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Safety recommendations It is recommended that the British Association of Urological Surgeons, in collaboration with other relevant specialties (such as the Royal College of Radiologists and British Transplant Society), develops national standards which support electronic and paperbased systems for stent logging/ tracking. These standards should include guidance on monitoring and human oversight. It is recommended that the British Association of Urological Surgeons works with the Patient Information Forum to review its stent patient information leaflet. This should include accessibility and clinical considerations, especially with regards to side effects and complications, and advice on the action to take should concerns arise. It is recommended that the British Association of Urological Surgeons provides guidance for staff working within the stone care pathway to promote consistent advice to patients as part of discharge planning. It is recommended that the British Association of Urological Surgeons encourages members to include information in discharge letters and other communication sent to GPs and patients regarding patients’ stent status, potential complications and the possibility of a retained stent. Safety observations The NHS Summary Care Records (SCR) system is being developed to allow for specific patient groups to be flagged. It may be beneficial for the British Association of Urological Surgeons to liaise with NHSX should opportunities arise in the future to use SCR to flag patients with ureteric stents to aid communication with primary/urgent care services. The National Institute for Health and Care Excellence (NICE) guidance for the management of urinary tract infections does not include ureteric stents as a cause of urinary symptoms which could mimic a urinary tract infection. It may be beneficial for this potential complication to be considered in the next review of this and other clinical practice guidance.

CQUIN.pptx CQUIN.pdf

Some key findings from the audit: Inpatient mortality was 26%. It has reduced from 34% in 2013 and represents the first time that mortality has improved since the first BTS audit in 2010. Compared to the last audit, an increased proportion of patients treated with acute non-invasive ventilation (NIV) had COPD, the indication with the strongest evidence. We saw a decreased proportion of patients who were treated with NIV despite no clearly documented indication. This suggests improved patient selection in line with the evidence base for NIV. 50% of patients treated with NIV started NIV treatment within 60 minutes of the blood gas that defined the need for NIV. Clinician responses indicate a reduced perception of treatment delay in comparison to prior audits. Acute NIV was successful in resolving respiratory acidaemia for 76% of patients treated, in comparison to 69% in the last audit (2013). Only 74% of organisations reported that they have sufficient capacity to deliver the routine acute NIV service. Only 52% of organisations had a nursing lead and 34% had a physiotherapy lead for their acute NIV service.

Key findings - Average diagnosis times for endometriosis have not improved in over a decade – it still takes 8 years on average to get a diagnosis; - Prior to getting a diagnosis and with symptoms: 58% visited their GP more than 10 times 43% visited doctors in hospital over 5 times 53% visited A&E; - Once diagnosed, only 19% know if they are seen in an endometriosis specialist centre; - 90% would have liked access to psychological support, but were not offered this. Recommendations In order to support those with endometriosis, the APPG has called on all Governments in the UK to commit to a series of support measures for those with endometriosis including: Commitment to reduce average diagnosis times with a target of 4 years of less by 2025, and a year or less by 2030. To ensure a baseline for endometriosis diagnosis, treatment and management by implementing the NICE Guideline on Endometriosis Treatment and Management (2017), adopted across the UK, but not implemented. Up to 10% of those with endometriosis will have the disease outside the pelvic cavity, yet the NICE Guideline only provides a care pathway only for endometriosis within the pelvic cavity. The APPG is calling for NICE to ensure that care pathways for all locations of endometriosis are developed and implemented, starting with thoracic endometriosis. Investigation into the barriers faced in accessing care for those from black, Asian and minority ethnic backgrounds and end the ethnicity and gender gaps in medical research. Invest in research to find the cause of endometriosis, better treatment, management and diagnosis options, and one day a cure. A commitment from all 4 nations to include compulsory menstrual wellbeing in the school curriculum so that young people recognise the warning signs of menstrual health conditions and know when to seek help. This is compulsory in schools in England from 2020, but is not UK wide.

Drawing together insights from an extensive expert roundtable in November 2019, prisoner consultation and wider research, the analysis covers primary care and chronic disease management, care of older prisoners, dementia care, social care provision, compassionate release, palliative care, culture, workforce and training. These findings lead to 15 recommendations grouped into the following themes: Improve join-up and information sharing across services and departments. Implement improvements to primary and secondary care. Take steps to improve provision and care for specific vulnerable groups. Improve end of life care across the prison estate. Enhance the profile of prison healthcare as a career. Improve learning and investigations. Ann Norman, the RCN’s Professional Lead for Criminal Justice, said: "We are seeing a growing number of natural deaths in custody and this has now reached an unacceptably high level. These deaths may be prevented if there is adequate care, particularly for those prisoners with long-term chronic conditions. The Government must act now to make sure that prisoners’ health is properly managed, as it would be in the community.” Juliet Lyon, Chair of the Independent Advisory Panel on Deaths in Custody, said: “Many so-called natural deaths in prison can and should be avoided. Our report draws together information from health and justice experts, investigators and people in prison to examine how such deaths could be prevented and how end of life care can be managed with dignity and compassion. During Covid-19, the struggle to identify prisoners who, for clinical reasons, would have been shielded in the community and the failure to effect safe temporary release for all but a few, has thrown the challenges presented by the poor health of the prison population into sharp relief.”

In May 2019, the World Health Assembly recognised patient safety as a key health priority, acknowledging the need to “take concerted action to reduce patient harm in healthcare settings”.[1] They asked the World Health Organization (WHO) to formulate an action plan to help improve patient safety, resulting in the first draft Global Patient Safety Action Plan 2021-2030, published for consultation in August 2020.[2] Patient Safety Learning is pleased to have contributed to the development of this global initiative, with our Chief Executive, Helen Hughes, having attended the initial consultation sessions earlier this year.[3] [4] At the end of September, we responded to the WHO with our feedback on the first draft. Here is a summary of that feedback. The WHO Global Patient Safety Action Plan Patient safety is an issue which impacts all countries, with the WHO estimating that unsafe care is one of the 10 leading causes of death and disability worldwide.[5] In high income countries, as many as one in 10 patients are harmed while receiving hospital care.[5] In low- and middle-income countries, the impact is even greater, with poor quality care estimated at accounting for 10-15% of total deaths, some 2.6 million deaths annually.[6] We welcome, therefore, the WHO’s focus on patient safety as a global priority, along with its vision of a “world in which no patient is harmed in health care, and everyone receives safe and respectful care, every time, everywhere”.[2] It sets out its goal as achieving the maximum possible reduction in avoidable harm as a result of unsafe care.[2] To help achieve this goal, the Action Plan outlines a set of guiding principles: Treat patients and families as partners in safe care. Achieve results through collaborative working. Analyse data and experiences to generate learning. Translate evidence into measurable improvement. Base policies and action on the nature of the care setting. Use both scientific expertise and stories of care to educate and advocate. These principles closely align with our six foundations for safe care that are needed to progress towards a patient-safe future, as we argue in our evidence-based report A Blueprint for Action.[7] The Action Plan subsequently goes on to outline seven strategic objectives which provide a framework for achieving its goal. Each objective is underpinned by specific strategies with accompanying actions for the WHO, governments, healthcare organisations and key stakeholders. Tackling the implementation gap and sharing learning A key issue that the Action Plan identifies as a barrier to making patient safety improvements is what it describes as the “knowing-doing” gap, known elsewhere as the “implementation gap”.[8] There are many examples where a team, organisation or even country may be implementing patient safety solutions, but this good practice or successful measure is siloed within that team, organisation, or country. Patients will then continue to experience harm from problems, despite successful solutions already in existence elsewhere. At Patient Safety Learning, we see the shared learning for patient safety as a vital means of tackling this ‘knowing-doing’ gap. We feel that the Action Plan could place a stronger emphasis on shared learning more widely, both by the WHO and between member states, stressing the importance of disseminating good practice and patient safety knowledge. As an example, where the WHO proposes that governments should publish an independently audited annual report on patient safety performance, we believe an additional action is needed, specifically that the WHO should collate these national reports and share their findings on annual basis. There would be huge value in seeing what progress member states are making and this would support active networking and collaboration. We are helping to tackle the knowing-doing gap with the hub, our platform to share learning for patient safety. We would be happy to share our experience and collaborate with the WHO in sharing learning to improve patient safety. Building high reliability health systems and organisations The Action Plan notes that a key safety success factor in other high-risk industries is “the emphasis placed on preventing accidents, harm and mistakes that have serious consequences”.[2] Related to this it sets a strategic objective focused on the creation of High Reliability Organisations in health, that are able to operate in complex circumstances where there are significant risks without serious accidents or catastrophic failures.[9] Such organisations “cultivate resilience by relentlessly prioritising safety over other performance pressures”.[9] We strongly agree with this approach, which aligns with our belief that patient safety should not simply be another priority but part of the purpose of health and social care. In our feedback, we noted that it is vital to also account for the role of Health IT (HIT) systems in making patient safety core to health and social care. Failure to do so can, under certain conditions, lead to patient harm. In the design, development and use of new technologies, patient safety should be embedded into all stages of the process, helping to reduce errors in healthcare and ultimately saving lives. We made the case in our feedback that the Action Plan should include guidance around the use of healthcare technology assessment and safety risk management when making decisions about the use of new IT systems.[10] This guidance would need to include steps to ensure that organisations have specific safety guidelines and tools for the use of HIT, and publicly available examples of HIT safety cases. Included in these steps should be the assessment of patient safety risks when introducing any changes, whether technology, operational or process changes. Working with partners to bring about change The Action Plan rightly emphasises the importance of working with stakeholders - beyond those charged with the delivery of health and social care - to improve patient safety and staff safety. We believe the following groups should also be considered as essential partners: Trade Unions - bodies that represent health workers have a key role to play if we are to ensure that patient safety considerations are at the core of healthcare. Ensuring the safety of health workers is intrinsically linked to making improvements to patient safety.[11] Human Factors/Ergonomics professionals - collaboration with these individuals will be particularly important in making the changes needed, as set out in the Action Plan’s Strategic Objective 2, to build high reliability health systems. Included in this group should be both experts in this area working in healthcare and those from other industries who are able to contribute their experiences and expertise. International Development organisations - the relationship between international development and patent safety is an underexplored area, worthy of further work. As such, we believe that Non-Governmental Organisations involved in development work should also be included on the stakeholders list. How do we create a global patient safety movement? Much of the focus of the Action Plan understandably centres on work that can be done by governments, healthcare organisations and the WHO to improve patient safety. To achieve the scale of change needed, however, Patient Safety Learning believes we also need to develop and support a social movement for patient safety. In early initial discussions about the Action Plan, Sir Liam Donaldson, WHO Envoy for Patient Safety, noted this, emphasising the value and impact of mobilising public pressure to deliver change. He also deemed it essential that we learn from past campaigns that have succeeded.[3] How do we start such a social movement? It is a difficult question, but we believe a key consideration is the democratisation of healthcare systems and the role of co-production with patients. This will mean overcoming some of the fears that exist around working in equal partnership with patients and avoiding the trap where patients can become ‘insiders’. Patients, families and carers need to be an effective independent voice for change. References 1. WHO, World Health Assembly Update, 25 May 2019. 2. WHO, Global Patient Safety Action Plan 2021-2030, 28 August 2020. 3. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 1, 6 March 2020. 4. Patient Safety Learning, Developing the next Global Patient Safety Action Plan - Part 2, 16 March 2020. 5. WHO, Patient Safety Fact File, September 2019. 6. National Academies of Sciences, Engineering and Medicine, Crossing the Global Quality Chasm: Improving Health Care Worldwide, 2018. 7. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. 8. Suzette Woodward, Patient safety: closing the implementation gap, 30 August 2016. 9. Agency for Healthcare Research and Quality - Patient Safety Network, High Reliability, 7 September 2019. 10. Health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology. It is a multidisciplinary process to evaluate the social, economic, organizational and ethical issues of a health intervention or health technology. The main purpose of conducting an assessment is to inform a policy decision making. WHO, Medical devices: Healthcare technology assessment, Last Accessed 13 October 2020. 11. Patient Safety Learning, Why is staff safety a patient safety issue?, 3 September 2020.

The HSIB investigation focused on what happens after thrombolysis treatment is given and how venous thromboembolism (VTE) risk is managed as patients recover. They identified issues such as a low rate of intermittent pneumatic compression (IPCs) being fitted despite their success in improving the survival rates of those who are not mobile after a stroke and their recommendation by NICE guidelines. As the investigation progressed, HSIB identified missed opportunities throughout the whole process of care. There is a lack of a national, stroke-specific assessment for VTE that considers the patient’s specific circumstances or determines the level of risk the patient has of blood clots forming. Even if an assessment identifies IPC as a treatment, the case examined in this report reflected a wider picture of confusion over how the devices are recorded i.e. on the patient’s chart and who then is responsible for fitting. The findings also show that national guidelines do not require a follow-up assessment or a check that the VTE preventative measure is in place. Safety recommendation As a result of the national investigation, HSIB have made one safety recommendation to facilitate the development of a stroke specific assessment, a system for the associated treatment to be recorded using a tool to ensure that the relevant information is documented and, importantly, reviewed. Dr Stephen Drage, HSIB Director of Investigations and intensive care unit consultant, said: “The time after a patient is admitted and treated for a stroke is incredibly precarious. It is important that any safety risks in the care process are mitigated to prevent life-threatening blood clots forming to give patients the best chance of making a full recovery. “A number of barriers to the most effective aftercare emerged through our investigation and the safety issues impact not only all specialist units but any wards where stroke recovery takes place in the NHS. The recommendation we have made is aimed at ensuring that VTE risk is managed in a targeted way that ensures that patients are getting the right treatment at the right time.”

The taskforce carefully considered an extensive range of issues in relation to the social care sector as a whole, brought together as key themes. These included the provision of personal protective equipment, COVID-19 testing arrangements, the winter flu vaccination programme, infection prevention and control, and issues of funding. The taskforce examined a number of issues relating to the workforce and family carers (unpaid), including how best to restrict the movement of people between care and health settings. Among other themes, the taskforce reviewed the role of clinical support within the sector, the availability and application of insights from data, and implications of inspection and regulation. This report sets out the action that will need be taken to reduce the risk of transmission of COVID-19 in the sector, both for those who rely on care and support, and the social care workforce. This report sets out how we can enable people to live as safely as possible while maintaining contacts and activity that enhance the health and wellbeing of service users and family carers. Throughout this report, a number of recommendations are made based on learning from the first phase of the pandemic. They range from 'quick wins' to consideration of topics that will require a degree of more substantial change and/or additional resource. In addition, there are a number of supporting recommendations in the annexed reports of the subject-specific advisory groups, which should be considered in tandem with the main report recommendations.

Notable achievements Working with the Office for Product Safety and Standards and the British Standards Institute to produce a guide to best practice for manufacturers and retailers of button and coin cell batteries. Instigating the Royal College of Paediatrics and Child Health and the Royal College of Emergency Medicine to produce a comprehensive guide on button battery ingestion in children covering common signs, symptoms and critical care situations. Recognising the importance of digital technology in healthcare by making multiple safety recommendations, nine to NHSX, across a number of our investigations. In our investigations with a digital impact, we discovered there were no standards for system interoperability for medication messaging; that a standardised digital care passport should be developed with a particular focus on supporting patients with autism; and, that there should be better electronic record sharing between the prison health electronic record system and the custodial services system. In the report ‘Design and safe use of portable oxygen systems’ one manufacturer decided to act quickly on HSIB's report’s safety recommendations and developed a new component to improve safe delivery of oxygen to patients. 88% of families engaging with maternity investigations. HSIB's maternity programme highlighting eight areas of learning from our initial investigations which will be developed into thematic national learning reports and published during 2020/21 (‘Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B’ report already published). Strengthening our collaborative working relationships with trusts and maternity stakeholders including, the Royal Colleges, Maternity Transformation Board, NHS Resolution and others. The relationship ensures that trusts are immediately informed when there are safety concerns, and actions implemented so similar incidents can be prevented from happening again.

The National Action Plan centres on four foundational and interdependent areas, prioritised as essential to create total systems safety, with 17 recommendations to advance patient safety. Culture, Leadership, and Governance 1. Ensure safety is a demonstrated core value. 2. Assess capabilities and commit resources to advance safety. 3. Widely share information about safety to promote transparency. 4. Implement competency-based governance and leadership. Patient and family engagement 5. Establish competencies for all healthcare professionals for the engagement of patients, families, and care partners. 6. Engage patients, families, and care partners in the co-production of care. 7. Include patients, families, and care partners in leadership, governance, and safety and improvement efforts. 8. Ensure equitable engagement for all patients, families, and care partners. 9. Promote a culture of trust and respect for patients, families, and care partners. Workforce safety 10. Implement a systems approach to workforce safety. 11. Assume accountability for physical and psychological safety and a healthy work environment that fosters the joy of the health care workforce. 12. Develop, resource, and execute on priority programmes that equitably foster workforce safety. Learning system 13. Facilitate both intra- and inter-organisational learning. 14. Accelerate the development of the best possible safety learning networks. 15. Initiate and develop systems to facilitate interprofessional education and training on safety. 16. Develop shared goals for safety across the continuum of care. 17. Expedite industry-wide coordination, collaboration, and cooperation on safety.

During the debate there were contributions from a range of parliamentarians reflecting on the First Do No Harm report and the implementation of its recommendations in Scotland. Some points of interest from the debate included: Jeane Freeman MSP indicated the intention of the Scottish Government to implement the recommendations of the First Do No Harm report which fall within its remit and powers. Their discussion about the report's recommendation that specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh. While Jeane Freeman noted that a National Mesh Removal Service had been established in Glasgow last year, Neil Findlay MSP expressed concerns that the levels of coproduction involved in the design and delivery of this service were inadequate. Alison Johnstone MSP highlighted the particular impact of these issues on women and noted nthat the findings reflected the ways in which women are disadvantaged in accessed health and social care services. In her closing remarks Clare Haughey MSP, Minister for Mental Health, noted the intention to begin a consultation on the Scottish Government's proposal to introduce a Patient Safety Commissioner. Follow the link below for the full transcript.

Today HSIB has published a new national intelligence report, Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response.[1] This looks at inconsistencies in the guidance on PPE requirements for care workers visiting ‘clinically extremely vulnerable’ individuals at home. The report is in response to a member of the public raising concerns when visiting a patient at home in the ‘clinically extremely vulnerable’ category. They noted that while they were visited by district nurses in PPE, their care workers did not wear this, advising that this was not required. The patient later died, and their death was confirmed as COVID-19 related. HSIB found that during April the guidance made available by Public Health England for care staff in this regard was inconsistent. While the primary guidance did not refer to the need to wear PPE when visiting ‘clinically extremely vulnerable’ individuals, other guidance issued in the same month did set out these additional safety provisions. As a result of this, multiple versions of the guidance were available to care workers, who would not be aware of the PPE requirements if they referred to the earlier version of this. Speed of the response HSIB state that they brought this to the attention of Public Health England on the 28 April 2020. They subsequently replaced the primary guidance with a link to a version with the additional PPE provisions on the 13 May. Given the importance of clarity on infection control and PPE, it is very concerning that the conflicting guidance remained live on the gov.uk website for a further two weeks after the issue was identified. A wider system issue The report acknowledges the complexity of providing and keeping up to date such a wide range of guidance, particularly in a crisis scenario, noting that this creates “a risk that patient safety issues may be missed”.[2] When considering the learning potential of this case, HSIB suggest that “there is an opportunity to introduce a document management system for guidelines to ensure that the latest information is available”.[3] While this specific issue is now resolved, it is disappointing that there is no wider recommendation relating to the systems risks above identified by HSIB. Patient Safety Learning believes that there should be an additional recommendation on this that clearly identifies the relevant healthcare bodies responsible for looking into this. There are also questions about how updated guidance is published and shared. Commenting on this in The Independent, Jane Townson, Chief Executive of the UK Homecare Association, mentioned problems with guidance being updated late at night with little notice.[4] She also stated that “there was a very high risk that care providers were not alerted to the changes unless they belonged to a membership association”.[5] Who can lead this change? While we have noted Public Health England's specific role in this case, formulating this type of guidance can involve a number of bodies across the UK, such as: Department of Health and Social Care NHS England and NHS Improvement Public Health England Public Health Wales Public Health Agency Northern Ireland Health Protection Scotland When system-wide patient safety issues arise all these organisations have a role to play. We know that when it comes to implementing changes the system is “confused and complex, with no clear understanding of how it is organised and who is responsible for what”.[6] Patient Safety learning believes it is vital that there is a clear approach to addressing such underlying safety issues. We need to ensure that learning and recommendations for change are prioritised and implemented widely across the health and social care system. References Healthcare Safety Investigation Branch, National Intelligence Report: Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response, August 2020. Ibid. Ibid. The Independent, Coronavirus: ‘Confusing’ advice from Public Health England put patients at risk, watchdog says, 26 August 2020. Ibid. Care Quality Commission, Opening the door to change: NHS safety culture and the need for transformation, 2018.