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  1. Content Article
    Findings While national guidance says that a patient’s risk of harm should not be stratified into categories such as high, medium or low, such stratification remains common in many trusts. This is because other methods of assessing and documenting risk are not available, and because staff fear being blamed if a patient comes to harm without a risk assessment, including risk stratification, having been completed. Current research only demonstrates a link between menopause and low mood, and not between menopause and more severe mental health symptoms. Women are frequently prescribed antidepressant medication when hormone replacement therapy may be a more appropriate treatment for their symptoms. Menopause is not routinely considered as a contributing factor in women with low mood who are assessed by mental health services, and staff do not receive training in this area as standard. While there is a significant amount of national guidance relating to family engagement when treating patients with mental health conditions, mental health practitioners often find it difficult to know how and when to engage with families with complicated relationships or when the patient withdraws their consent for information sharing. There is a lack of training in this area to support staff with decision making. National guidance raised the upper age limit for referral to the Early Intervention in Psychosis pathway in 2016. Some trusts continue to prioritise younger patients for a variety of reasons – including funding, capacity and misconceptions about whether an older person can actually be experiencing a true first episode of psychosis in later life. Safety recommendations HSIB has made four safety recommendations as a result of this investigation. NHS England: HSIB recommends that NHS England works with appropriate stakeholders, including experts with appropriate experience, to create guidance on culture change. A quality improvement programme should also be developed to support practitioners in undertaking psychosocial assessments that are in line with guidance from the National Institute for Health and Care Excellence. Person-centred safety planning should be embedded within the process. Care Quality Commission (CQC): HSIB recommends that the Care Quality Commission evaluates the way in which it reviews how community mental health services assess risk of harm, to ensure its inspections are in line with the latest national guidance. National Institute for Health and Care Excellence (NICE): HSIB recommends that the National Institute for Health and Care Excellence evaluates the available research relating to the risks associated with menopause on mental health and if appropriate, updates existing guidance. Royal College of Psychiatrists (RCPsych): HSIB recommends that the Royal College of Psychiatrists forms a working group with relevant stakeholders to identify ways in which menopause can be considered during mental health assessments. Safety observations HSIB has made the following safety observations: It may be beneficial for mental health organisations to have a dedicated liaison officer who acts as a point of contact for both families and clinicians when navigating involvement in a patient’s care and decision making. It may be beneficial for organisations to involve families in care planning and assessments, and that practitioners are appropriately trained in working with families. It may be beneficial for education bodies to develop training programmes in safety planning and psychosocial assessments, once NHS England has provided guidance on how such assessments should be conducted. It may be beneficial for mental health organisations to ensure their Early Intervention in Psychosis referral process is in line with the national guidance, and that staff are clear about the upper age limit of patients accepted onto the pathway. Safety actions HSIB has noted the following safety action: NHS England has written to all mental health trusts in England to highlight the importance of taking a person-centred approach to psychosocial assessments and safety planning. The communication asks trusts to move away from risk assessment tools that stratify an individual’s risk of suicide or self-harm.
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    The provision of safe and quality care is the most fundamental principle to consider for patients in perioperative practice. Alongside this commitment, is the safety and welfare of all staff and visitors within the setting. Risk assessment, staffing ratios, competency and skill are crucial to ensuring that the intended outcome for patients is achieved as far as is reasonably practicable. The discussion will outline how this can be achieved utilising the recommendations by the Association for Perioperative Practice (AfPP). Learning outcomes: Understanding risk and the process of risk assessment in perioperative practice. The components of a safe perioperative environment. How to calculate a safe staffing model for your environment based on the AfPP standard. Register
  3. Content Article
    The impact of tiredness on performance Tired from work? No matter what your job, work can sometimes wear us out and leave us feeling drained and weary. For those of us that work in healthcare, this can have huge impacts on the care we are able to deliver to our patients. Our workloads are heavy, stressful and often involve complex decision making, compounded by a shortage of staff and a lack of support in the workplace. On top of this, there are the usual out of work demands: family, social, studying and keeping fit to name but a few. With more and more things needing attention in our waking hours, sleep has a tendency to fall down the list of priorities. Many healthcare workers are chronically sleep restricted and don’t routinely get their required 8 hours’ sleep. Early starts and night shifts only serve to make matters worse. In fact, chronic sleep restriction reduces our subjective feelings of drowsiness, so we may miss the important warning signs that our performance is deteriorating. There’s good evidence that as we tire our performance get worse. It’s harder to make complex decisions or perform complicated tasks, manage our emotions and interact empathically with colleagues. Staff have less respect for sleep deprived managers. Our vigilance, short term memory, and mood suffer; we are more impulsive, poorer at assessing risk and less effective at teamwork.[1] And we are more accident-prone, sometimes with tragic consequences. Doctors, nurses, midwives – all have died driving home tired. The patient safety implications Sleep restriction also impacts on the care we deliver to patients. GPs prescribe more antibiotics when they have been working long hours without a break, surgeons are slower at operating, and patients anaesthetised later in the day have higher rates of postoperative pain, nausea and vomiting than those on morning lists. At the end of a long shift, neonatal ICU clinicians are less meticulous about hand asepsis.[2] Tired practitioners make more errors prescribing and dispensing drugs at night, and patients operated on out-of-hours have an increased risk of unexpected death. Patients of nurses working shifts longer than 12 hours have higher rates of mortality and morbidity.[3, 4] Staff wellbeing It’s not only the patients that may come to harm, night shift workers themselves have a higher risk of several diseases, including cardiovascular disease, type 2 diabetes, mental health problems, accidents, injuries and some forms of cancer.[5–8] Our bodies are not designed to be awake at night. As well as the brain’s internal body clock controlling our circadian sleep rhythm, many of our cells function differently at night. The pancreas goes into a tailspin if we eat a large meal in the middle of the night; digestion, blood sugar control, muscle strength and cognitive function are all diurnal (day-active). These systems don’t respond when we change from day to night shift. No matter how hard we try, we are unable to shift the phase of our internal clock to match our work demands, so we may be sleepy during night shifts and struggle to sleep in the day. What can we learn from other industries? Every other safety-critical industry realises that employee fatigue is a problem and has ways of recognising and mitigating its impact. But for some reason, healthcare does not. It’s a legal requirement for other 24/7 industries, such as airlines, road haulage and nuclear, to have a formal fatigue risk management system as part of the work culture. So what can we learn from them? The first thing is education: ensuring everyone in an organisation understands the risks of fatigue and the importance of prioritising our sleep – so-called ‘good sleep hygiene’. At work we need easily accessible facilities in quiet dark safe areas where we can nap during breaks. Even a 20 minute ‘power nap’ makes us safer. We need a culture that encourages staff to take breaks and to nap. We also need to minimise the amount of work we do between 3 and 6am, the circadian nadir, perhaps changing the time we traditionally give 6 hourly medicines from midnight and 6 am, where drug errors are more common at these times, to 1 am and 7 am. Where activity cannot be avoided, we need to look out for each other; double check what we are doing with a colleague and have some experienced staff on each shift who can support our thinking in fast-moving situations. Most of all we need to talk about fatigue, to find out who is already tired when we come to work and recognise that fatigue-aware cultures make healthcare safer, for staff and for our patients. What can organisations do to improve their culture? Organisations can take steps to improve their culture, including: Putting fatigue on the risk register. Improving facilities with sofa beds in staff rooms. Raising awareness of fatigue amongst medical and nursing staff, particularly in acute medical disciplines, such as anaesthesia, obstetrics, critical care and emergency medicine. But rather than work piecemeal, we need a national effort; governments should require all healthcare organisations to have fatigue on the risk register, and to demonstrate how they are mitigating the impact of long hours and nightshift work. Driving to and from work should become part of ‘driving for work’ – the regulatory framework that covers lorry drivers and train drivers – so that the employer has a stake in the employee getting home safely. The employee would then get a power nap during a shift, which is known to drastically reduce the chance of having 'microsleeps' at the wheel. In a healthcare system that’s under huge strain, taking fatigue seriously is an easy win, it will make patients and staff safer and provide a much-needed boost to morale and wellbeing. References Kayser KC, Puig VA, Estepp JR. Predicting and mitigating fatigue effects due to sleep deprivation: A review. Front Neurosci 2022; 16. doi: 10.3389/fnins.2022.930280. Rittenschober-Böhm J, Bibl K, Schneider M, et al. The association between shift patterns and the quality of hand antisepsis in a neonatal intensive care unit: An observational study. Int J Nurs Stud 2020; 112:103686. doi: 10.1016/j.ijnurstu.2020.103686. Gurubhagavatula I, Barger L, Barnes C, et al. Guiding Principles For Determining Work Shift Duration And Addressing The Effects Of Work Shift Duration On Performance, Safety, And Health. Sleep 2021; 44(11). doi: 10.1093/sleep/zsab161. Linder JA, Doctor JN, Friedberg MW, et al.. Time of day and the decision to prescribe antibiotics. JAMA Intern Med 2014; 174(12):2029-31. doi: 10.1001/jamainternmed.2014.5225. Papantoniou K, Castaño-Vinyals G, Espinosa A, et al. Shift work and colorectal cancer risk in the MCC-Spain case-control study. Scand J Work Environ Health 2017; 43(3): 250-259. doi: 10.5271/sjweh.3626. Park J, Shin SY, Kang Y, Rhie J. Effect of night shift work on the control of hypertension and diabetes in workers taking medication. Ann Occup Environ Med 2019; 31(27): e27. doi: 10.35371/aoem.2019.31.e27. Patterson PD, Weiss LS, Weaver MD, et al. Napping on the night shift and its impact on blood pressure and heart rate variability among emergency medical services workers: study protocol for a randomized crossover trial. Trials 2021; 22(1): 212. doi: 10.1186/s13063-021-05161-4. Ponsin A, Fort E, Hours M, Charbotel B, Denis MA. Commuting Accidents among Non-Physician Staff of a Large University Hospital Center from 2012 to 2016: A Case-Control Study. Int J Environ Res Public Health 2023; 17(9): 2982. doi: 10.3390/ijerph17092982. Further resources on fatigue Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett Association of Anaesthetists fatigue resources. Fatigue resources on the hub.
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    Actions Identify if the accidental ingestion of dry thickening powder has occurred, or could occur, in your organisation. Consider if immediate action needs to be taken locally, and ensure that an action plan is underway if required, to reduce the risk of further incidents occurring. Distribute this alert to all relevant staff who care for children or adults in primary care, emergency care, and inpatient care settings, including mental health and learning disability units. Share any learning from local investigations or locally developed good practice resources by emailing patientsafety.enquiries@nhs.net.
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  8. Content Article
    Risk assessment themes The review identified seven key areas: The language used to discuss and document risk assessments should encourage a dynamic and holistic assessment of the individual pregnant woman/person’s risk (‘dynamic’ means the risk is continually assessed to allow for unknown factors and to handle uncertainty, while ‘holistic’ refers to looking at other factors that might be relevant) that promotes the need for maternity care to be provided by multi-professional teams. Telephone triage services should support 24-hour access to a systematic structured risk assessment of pregnant women/people’s needs. Telephone triage services should be operated by appropriately trained and competent clinicians who are skilled in the specific needs required for effective telephone triage. Face-to-face triage in maternity units should use a structured approach to prioritise pregnant women/people to be seen in order of clinical need. Clinicians should be enabled to proactively monitor and recommend the place of labour care and birth for pregnant women/people based on the individual’s specific care needs during the course of their pregnancy and labour. Each pregnant woman/person should be helped to understand their individualised risk associated with a vaginal or caesarean birth after a previous caesarean birth, based on their specific risk factors and care needs. Pregnant women/people whose labour has been induced need clinical oversight and an individualised plan of care for maternal and fetal monitoring. Prompts for NHS trusts This thematic review also includes prompts for NHS trusts to consider how these risks may be mitigated: Are risk assessment and screening documents designed and presented in a consistent and logical way? Does the language used in risk assessment and screening documents avoid binary definitions of risk, and instead promote dynamic and holistic risk assessments supporting a multi-professional approach? Does risk assessment and screening documentation support a holistic consideration and documentation of risk, or does it focus on only single risk factors? Do telephone triage services facilitate 24-hour support for systematic risk assessment? Are clinicians equipped with the appropriate training, skills and competencies to manage an effective telephone triage service? Is a structured approach used so that pregnant women/people are seen in order of clinical need within your maternity face-to-face triage service? Are there frequent opportunities to revisit and recommend the place of birth based on the pregnant woman/person’s individual needs? Does your risk assessment tool encourage clinicians to think about the most suitable place of birth when a pregnant woman/person in labour is admitted? Do processes support holistic risk assessments to be revisited during labour to proactively assess the most suitable place for fetal monitoring and birth? In antenatal discussions with pregnant woman/people, are structured tools used to support individualised care planning and decision-making when planning a birth after a previous caesarean birth? Is there an opportunity to revisit these discussions when there is a change in circumstance, such as induction of labour? Are clinicians encouraged to make individual plans, taking into consideration a pregnant woman/person’s and baby’s risk during the induction of labour process and including frequency of observations, fetal monitoring and place of induction? Is there a system to prioritise pregnant women/people requiring induction of labour according to clinical need, and to ensure appropriate escalation and action when there are delays?
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  10. Content Article
    The list for 2023 1. Gaps in recalls for at-home medical devices cause patient confusion and harm. 2. Growing number of defective single-use medical devices puts patients at risk. 3. Inappropriate use of automated dispensing cabinet overrides can result in medication errors. 4. Undetected venous needle dislodgement or access-bloodline separation during hemodialysis can lead to death. 5. Failure to manage cybersecurity risks associated with cloud-based clinical systems can result in care disruptions. 6. Inflatable pressure infusers can deliver fatal air emboli from IV solution bags. 7. Confusion surrounding ventilator cleaning and disinfection requirements can lead to cross-contamination. 8. Common misconceptions about electrosurgery can lead to serious burns. 9. Overuse of cardiac telemetry can lead to clinician cognitive overload and missed critical events. 10. Underreporting device-related issues may risk recurrence. You can download the full report via the link below. ECRI Members can also download the Top 10 Health Technology Hazards for 2023 Solutions Kit on their member page.
  11. News Article
    Experts are assessing a very rare but potentially serious brain side effect of nasal decongestants bought on the High Street. Ones containing pseudoephedrine are being reviewed because they may cause vessels supplying the brain to contract or spasm, reducing blood flow. The concern is this could lead to seizures and even a stroke. However, drug regulators stress the likelihood of this happening is extremely low. The UK-wide review for pseudoephedrine was initiated after regulators in France alerted European drugs regulator the EMA, which is also conducting a review, about some recent, rare cases. Experts say anyone with concerns about medication should speak to a doctor or pharmacist. Read full story Source: BBC News, 23 February 2023
  12. Content Article
    Principles for managing fatigue: A shared approach between the organisation and workers. A sound risk management approach through the application of the Defences in Depth model for fatigue risk management. A systemic approach that is incorporated into core business operations. An aware and informed workforce approach. An integrated approach that achieves consistency with existing health, safety and wellbeing management systems.
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    Yvonne had experienced mental health problems since childhood and was considered originally to have a personality disorder. She was treated by mental health services for many years and had several inpatient admissions, some of which were compulsory. After a period of self-neglect and refused admission, Yvonne was finally detained under the Mental Health Act on 27 January 2020 at Park House Psychiatric unit, Manchester. On admission she was found to be significantly malodorous and have several long-standing serious deep infected ulcers. She had to be transferred to the acute hospital for assessment and treatment where her condition gradually improved and she was given prophylactic venous thromboembolism (VTE) medication until she was medically fit enough to be discharged back to the psychiatric unit on 12 February 2020. When she was readmitted, despite discharge information from the acute hospital stating that she had been treated with VTE prophylaxis and despite Yvonne fulfilling several trigger criteria, a VTE risk assessment was not undertaken in accordance with the detaining authorities’ policy. There was a failure to monitor her condition and make appropriate records or an action and management plan and she did not have further mental capacity assessments. On 19 February 2020 she was again detained and on the morning of 23 February 2020, she had a cardiorespiratory arrest and was resuscitated for a brief period of time before being taken to the emergency department of North Manchester General Hospital. Further attempts at resuscitation proved unsuccessful and she was pronounced dead due to a pulmonary thromboembolism. The Greater Manchester Mental Health NHS Foundation Trust (GMMH) serious incident investigation failed to establish: whether the responsible clinician, junior doctors or nursing staff were aware of the trusts VTE policy and if not, why not. if they were aware of it, why was it not complied with. whether there was an awareness and compliance with the policy Trust wide. It also failed to identify, acknowledge or be aware of the death of a patient in 2016 from a VTE at Park House unit. In their report, the Coroner raised the following matters of concern: There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed. It did not appear that all permanent or locum clinical and nursing staff Trust-wide were aware of the VTE policy and how it should be implemented including initial assessments and reassessments of the risks as well as consequent medical management. There was no regular audit of compliance with the VTE policy. There was no training programme to ensure familiarity and compliance. A copy of the report was sent to the Chief Coroner.
  15. News Article
    NHS 111 sends too many people to accident and emergency departments because its computer algorithm is “too risk averse”, the country’s top emergency doctor has warned. Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), said that December was the “worst ever” in A&E with 9 in 10 emergency care leaders reporting to the RCEM that patients were waiting more than 24 hours in their departments. Asked what measures could help improve pressures in emergency care, Dr Boyle said more clinical input was needed in NHS 111 calls. “In terms of how we manage people who could be looked after elsewhere, the key thing to do is to improve NHS 111,” Dr Boyle told MPs. “There is a lack of clinical validation and a lack of clinical access within NHS 111 - 50 per cent of calls have some form of clinical input, there’s an awful lot which are just people following an algorithm.” Dr Boyle added where clinical input is lacking “it necessarily becomes risk averse and sends too many people to their GP, ambulance or emergency department”. Read full story (paywalled) Source: The Telegraph, 24 January 2023
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    This virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
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    This virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
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    This virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
  19. Content Article
    Key points Rural and remote areas experienced problems that differentiate them from their more urban counterparts even before the Covid-19 pandemic. However, the pandemic has both exacerbated some of these challenges, as well as thrown up new ones. Covid-19 has had a more detrimental effect on hospital waiting times in rural and remote trusts than for trusts in more urban areas. In April 2020, the proportion of patients seen for their first consultant appointment for cancer fell by two-thirds (66%) in rural trusts compared with April 2019, whereas a decrease of 59% was seen in trusts located in more urban areas. Activity has fallen particularly dramatically in rural areas. Emergency admissions in April to June 2020 fell by 57% in rural trusts compared with the year before, while they fell by 45% elsewhere. The level of referral for talking therapies – via the Improving Access to Psychological Therapies (IAPT) programme – in rural areas was below half the level in April 2020 than it was a year before. The pandemic has exacerbated workforce issues in remote trusts. Remote trusts spend more on temporary staff (8% of their staffing budget) compared with other areas (6%). While the number of hospital and community health staff increased by 7% nationally in the year to June 2020, the workforce of remote trusts grew by only 5% over the same period. The underlying financial position of rural and remote services was worse than the position of more urban trusts before the pandemic started, and the pandemic may well have exacerbated this. Remote trusts’ debt was equivalent to more than half (56%) of their annual operating income in 2018/19. Remote trusts also typically do not seem to get their fair share of additional funding that goes into the NHS.
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    Mrs Hazel Fleur Wiltshire was admitted to the Princess Royal University Hospital on 14 January 2021 following a fall at home. Although she had a number of factors indicating a risk of further falls, no risk assessments were completed on three wards and there was no evidence that measures that could mitigate the risk of falls were considered. Mrs Wiltshire's toileting care plan indicated that she was to be assisted with her toileting needs and she had access to a call bell. However, there were lengthy delays in responding to the call bell and on the night of 22 January 2021 she tried to relive herself without assistance which caused her to fall. She died in hospital on 19 February 2021 from pneumonia caused by the fall and by Covid 19 that she acquired in hospital. Coroner's concerns: The matron who gave evidence was not aware of obtaining data on response times from the call bell system and had not introduced any other system to monitor response times. Staffing levels were inadequate due to higher dependency of patients with Covid. I heard that one patient had to soil herself in her hand as no one was available to assist her with her toileting needs. Mrs Wiltshire phoned home on occasion to ask her family to call the ward because they were not responding to her call bell. The family could hear other patients on the ward crying out for help. Although Mrs Wiltshire was at risk of falls, no risk assessments were completed on any of the three wards in which she stayed. This suggests a systemic problem across the hospital that requires remedial action.
  22. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives Understanding the role of the Senior Information Risk Owner. Identifying information risks across the organisation. Working with others to mitigate the risk to patients, staff and organisation. Confidence that all reasonable technical and organisation measure are in place. Giving assurance to the Board that risks have been considered, mitigated or owned. Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches, For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/masterclass-developing-your-role-as-a-senior-information-risk-owner-siro or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for discount code.
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    Findings: Most of these risk controls – 35 out of 42 – would be classified as ‘administrative’ by the HoC, and thus considered weak. The risk controls that fell into this ‘administrative’ category included training, standardising processes and procedures, and changing the design and organisation of care. Since other evidence shows these approaches can sometimes be very successful in healthcare, it is probably a mistake to automatically assume they are weak. Completely eliminating reliance on human behaviour is very difficult in the healthcare context and would introduce new risks. A rigid hierarchical approach to classifying risks may not be right for healthcare. Caution is needed before abandoning apparently weak interventions. Learning from other industries may be useful, but it is not always straightforward.
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