This is an independent review of the SLS:
1. To consider recommendations made by the State Coroner and by independent reviews conducted in response to the Chemotherapy Underdosing that relate to incident reporting and management.
2. To determine and describe how the SLS is used across SA Health for patient incident reporting and management including:
a. adoption and uptake;
b. data extraction;
d. incident management; and
e. open disclosure to patients and feedback to staff.
3. To identify factors that are impeding or may impede the use of SLS, including;
a. the culture of reporting and incident management, and
b. the availability and uptake of training and education.
4. To determine if Datix Web, the software platform used for the SLS, meets the needs of SA Health and whether its functionality is comparable to alternative programs.
5. To make recommendation to the Chief Executive (CE), Department of Health and Wellbeing that will assist in assuring robust incident reporting and management and the sharing of learnings across SA Health.
The report identified five essential learnings:
More than half of adults and over two thirds of young people said that their mental health has gotten worse during the period of lockdown restrictions, from early April to mid-May.
Restrictions on seeing people, being able to go outside and worries about the health of family and friends are the key factors driving poor mental health. Boredom is also a major problem for young people.
Loneliness has been a key contributor to poor mental health. Feelings of loneliness have made nearly two thirds of people’s mental health worse during the past month, with 18–24 year olds the most likely to see loneliness affect their mental health.
Many people do not feel entitled to seek help, and have difficulty accessing it when they do. 1 in 3 adults and more than 1 in 4 young people did not access support during lockdown because they did not think that they deserved support.
A quarter of adults and young people who tried to access support were unable to do so. Not feeling comfortable using phone/video call technology has been one of the main barriers to accessing support.
Reviewed more than 300 innovations and supported the adoption of 50 of them.
Prevented 30 strokes per year through atrial fibrillation initiatives in primary care.
Met 500 companies and established 30 industry partnerships.
Leveraged £123m to improve health in our region and support economic growth.
Key local projects
Mental health: Relapse prevention following psychological therapy – includes launch of Paddle smartphone app providing ongoing support for patients.
Heart failure: Improving treatment in primary care – working with Novartis to deliver better patient outcomes and reduce hospital admissions.
Sleep improvement: Enhancing mental health and self-care at scale – real-world evaluation of the experiences of thousands of people who used the Sleepio online digital support programme.
Maternity: Developing an e-learning package for fetal heart rate monitoring – helping midwifery colleagues deliver an award-winning tool developed in Reading/Oxford.
Key national programmes
Reducing stroke risk: Working with all clinical commissioning groups and primary care, sharing learning and spreading best practice to reduce strokes related to atrial fibrillation, diagnosing 3,000 more patient.
Better outcomes following emergency surgery: Working with the five acute NHS trusts in the Oxford AHSN region which perform emergency laparotomy surgery, reducing mortality and length of stay for more than 800 patients.
Preventing cerebral palsy: Promoting the adoption and spread of magnesium sulphate in pre-term labour through the ‘PReCePT’ initiative, sustaining uptake at over 85% and improving life-chances of more than 100 babies.
Reducing medication errors: Working with all CCGs, pharmacists and GPs to train almost 200 practices in our region through the PINCER programme.
Between 1 April 2017 and 31 March 2019, 19,331 cases were raised to FTSU Guardians in trusts and foundation trusts.
12,244 cases were raised to FTSU Guardians in trusts and foundation trusts between 1 April 2018 and 31 March 2019.
The total number of cases raised in 2018/19 was 73% higher than that raised in the 2017/18 reporting period.
The number of cases raised in Q4 of 2018/19 was 38% higher than that raised in Q1 of the same year.
The average number of cases per trust was largest among combined acute and community trusts (an average of 75 cases per trust reported over the year). This is the same trend as was observed in 2017/18.
More cases (3,728, 30% of the total) were raised by nurses than other professional groups.
1,491 cases (12%) were raised anonymously, compared to 18% of cases the previous year.
3,523 cases (29%) included an element of patient safety / quality.
4,969 cases (41%) included an element of bullying / harassment.
564 cases (5%) indicated that detriment as a result of speaking up may have been experienced
The highest number of cases in a single trust reported over the year was 270. The lowest number of cases reported was 1.
The paper sets out how the AHSN alongside the PSCs have improved patient safety and their goals for the future:
We will support the foundations of the national strategy: a patient safety culture and a patient safety system, across all settings of care.
The PSCs will deliver the patient safety strategy improvements and seek the next tranche of national programmes for national adoption and spread.
We will work with our members, Sustainability and Transformation Partnerships (STPs) and Integrated Care Systems (ICSs) to roll out and embed these national initiatives in the local areas, ensuring ownership and sustainability.
We will work alongside the Regional Patient Safety Teams focusing on their system-wide objectives to support STPs and ICSs to identify and implement transformational change. Each region will have differing local needs depending on their starting point, but there will be cross-cutting themes that every PSC can support in a standardised way. Following the adoption and spread of the national initiatives, the AHSN network can support the seven regions with the national programme of capacity and capability building, utilising our local academies and delivery mechanisms for integrated quality improvement, Health Foundation training and innovation training.
We will support the capacity and capability and leadership development programmes particularly helping our local system leaders and partners to build knowledge and understanding of the innovation landscape and the opportunities this affords their own organisation’s and wider system’s safety agendas.
We will build on the operational and strategic relationships we have with other national bodies also interested and engaged in the world of patient safety. In particular, we will strengthen our partnership with:
The Health Foundation (HF), which has supported the development of the early phases of a number of projects that have developed into national patient safety initiatives;
Health Education England (HEE) to deliver the safety mandate, building on our existing relationship which sees us working together on joint programmes of work such as learning from deaths and the response to the Topol Review, focusing on the opportunities for safety from genomics, artificial intelligence (AI) and the digital revolution.
FOAMcast reviews Dr Josh Farkas's PulmCrit blog posts on 'Renal microvascular haemodynamics in sepsis: a new paradigm' and 'Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications', in which he posits that renal protection in sepsis may prove beneficial for patients.
In this report the CQC have seen much good and outstanding care, in particular around:
staff interactions with patients
leadership and engagement with staff and patients.
However, there were a number of areas where services needed to make substantial improvements:
NHS Improvement publish two sets of National patient safety incident reports (NaPSIRs) simultaneously. This publication includes reports covering incidents to June 2019 and to March 2019; the commentary analyses data to March 2019. NaPSIRs were previously called Quarterly Data Summaries (QDS).
Who is this aimed at?
This tool kit is aimed at everyone.
There are different sections for each target group
What will I learn?
Recognition and response to AKI
Primary care management post AKI episode
Embedding a holistic approach to AKI