing Street to hand in a letter calling on the government to reinstate a national fund for maternity safety training. Baby Lifeline, which has also launched an online petition today, said the government needed to find £19m to support training of both midwives and doctors to prevent deaths and brain damage, which can cost the NHS millions of pounds for a single case. The letter to Mr Johnson has also been signed by Dr Bill Kirkup, who led the investigation into baby deaths at the Morecambe Bay NHS trust and is investigating poor care at the East Kent Hospitals University Trust. He said: “There have been real improvements in maternity services, but as recent events in Kent and Shropshire have shown only too clearly, much more remains to be done. The Maternity Safety Training Fund is badly needed.” Sir Robert Francis QC, Chairman of the public inquiry into poor care at Stafford Hospital, who also signed, said: “The cost in lost and broken lives, not to mention the unsustainable financial burden and the distress of staff caused by these avoidable mistakes, is indefensible.” Other signatories included former health secretary Jeremy Hunt, the Royal College of Midwives, the Royal College of Obstetricians and Gynaecologists and a number of senior maternity figures, charities and clinical associations. Read full story Source: The Independent, 6 March 2020
  25. Content Article
    This resource from NHS England provides guidance on how to make improvements in any area that involves safety. The guide includes explanations and advice involving improvement projects, the process of collecting, analysing and reviewing data, the Model for Improvement and how to use it.
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