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Showing results for tags 'Process redesign'.
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Content Article
The transition of older adults from the emergency department (ED) to home remains a potential area of preventable harm. Through a human-centred design process, the authors developed a patient-centred intervention aimed at improving communication and coordination between ED staff and patients. The intervention included a new electronic health record (EHR)-based template for physicians to enter discharge instructions, a redesigned after-visit-summary (AVS), enhanced nurse training for patient teach-back, and EHR-embedded tips for nurses at the time of follow-up call. The research objective was to evaluate this patient-centred ED discharge process redesign from multiple perspectives. The authors used A SEIPS 3.0 model to evaluate the intervention, in particular work system barriers and facilitators in the three subprocesses of the redesigned ED discharge process: physician writing discharge instructions, nurse/patient communication at discharge, and nurse/patient communication at follow-up call. The authors used multiple methods to collect quantitative and qualitative data from the perspectives of patients, and ED physicians and nurses. Overall, the redesigned patient-centred discharge process was perceived positively by ED physicians and advanced practice providers, ED nurses, and patients. All three groups identified work system facilitators regarding the intervention, in particular the usability of the AVS. Work system barriers pointed to areas for future improvement of the intervention, such as adding prepopulated information to the AVS. Using a human-centred design process, the authors improved ED discharge for older adults. The SEIPS-based research and evaluation fit with the learning health system concept as it provides input for future work system and patient safety improvement.- Posted
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- Older People (over 65)
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Event
The future of surgical pathways
Patient Safety Learning posted an event in Community Calendar
untilSurgical teams are under growing pressure, from rising case complexity and elective backlogs to increasing care demands and system fragmentation. But is it possible to redesign surgical pathways to improve both outcomes and efficiency? And what does good clinical pathway management really look like? On Wednesday 16 April 2025, Surgery International will host a free online webinar exploring the future of clinical pathway management through the lens of perioperative medicine. The session will bring together leading voices in surgery and digital health to explore how we can build safer, smarter and more connected surgical pathways, without losing sight of individual patient needs. Register- Posted
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Patient falls are a significant concern in healthcare settings, often leading to severe injuries, prolonged hospital stays and increased healthcare costs. The importance of fall prevention extends beyond patient safety—it reduces hospital liability, enhances patient outcomes and improves overall healthcare efficiency. By proactively assessing and addressing fall risks, healthcare providers can significantly lower the incidence of falls, ensuring a safer environment for patients. Given the aging population and increasing chronic disease burden, fall prevention remains a top priority in improving patient care and quality of life. This blog from Augustine Kumah, Deputy Quality Manager at The Bank Hospital, Accra, Ghana, explores the significance of fall risk assessment, its implementation and its role in reducing fall-related incidents in healthcare settings. Introduction Falls among patients, particularly in healthcare facilities, remain a pressing concern worldwide. These incidents not only lead to injuries, prolonged hospital stays and increased healthcare costs, but can also have lasting psychological impacts on patients. Preventing patient falls necessitates a multifaceted approach, with fall risk assessment at its core.[1] Understanding the impact of patient falls Patient falls are defined as unintentional descents to the ground that occur in healthcare facilities, including hospitals, nursing homes and rehabilitation centres. According to the World Health Organization (WHO), falls are the second leading cause of unintentional injury deaths globally, with older adults being most at risk.[2] In healthcare facilities, the consequences of falls extend beyond physical injuries; they also affect a patient’s confidence, independence, and quality of life. The financial burden of falls on healthcare systems is substantial. Costs include direct expenses such as treatment for fall-related injuries and indirect costs like litigation, reputation damage and loss of trust. Additionally, healthcare providers experience emotional distress and professional repercussions when preventable falls occur under their watch. Hence, fall prevention is not just a patient safety priority but also an ethical obligation and a cost-saving measure. The role of fall risk assessment Fall risk assessment is a systematic process to identify patients at risk of falling. Healthcare providers can implement targeted interventions to mitigate these risks by evaluating intrinsic and extrinsic factors. Intrinsic factors include age, medical history, mobility impairments and cognitive status, while extrinsic factors encompass environmental hazards, medication side effects and inadequate assistive devices. Risk assessment tools, such as the Morse Fall Scale, Hendrich II Fall Risk Model and STRATIFY Risk Assessment Tool have been widely used. These tools provide a structured approach to assess risk levels and guide preventative measures. However, their effectiveness depends on accurate application and regular updates based on patient conditions. Implementing effective fall risk assessments To maximise the efficacy of fall risk assessments, healthcare facilities must adopt evidence-based strategies and integrate them into their workflows. Key steps include: Standardised assessment protocols: Developing and adhering to standardised protocols ensures consistency in evaluating fall risks across different departments and shifts. Protocols should specify the frequency of assessments, criteria for reassessment and documentation requirements. Staff training: Comprehensive training programme for healthcare workers are essential to enhance their competency in conducting fall risk assessments. Training should cover assessment tools, recognition of risk factors and communication of findings to the care team. Patient and family education: Involving patients and their families in fall prevention efforts fosters a collaborative approach. Educating them about potential risks and preventive measures empowers them to contribute to safety. Technology integration: Advanced technologies such as wearable sensors, predictive analytics and electronic health records (EHRs) can augment traditional fall risk assessments. For instance, sensors can monitor patient movements and alert staff to potential falls, while EHRs can flag high-risk patients for closer observation. Challenges in implementing fall risk assessments Despite its benefits, implementing fall risk assessments is not without challenges. Common barriers include: Resource constraints: Limited staffing, time pressures and inadequate funding can hinder comprehensive risk assessments. Overburdened staff may struggle to prioritise fall prevention alongside other responsibilities. Inconsistent application: Variability in applying risk assessment tools can lead to inaccurate results. Subjective judgment, incomplete data collection and lack of protocol adherence contribute to inconsistencies. Resistance to change: Resistance from staff and administrators to adopt new practices or technologies can impede the integration of fall risk assessments into routine care. Patient non-compliance: Some patients may resist interventions such as bed alarms, mobility aids or supervision, increasing their risk of falling. Strategies to overcome the challenges To address these challenges, healthcare facilities can adopt the following strategies: Leadership support: Strong leadership commitment is crucial to allocating resources, establishing accountability and creating a safety culture. Interdisciplinary collaboration: Engaging multidisciplinary teams, including nurses, physicians, physical therapists and pharmacists, ensures a holistic approach to fall risk assessment and prevention. Continuous Quality Improvement: Regular audits, feedback sessions and performance evaluations help identify gaps in fall prevention efforts and drive improvements. Tailored interventions: Personalising interventions based on individual patient needs and preferences increases their acceptability and effectiveness. Conclusion Preventing patient falls requires a proactive and comprehensive approach, with fall risk assessment as a foundational element. Healthcare facilities can significantly reduce fall-related incidents and their associated consequences by identifying at-risk individuals and implementing tailored interventions. However, the success of fall prevention efforts hinges on overcoming implementation challenges through leadership support, interdisciplinary collaboration and continuous improvement. As healthcare systems evolve, leveraging technology and prioritising patient-centred care will be instrumental in advancing fall risk assessments. By embracing these advancements, healthcare providers can create safer environments that uphold all patients' dignity, independence, and well-being. References The Joint Commission. Fall Reduction Program - Definition and Resources, 28 August 2017 WHO. Falls Factsheet. World Health Organization, 26 April 2021.- Posted
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Content Article
When someone needs a joint replacement, there are many factors that affect how well they will respond, how quickly they will recover from the procedure and the potential risks of surgery. Patient complexity is the term used to describe these factors and includes other health conditions, sometimes called co-morbidities, as well as local risk factors related to the specific joint needing to be replaced. In this interview, consultant orthopaedic surgeon Sunny Deo and engineer and founder of TCC-Casemix Matthew Bacon, discuss how new technology is allowing surgeons to more accurately predict the surgical risk and outcomes for patients having knee replacement surgery. They describe how a new approach to data modelling is allowing the orthopaedic team at Great Western Hospital NHS Foundation Trust to more accurately assess complexity for individual patients. This has benefits for patient care and outcomes, theatre productivity and the development of pathways that are more patient-centred. They also highlight some patient safety issues associated with elective surgical hubs, which were set up to deal with high volume low complexity patients, including the deprioritising of more complex patients who may be at greatest need of surgery. Finally, they discuss the applicability of this approach to other specialties and areas of healthcare. Read more about clinical complexity in joint replacement surgery in this presentation by Sunny Presentation - Overview of clinical complexity by Sunny Deo.pdf- Posted
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- Surgery - Trauma and orthopaedic
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Content Article
Healthcare policies and initiatives are designed to save lives and enhance well-being, but they can also entrain unintended negative effects, writes Gary Humphreys for the Bulletin World Health Organization.- Posted
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Content Article
The early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study in the Journal of Patient Safety aimed to improve the proportion of patients receiving antibiotics within one hour of triage and compliance with sepsis bundles. A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 2018 to December 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. After this initial stage, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared and showed that: the proportion of patients receiving antibiotics within one hour of triage improved from 44% to 84%. intravenous crystalloid administration within three hours improved from 62% to 94%. serum lactic acid measurement within three hours improved from 62% to 94%. vasopressor initiation within six hours improved from 76% to 94%. mortality rates decreased from 32% to 21% between the 2 study periods.- Posted
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Community Post
A loophole in resilience
Clive Flashman posted a topic in Improving systems of care
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I was just listening to a podcast interview between Dr Rangan Chatterjee and Matthew McConaughey (In the series 'Feel better, live more'). Matthew M. mentioned that he came from a highly resilient family. If someone fell over, his mother would tell them to get right back up straight away and carry on. He added that he thought that while this resilience was generally a good thing, there should be (what he called) a 'loophole' in it so that there was time to learn why they have fallen over to begin with. Was there a crack in the pavement that needed to be avoided? That way, it wouldn't happen again in the future. This made me think about whether there really was a conflict between resilience in organisations and the need to learn from failure. What do you think??- Posted
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Community Post
Strategy - NHS Culture Change.pdf- Posted
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- Culture of fear
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Content Article
Engagement Value Outcome (EVO) promotes collaborative working between clinical and finance teams to enhance their collective understanding of patient level costing. It provides the NHS with a framework to ensure resources are used in the most effective way possible to provide high-quality care to patients. This clinical transformation case study focuses on the North Staffordshire Combined NHS Trust EVO project. The lead consultant for the service was concerned that the clinical pathways were not optimised and bottlenecks were delaying access, assessment and diagnosis of patients. As a result there were delays to initiating treatment. In addition to potential harm to patients this was resulting in inefficient and wasteful use of resources Impact on value and efficiency While the EVO pilot framework ended after the fourth session, the trust was keen close the loop and measure the benefit of the changes made. Following pathway changes the service could see the positive impact on patient experience but needed to work with the costing team to understand the impact on activity and cost, and therefore demonstrate if there had been any realisable efficiency and productivity gains. Because head CT scans are provided by a neighbouring acute trust, reducing the number of patients referred had a direct impact on service cost as well as releasing capacity in the wider system. Comparing baseline activity with the review period showed a 30% reduction in CT scan referrals and a £7,800 direct cost saving. The number of patients not attending appointments reduced from 572 in the baseline period to 379 after implementing pathway changes. While not a cash releasing saving this improved overall efficiency and productivity for the service and contributed to a reduction in overall unit price per attendance. At the start of the project, the average unit price for patients attending the memory service was £280.93. Through a combination of direct cost savings and efficiency and productivity gains arising from the revised pathway, this figure had reduced to £205.12 in the review period. Read the full case study via the link below. -
Content Article
Claire Cox, Patient Safety Lead at Kings College Hospital NHS Foundation Trust, shares a recent technique she used to explain the difference between 'work as imagined' and 'work as done'. Claire's example (a pathway for a patient coming to A&E, who also has a mental health issue) highlights the safety risks of competing guidance and the importance of co-production moving forward. The phrase work as imagined vs work as done is often used within patient safety but it's not always an easy concept to explain. I recently tried a new tactic to bring the realities of this concept to life, and show why it is so important to address these issues - in this case relating to a mental health pathway in A&E. My aim was to explain how some of the policies we try to use don't actually work well together in practice when we have a patient come to A&E with a both a mental and physical health problem. I started off by printing every piece of policy, guidance, standard operating procedure, related documentation on the trust intranet, HSIB reports, NICE guidance and anything I could find from the wider NHS. I pinned it across the walls in the meeting room. There were more than 150 items relating to how we should care for the patient in these circumstances. We put the pathway that we 'imagined' at the top, like a process map along the wall. We then placed all of the policies and documents below the pathway at the relevant points. Then I got the staff to tell me what actually happens. It became clear very quickly that the policies contradict each other. In trying to follow two policies, you couldn't actually adhere to either one properly. It was impossible for staff. Once we did that exercise, participants in the room could see how the people writing policies did not perhaps understand how 'work is done'. So it was decided that any new policy that encompassed this mental health pathway for A&E would be co-written by patients, families and the staff doing the work. Importantly, this would include all staff involved - admin, clinical and management. Once that had been written it would go through stages of testing to make sure it was working well and to incorporate necessary flex in the system when unexplained or unintended things happen. We would look at and test the vulnerabilities within that system or process. The exercise took time and effort but it was an effective way to show people the challenges and barriers to safe care in a specific context. My advice to others trying to do the same would be to get it all out, expose it, make it as visible as possible. Sometimes you have to be the one to put the writing on the wall. Related reading Postcards from work: Exploring archetypes of human work through micro-narratives Work as is done, work as imagined Electronic observations – how safe is it? Proxies for work-as-done: a blog series by Steven Shorrock, Humanistic Systems Share your thoughts What did you think of Claire's example? Could you see this working in a different area of healthcare?Do you have any tips or techniques to share that could help others explain the challenges they face on the ground to large groups of people? Share your thoughts by commenting below (sign up here first for free), or get in touch with our content team at [email protected]- Posted
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Content Article
On Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar. The first half of the webinar featured the following subjects and speakers: Introduction - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. The CPOC Perspective - Professor Scarlett McNally, CPOC Deputy Director. The Patient Safety Learning Perspective - Helen Hughes, Chief Exuecutive of Patient Safety Learning. Photo review of why NatSSIPs matters and what is new in NatSIPPs 2 - Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. The Patient Perspective - Susanna Stanford, NatSSIPs 2 Patient Lead. The second half of the webinar featured the following subjects and speakers: Our NatSSIPs 2 workshop and how to consider a NatSSIPs gap analysis - Joe Allen, Suffolk and North East Essex Integrated Care Trust. Team Training for NatSSIPs 2 - Philip Gamston, Perfusion Service Manager at Barts Health NHS Trust. Resources to support NatSSIPs 2 implementation - Dr Dr Annie Hunningher, CPOC NatSSIPs 2 Lead. Q&A - Professor Iain Moppett, CPOC NatSSIPs 2 Lead. Are you a healthcare professional interested in learning more about NatSSIPs? On the hub we host the National NatSSIPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSSIPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email [email protected].- Posted
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Content Article
Overcrowding in the emergency department (ED) is a global problem that causes patient harm and exhaustion for healthcare teams. Despite multiple strategies proposed to overcome overcrowding, the accumulation of patients lying in bed awaiting treatment or hospitalisation is often inevitable and a major obstacle to quality of care. This study in BMJ Open Quality looked at a quality improvement project that aimed to ensure that no patients were lying in bed awaiting care or referral outside a care area. Several plan–do–study–act (PDSA) cycles were tested and implemented to achieve and maintain the goal of having zero patients waiting for care outside the ED care area. The project team introduced and adapted five rules during these cycles: No patients lying down outside of a care unit Forward movement Examination room always available Team huddle An organisation overcrowding plan The researchers found that the PDSA strategy based on these five measures removed in-house obstacles to the internal flow of patients and helped avoid them being outside the care area. These measures are easily replicable by other management teams.- Posted
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- Emergency medicine
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Content Article
Rethinking healthcare as a safety-critical industry
Patient Safety Learning posted an article in Barriers
The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries.- Posted
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Content Article
Central line–associated bloodstream infections (CLABSI) account for many harms suffered in healthcare and are associated with increased costs and disease burden. Central line rounds, like medical rounds, are a multidisciplinary bedside assessment strategy for all active central lines on a unit. The project team designed a HIPAA-protected, text-based process for assessing central lines for risk factors contributing to infection. Staff initiated a consultation via a virtual platform with an interdisciplinary team composed of oncology and infectious disease experts. The virtual discussion included recommendations for a line-related plan of care.- Posted
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Content Article
Physicians raised a concern to the Quality Department about patients who were diagnosed in the emergency department (ED) with a urinary tract infection (UTI) but who later were clinically reviewed and found to be without disease. These patients were often admitted and treated with potentially unnecessary antibiotics. Literature reviews show patient and staff education of a clean catch urine culture collection technique alone is not always effective at consistently reducing urine culture contamination. The intervention team hypothesised that an effective multifactorial method to reduce urine culture contamination would be a combination of staff education on appropriate midstream and straight catheter collection techniques, verbal and visual education for patients, and staff and physician identification of patients who would provide more accurate urine cultures via straight catheterisation than clean catch. The goal of this process improvement was to reduce unintended patient consequences of unnecessary admissions, unnecessary antibiotic treatment, and repeat urine cultures through reducing contaminated ED urine samples to ≤10% monthly contamination. The results found that combined interventions resulted in a six-month decrease of contaminated urine samples from the initial 51% to <10%, resulting in an 80% decrease. The authors concluded that urine culture contamination in an acute care ED was sustainably decreased through multiple process improvement interventions. Secondary outcomes included reduction in unnecessary antibiotic use and unnecessary admissions.- Posted
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- Urinary tract infections
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Content Article
This video offers an introduction to the Systems Engineering Initiative for Patient Safety (SEIPS) framework, an approach that looks at work systems and processes from a systems-based perspective. SEIPS is the main model used within the Patient Safety Incident Response Framework (PSIRF) adopted by the NHS. This video includes an explanation of the model and a dramatisation of the process of making a round of tea in a staff room, illustrating the error traps and design issues present in the environment.- Posted
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Event
untilThis webinar is part of the HSJ Elective Care Recovery Virtual Series. To clear the waiting list backlog, hospitals will need to drive more elective activity within capacity and resource constraints. It demands the need to think differently and to work differently, questioning assumptions about the ‘normal’ ways of doing things. In this session we’ll explore innovative ideas, digital interventions and transformation programmes designed to free up time in elective pathways. Key topics include: Patient-initiated follow-ups Reducing outpatient appointments Pre-operative transformation / digitisation Investing in digital tools to improve efficiency in elective care pathways Register- Posted
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News Article
Wall Street Journal: How the Swiss Cheese Model can help us beat COVID-19
Clive Flashman posted a news article in News
No single solution will stop the virus’s spread, but combining different layers of public measures and personal actions can make a big difference. It’s important to understand that a vaccine, on its own, won’t be enough to rapidly extinguish a pandemic as pernicious as Covid-19. The pandemic cannot be stopped through just one intervention, because even vaccines are imperfect. Once introduced into the human population, viruses continue to circulate among us for a long time. Furthermore, it’s likely to be as long as a year before a Covid-19 vaccine is in wide-spread use, given inevitable difficulties with manufacturing, distribution and public acceptance. Controlling Covid-19 will take a good deal more than a vaccine. For at least another year, the world will have to rely on a multipronged approach, one that goes beyond simplistic bromides and all-or-nothing responses. Individuals, work-places and governments will need to consider a diverse and sometimes disruptive range of interventions. It helps to think of these in terms of layers of defence, with each layer providing a barrier that isn’t fully impervious, like slices of Swiss cheese in a stack. The ‘Swiss cheese model’ is a classic way to conceptualize dealing with a hazard that involves a mixture of human, technological and natural elements. This article can be read in full on the WSJ website, but is paywalled. The illustration showing the swiss cheese pandemic model is hyperlinked to this hub Learn post. -
News Article
Swann reveals future of Northern Ireland health service post COVID-19
Patient Safety Learning posted a news article in News
Northern Ireland faces a massive challenge rebuilding health and social care in the wake of the first COVID-19 wave, Health Minister Robin Swann has said. Speaking at the Northern Ireland Assembly on Tuesday, Mr Swann said that the rebuilding process can secure better ways of delivering services but will require innovation, sustained investment and society-wide support. He said that services will not be able to resume as before and that rebuilding will be significantly constrained by the continuing threat from COVID-19 and the need to protect the public and staff from the virus. “Our health and social care system was in very serious difficulties long before Coronavirus reached these shores. The virus has taken the situation to a whole new level. The Health and Social Care system has had its own lockdown – services were scaled back substantially to keep people safe and to focus resources on caring for those with COVID-19." The Health Minister said that despite the pressures, there are opportunities to make improvements. “I have seen so many examples of excellence, innovation and commitment as our health and social care staff rose to the challenges created by COVID-19. Decisions were taken at pace, services were re-configured, mountains were moved. Staff have worked across traditional boundaries time and time again. I cannot thank them enough. We must build on that spirit in the months and years ahead. Innovations like telephone triage and video consultations will be embedded in primary and secondary care.” Mr Swann added that the health system can't go back to the way it was and that it must be improved. Read full story Source: Belfast Telegraph, 9 June 2020 -
Content Article
Presentation from Terry Wilcutt Chief, Safety and Mission Assurance, and Hal Bell Deputy Chief, Safety and Mission Assurance at NASA.- Posted
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Kate Pym, Managing Director of Pym's Consultancy, discusses the barriers involved in getting an innovative product into the NHS. The NHS will not pay to improve patient safety You may think that I am saying this to be contentious, but sadly I am not. As an independent business consultant who supports new businesses and entrepreneurs in the health and care sector, this is a conversation which I have on almost a weekly basis. The reason for this is that most innovations are in response to a perceived problem, and there is no problem more obvious than harm caused to patient during medical treatment. The British are by nature innovative (36,558 Patent Applications were made by UK citizens in 2019, ranking in the top 10 worldwide in several indicators) and, for many people faced with a problem, their first response is to try and solve it, in this instance to prevent another patient from being harmed. This means that people have an idea, design, prototype or product, then find me to help them take the product to market and sell it. Unfortunately, many years of experience selling to the NHS across multiple organisations, from primary to tertiary care, has taught me that the NHS will not pay to improve patient safety. This applies even in the instance of never events – events that occur with the potential to harm patients, where if all guidelines and protocols are followed correctly this should never happen. My advice to innovators in patient safety I tell all prospective and current clients working in the field of improving patient safety to prove their concept in the UK, then sell overseas. An insurance-based health economy aligns the cost of patient harm and litigation with provision of healthcare and, as such, are risk-averse and highly motivated to provide the best possible levels of patient safety. The NHS system does not align costs and consequences of poor patient care with provision. Why won’t the NHS pay to improve patient safety? The NHS won’t pay because it is always the responsibility of somebody else’s budget. In all things commercial you have to look at motivation and reward. If, for example, a surgeon is the responsible clinician in theatres where a never event occurs, that surgeon will be held accountable and go through a rigorous investigation process to uncover the root cause. Although the investigation is not meant to be punitive, the sense of personal guilt, anxiety for the patient and family, and the potential for referral to governing bodies and even loss of their job, means that surgeons are very highly motivated to prevent never events. But the surgeon doesn’t hold the budget. If a piece of technology could prevent a never event in theatres, it would be the theatre manager who holds budgetary responsibility for purchase. However, the theatre budget is always fully accounted for; the NHS runs a very lean ship, and if an additional item is to be purchased something else is not – so what should be left out? PPE? Autoclave? Staff? Another point for the theatre manager is that, although they would be part of any investigation, they are not held responsible for an event and any consequential costs of extra bed days, rehabilitation and litigation are also not their responsibility. A real-life example... To give a real-life example, I consulted with Uvamed in 2016. They had an innovative product which reduced the risk of medication errors in anaesthesia. I conducted research to uncover the scale of the issue in the UK and in 2015 the Patient Safety Update from The Royal College of Anaesthetists (RCoA) reported 7,992 anaesthesia errors between April and June 2015 (yes, that’s right a quarter of a year), of these errors, 2,235 caused harm to patients, including 21 deaths and 22 severe harm. 13.5% of these errors were medication errors. In 2016 there had been a recent change in NHS Litigation Authority premiums paid by each NHS trust for Professional liability and negligence, using a claims history of 10 years instead of the previous 5 years, which meant that for some trust’s premiums had increased in excess of £2 million per year. This also meant that the litigation history of a trust would impact trust budget for 10 years. A freedom of information request to the NHS Litigation Authority uncovered the total number of anaesthesia claims received in 2014/15 to be 148; the total cost of settling the successful anaesthesia claims over the 10-year period was £140,962,157.17, £6,598,988.38 in the year ending April 2015. Anaesthesia is usually about a regular practiced routine. Standard practice is that syringes are prepared in advance of surgery and labels are applied to each according to strict colour coding, the syringes are then put in a receptacle (usually a cardboard kidney dish), with a second selection of prepared syringes in case of emergencies in theatre. Most errors involve human factors, such as tiredness or distraction, and in the heat of the moment it is easy to reach for a syringe in a jumble of other syringes and think that you have selected the right one, only for a different syringe to slip into your hand by mistake. Uvamed's product was Rainbow Trays®. Rainbow Trays consist of a base tray with coloured sections and disposable inserted trays, which are made of bacteriostatic plastic and have physical barriers between sections. The colour coding is the same as that used in critical care labelling for syringes, with sections in a logical progression for use. Unsurprisingly, anaesthetists loved them and wanted to trial and purchase. Trials went well and everyone was happy. The purchase had to come out of theatre budgets. The theatre managers saw no financial benefit to their department in return for the spend so they wouldn’t pay, neither would any other department. The happy ending for Uvamed and international healthcare is that Rainbow Trays® are “flying off the shelves” in the USA, Australia and New Zealand. Rainbow Trays are on NHS Supply Chain and have been purchased at quantity by Health & Social Care Northern Ireland for their Nightingale Hospitals. For further information on Rainbow Trays, contact Keith Fawdington [email protected] Conclusion Unfortunately, NHS England will not pay to improve patient safety until either the silo mentality of internal budgets is removed (which is as likely as an effective fireguard made of chocolate) or someone at senior level in each trust is made accountable for the impact (financial and social) of unsafe patient care and given a budget to improve outcomes and reduce risks. Call for action Some forward-thinking Trusts have Board-level roles for Innovation. I appreciate that no Trust wants a senior member of staff 'bothered' by every good idea out there, but with a triage qualification for appointments this could offer the opportunity for our innovators to help the NHS improve care, efficiency and outcomes. Institute a team of clinicians and business managers who hold the responsibility for patient safety, making them responsible and accountable for seeking improvements in patient care (both internal and external). This would only work if they are allocated a budget, and a target of identifiable improvements. Other hub articles you may be interested in Why NHS procurement must change if we want to improve patient safety- Posted
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News Article
‘Fundamental’ changes to London’s NHS in wake of COVID-19
Patient Safety Learning posted a news article in News
The NHS in London is planning to “fundamentally shift the way we deliver health and care” in the wake of coronavirus, according to documents obtained by HSJ. The plans from NHS England and Improvement’s London office say leaders should: Plan for elective waiting times to be measured at integrated care system level, rather than trust level. Accept “a different kind of risk appetite than the one we are used to”. Expect decisions from the centre on the location of cancer, paediatric, renal, cardiac, and neurosurgical services. Plan for a permanent increase in critical care capacity. Transform to a “provider system able to be commissioned and funded on a population health basis”. Work towards “a radical shift away from hospital care”. Expect “governance and regulatory landscape implications” plus “streamlined decision-making”. The document, titled Journey to a New Health and Care System, says there are three “likely” phases, with the final new system in place “from November 2021”. The preceding two phases are “action programmes” over the next 12 to 15 months which will be about reconfiguring services to deal with “immediate covid, non-covid and elective need”, and “transition” when the move to new configurations is evaluated and “public consent” sought. Read full story Source: HSJ, 11 May 2020- Posted
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News Article
London begins major COVID-19 reconfiguration
Patient Safety Learning posted a news article in News
St Bartholomew’s Hospital is to be the emergency electives centre for the London region as part of a major reorganisation to cope with the coronavirus outbreak. Senior sources told HSJ the London tertiary hospital, which is run by Barts Health Trust, will be a “clean” site providing emergency elective care as part of the capital’s covid-19 plan. It is understood the specialist Royal Brompton and Harefield Foundation Trust will also be taking some emergency cardiac patients. The news follows NHS England chief executive Sir Simon Stevens telling MPs on Tuesday that all systems were working out how best to optimise resources and some hospitals could be used to exclusively treat coronavirus patients in the coming months. Read full story (paywalled) Source: HSJ, 18 March 2020- Posted
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- Accident and Emergency
- Medicine - Infectious disease
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News Article
‘Inherently risky’ children’s cancer service to be overhauled
Patient Safety Learning posted a news article in News
Children’s cancer services in south London are to be reconfigured after a new review confirmed they represented an “inherent geographical risk to patient safety” — following HSJ revelations last year of how serious concerns had been “buried” by senior leaders. Sir Mike Richards’ independent review was commissioned after HSJ revealed a 2015 report linking fragmented London services to poor quality care had not been addressed, and clinicians were facing pressure to soften recommendations which would have required them to change. The review, published in conjunction with Thursday’s NHS England board meeting, recommended services at two sites should be redesigned as soon as possible to improve patient experience. Read full story (paywalled) Source: HSJ, 31 January 2020- Posted
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- Cancer
- Process redesign
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Content Article
WireSafe® is an innovative solution designed to prevent retained guidewires during central venous catheter (CVC) insertion. Retained guidewires are never events that require urgent removal if accidentally left in. They occur in about 1 in 300,000 procedures. We interviewed Maryanne, who developed the WireSafe®, on the innovation, the human factor considerations in designing it and the difficulties she faced getting a new product into the NHS.- Posted
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- Medical device / equipment
- Innovation
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