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A set of 5 infographics describing the the factors that influence the risk of nosocomial transmission of infections (such as Covid19), and how health and care staff can take action to manage the risks and reduce the infection rate. The factors explained are: People Equipment Task Environment Organisation These infographics are from the summary HSIB report (22 October 2020) entitled "COVID-19 transmission in hospitals: management of the risk – a prospective safety investigation". The exec report can be found here. They explain the five main aspects related to the nosocomial transmission of infection, and how the risks of this happening can be properly managed.

In this article in the Pharmaceutical Journal, Carolyn Wickware asks if liquid morphine should be reclassified. She cites research that Oramorph or oral morphine sulphate solution was directly linked to the cause of death in 13 reports since 2013. "Several concerns have been raised about the risk of overdose and death from oral morphine sulphate solution over the past few years, but they have gone unheard." In light of coroners reports of deaths related to abuse, or accidental overuse of Oramorph or oral morphine sulphate solution. the author argues for increased regulation. Commenting: "In the absence of any action from ministers, it seems that healthcare professionals are going to have to take the care of vulnerable patients into their own hands." My reflections on this are: Is this a signal for increased regulation or improved prescribing practice, improved medicine management, and more education & acces to trusted information for patients? Would there be downsides to increased regulation?

The following account was shared with Patient Safety Learning by a patient called Sarah. She describes her experience of attending hospital with symptoms of COVID-19 and expresses concerns that she could have infected NHS staff due to a negative test result which later turned out to be inaccurate. My symptoms began towards the end of April. I started to cough and feel really cold. I developed a severe headache, was bothered by light and started to hurt in my kidney area and my neck. I stopped being able to complete a sentence without breathing in between words and felt like I had a tight chest. I found it hard to stay awake. I struggled to breathe if I even stood up. We started to isolate as a family of six. My GP tried to call but I was too breathless to speak on the phone so she asked me to take my blood pressure. It was 130/95 with a pulse of 38. She told my husband to take me to the hospital in case I needed oxygen. I was taken to a ward specifically for those showing signs of COVID-19. Three nurses treated me while I was crying and coughing and unable to breathe. They had a mask and gloves and had put a mask on me but the masks were not great and I didn't think it would be sufficient protection. One swabbed my throat and up my nose. I knew I had COVID-19 and didn't want them touching me as I thought they would get it. Two hours later was told I was fine and should go home. The doctor said my blood results were clear, my chest X-ray was clear I didn't have COVID, just anxiety. On my way out I was distressed as my husband and I were sure I had it. We continued to isolate as a family, despite what I was told in hospital. I haven't had anyone contact me with my swab results. At home, my symptoms got worse. I was freezing and coughing, headache, diarrhoea, aches, foggy, couldn't taste or smell, craved sugar to keep me awake. My fever came on and off. I had three teenagers and a five year old at home. I had extreme exhaustion and was unable to walk or complete sentences. A week or so later, following a phone call, the GP sent a Healthcare Assistant (HCA) to take my blood pressure and SATS. The HCA said that I had tested negative for COVID but I told her that I didn't believe it to be accurate. She gave me the SATS monitor to use myself while she watched from the doorway. My SATS went down to 80percent when I lifted my arms so the HCA called the GP who called an ambulance. The paramedics said that I should be in a coma according to my obs. He was only wearing gloves and a mask so I was upset as I was sure I had COVID. He commented that it was in my notes, COVID negative. The paramedics were with me for over an hour in my house. My daughter was in the room and husband who were not wearing masks and my other three children not wearing masks came to say goodbye to me. It would have been quite possible for them to be spreading it to the paramedics too. Upon walking to the ambulance, my SATS went down to 68% with a blood sugar of 2, so I was given sugar and given oxygen in the ambulance. I started to shake. The paramedic then changed into a hazmat suit. The other paramedic carried on treating me as he wanted to put a cannula into me. Acknowledging my concerns, they reassured me that they would speak to the staff to say that I may have had a false negative as I was showing signs of COVID. The staff in the resuss part of the hospital were wearing full PPE with plastic over their faces. A few hours later the doctor made me walk round the ward with a SATS monitor attached to my ear. My SATS went down to 96 then 94 then 92 and then 90 and then I went back to my bed. The doctor told me that I did have COVID-19, that it had been a false negative and that I needed to rest. My biggest concerns are for the safety of the paramedics, who were seriously at risk thinking I was a negative for COVID-19 because of my initial test results. I'm interested to know if anyone else had a similar experience.

Healthcare organisations are committed to the safety of the patients receiving care, treatment, and services. Healthcare organisations are also committed to the safety of those who serve those patients – healthcare workers, whether they be nurses, physicians, medical technicians, pharmacists, lab workers, housekeeping staff. This new book from The Joint Commission pulls together a collection of checklists to keep those healthcare workers safe from chemical and physical hazards, infectious agents, workplace violence, ergonomic problems, work-related stress, and more. The checklists are built upon authoritative guidelines from OSHA, NIOSH, CDC, and others and are intended to simplify healthcare worker safety. Most of the checklists are intended for use by health care workers themselves, depending upon their clinical or other responsibilities. Some of the checklists are intended for management to ensure that policies, procedures, and resources are in place to ensure health care worker safety in all areas of the organization. All of the checklists are straightforward and easy to use and understand and cover the key areas of risk for healthcare workers. Each section of checklists is introduced by compelling statistics that show how dangerous working in the health care environment can be, without proper precautions. The checklists provide the procedures or must-do activities to ensure that health care workers are as safe as can be.  Sample pages

In this blog, Martin Hogan shares his experience of working as an agency nurse and how different behaviours can impact on the safety of both staff and patients.   Six months ago, I left my band 7 managerial role to work as a band 5 agency nurse on the wards. Despite the band drop, this move has financial advantages which will help me to achieve some personal goals. Signing up After successfully completing the recruitment process, I am asked to attend mandatory training. This includes basic life support, manual handling and infection control. The usual, run of the mill stuff. I can book shifts a week or a day in advance, but these shifts can change to any speciality or department in the hospital, depending on staffing levels. I book my first shift after six years of having not worked within a ward setting. An unsafe start I turn up to the shift and introduce myself to be met with a mutter. The team and I receive handover and I am allocated my bay of patients. I notice I have twelve patients, three more than the other nurses. I reiterate this is my first time here and that I haven’t worked in ward work for some years. I ask if it would it be possible for someone to show me around – resuscitations trolley, toilets, codes to the drug cupboards. General housekeeping. I receive a grunt and a point, followed by some numbers hurled at me, along with keys. Ok, perhaps they’re just not morning people. I will give them the benefit of the doubt. Off I go to introduce myself to my patients and to immediately make use of my prioritisation skills, escalating any concerns I have to the seemingly disengaged shift leader and (more helpful) doctors. I find that my patients are acutely unwell and in need of a lot of care. I have to remind myself of my 13 years’ experience and how good I am at communicating, reassuring myself I will be ok. Hours later and still no toilet break Seven hours later, hungry and in need of a wee, I ask my shift leader if she could cover me so I can take a break. I am met with, ”your patients are too unwell for you to leave them for 15 minutes, and I don’t have the staff to cover you”. Followed by the ultimate toxic saying within the NHS, ”that’s just how we do it here, always have”. I start to feel neglectful that I would even have thought to have a drink and pass urine. Ten hours pass and still I haven’t had any water or a wee. Three emergencies have taken place without me even having had a proper induction. I take solace in my bond with my patients and lovely doctors who understand how it feels to be isolated and new to an area. Speaking up Perhaps out of dehydration and kidney shut down, I find the voice to politely approach the other nurses and shift leader. I explain that my patients are now stable and highlight my own personal fluid needs. I mention that I still haven’t received an induction. No one has asked me my skills or background nor if I know how to use the different IT systems (drug charts are now on computers). Again, I am met with, “well you choose to be agency, we just all get on with it here”. These are words that frighten me. It isn’t safe to get on with it. I felt out of my depth, overwhelmed, deprived of basic human rights and unwell. Losing confidence Then, a patient’s relative approaches me to say, ”I didn’t want to trouble you as you were running around looking so busy, but dad has chest pain”. At that point my heart breaks. How have I given the impression that I am the unapproachable one on this ward? Have I neglected this poor man? The same man who had cried with laughter at a joke I had made about some TV show we both watched the night before while I was catheterising him. Protocol follows and I investigate his chest pain. No acute cause. Phew. I still leave his side feeling that I am terrible at this. The end of my shift approaches, still no break, still no water or food. Handover time… I introduce myself to the night team. Finally, someone kind welcomes me to the ward. They tell me they all feel like they are doing a bad job and not giving satisfactory care. I think they are trying to reassure me. I cycle home in tears; shattered and broken. The next day I have serious doubts about my own ability. I call my agency and have a long chat with my recruitment consultant (who has never set foot inside a hospital and works on commission). His response? ”Well, you don’t have to go back”. I start to have serious doubts about my choice to work in this way and feel even more perplexed that our wards and teams have become like this. What a difference a day makes My next shift is in an emergency department. Dreading it, I don’t sleep the night before and I turn up riddled with anxiety about what is to fall upon me. I meet the team and prep myself to ‘kill them with kindness’. Everyone is pleasant and welcoming. The senior nurse asks me about my skills and mandatory training and shows me around. She informs me of their expectations and what I could, in return, expect of her team. It seems so simple, a five-minute job, huddling with your team for the sake of patient safety. But what a huge impact it has on my shift. My patients are more acute, I am busier and still don’t urinate. But I am supported and able to escalate concerns without being gas-lighted. Final thoughts I have now booked all of my shifts on that busy emergency department, simply because of the manager. I respect her management style and her approach to the safety of her unit. She doesn’t use those unhelpful and unsafe words, ”we just get on with it” or ”that’s how we do it here”. Since becoming a bit more settled in this world of agency nursing, I have spoken with matrons and lead directorate nurses within this trust about my experience. Often met with, ”what can I do about that?”. But sometimes met with, ”I will look into how that particular ward manages staff safety”. The latter leads on to better patient safety. Key learning points Inductions to new staff in new areas, should be mandatory. It should be the nurse in charge's duty to support junior staff. Doing safety rounds and checking in on all staff would help to manage workload, support flow and build confidence and reassurance among staff on duty. Safety huddles at the beginning, middle and sometimes end of each shift are a simple way of combating so many of the patient safety issues raised in this account. Early warning scores should be displayed and visible for all professionals on duty. They should be checked regularly and actioned accordingly.

Expanding on his previous commentary 'What does all this safety stuff have to do with me', Dan Cohen, Patient Safety Learning's Trustee and former Chief Medical Officer at DATIX, has written this article for the hub on personal responsibility in patient safe care. In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement. If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care. Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance. Further reading on the hub from Dan: Clarity and the Art of Communication for Patient Safety Late night reflections on patient safety: commentaries from the frontline (2014) Patient safe care as a moral imperative: The mandate of medical ethics Diagnostic errors and delays: why quality investigations are key Patient Safety Spotlight Interview with Dr Dan Cohen, Patient Safety Learning Trustee What does all this safety stuff have to do with me? How one professional’s arrogance led to new insights Interview with Dr Dan Cohen on human performance

Human factors and ergonomics (HFE) approaches to patient safety have addressed five different domains: usability of technology; human error and its role in patient safety; the role of healthcare worker performance in patient safety; system resilience; and HFE systems approaches to patient safety. This paper from the British Medical Journal, describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains.

Harold Shipman was an English doctor who killed approximately 15 patients while working as a junior hospital doctor in the 1970s, and another 235 or so when working subsequently as a general practitioner. Is it possible to learn general lessons to improve patient safety from such extraordinary events? In this paper, published in the US Journal of the Royal Society of Medicine, it is argued that it is not possible fully to understand how Shipman came to be such a successful and prolific serial killer, nor to learn how the safety of healthcare systems can be improved, unless his diabolical activities are studied using approaches developed to investigate patient safety.

Connor Sparrowhawk died in July 2013 while he was in the care of Southern Health NHS Foundation Trust. An independent report concluded that Connor’s death was preventable and that there were significant failings in his care and treatment. This moving film describes what Connor was like by his friends and family and highlights the failings that caused the avoidable death of Connor.

In his blog, published by onthewards website, Joe Farmer (a doctor working in psychiatry) discusses rudeness in the workplace and the impact it can have on clinical performance and subsequently patient safety.

Homerton University Hospital describes how they have embedded the Redthread Youth Violence Intervention Programme into their A&E department. What is Redthread? Redthread, a Youth Violence Intervention Programme, runs in hospital emergency departments in partnership with the major trauma network. The innovative service aims to reduce serious youth violence and has revolutionised the support available to young victims of violence. Every year thousands of young people aged 11–24 come through hospital doors as victims of assault and exploitation. It is then, at this time of crisis, that our youth workers use their unique position embedded in the emergency departments alongside clinical staff to engage these young victims. Redthreads extensive experience tells us that this moment of vulnerability, the ‘Teachable Moment’, when young people are out of their comfort zone, alienated from their peers, and often coming to terms with the effects of injury, is a time of change. In this moment many are more able than ever to question what behaviour and choices have led them to this hospital bed and, with specialist youth worker support, pursue change they haven’t felt able to before. Redthread workers focus on this moment and encourage and support young people in making healthy choices and positive plans to disrupt the cruel cycle of violence that can too easily lead to re-attendance, re-injury, and devastated communities. Redthread and the Homerton Redthread is embedded within Homerton’s A&E department. The Redthread youth work team work hand in hand with the emergency department team to safeguard young people between the ages of 11-24 who are at risk of violence or exploitation. Emergency department clinicians send referrals for at-risk young people to the Redthread team, who work on an individual basis with the young people to support them and endeavour to alleviate the risk in their environment. Redthread achieves this by liaising with statutory services such as CAMHS, Children’s Social Care and Housing to ensure that the young person is being placed first. By linking up services, Redthread ensures that the young person is the focal point and that help is being given, without duplicating existing services. Redthread works in several major trauma centres across the UK; however, the Homerton practice is the first community hospital based service. The Redthread service would not be possible without the support of the emergency department staff. Not only is the clinical and non-clinical body supportive of the service and actively referring young people, the emergency department as a whole takes an active interest in Redthread’s work – talking to Redthread staff about their work, fundraising and attending training sessions. Thanks to the initial efforts of emergency department doctors and nurses in gaining funding and support for this project at Homerton, and the continued work and collaboration by the emergency department and Redthread, the service has excellent track record after its 1 year of service. The Redthread youth workers work closely with young people in a way that clinicians do not have time to. This means that patients are cared for both medically and holistically. Though difficult to quantify results, a strong qualitative difference to the service is that there is a caring external presence within the emergency department. For young people in crisis, being seen one-to-one by someone in a non-clinical role means that there is someone solely on their side. In a lot of cases, a Redthread worker might be the first person in a long time to ask if they are ok, and to see them for who they are as opposed to the trauma that they have suffered. For the emergency department team, having a constant youth work presence acts as a reassurance that when a safeguarding issue does arise, this will be followed up and the young person will continue to be cared for. The emergency department safeguarding has improved as awareness has grown among staff members of safeguarding procedures. The Redthread collaboration has also prompted staff to be more inquisitive with the patients they see, and to consider how that patient’s behaviour may be a manifestation of underlying problems. As such, young people coming into the emergency department are safer as they are more likely to be seen and understood by clinicians, as well as receiving long term assistance as part of the emergency department care package. As the first community hospital in the Redthread network, the Homerton Redthread team have tailored and changed their service to best fit the community it serves. The team spend longer working with young people, in addition to working more closely with them than in other hospitals – taking on a constant role in our young people's lives. The breadth of presentations seen at Homerton has also resulted in a broader case-load. The result is a service which is ready to adapt to individual cases to best serve young people both in hospital and out in the community. Redthread at Homerton are also innovating and adding value structurally by meeting young people at the earliest opportunity – the statistic is that young people present to hospitals like Homerton four to five times on average before they are injured to the extent that they have to be taken to a major trauma centre. By being embedded in a local hospital such as this, we have an opportunity to engage people and help them to change their trajectories and avoid escalating harm. We’re also pioneering work around contextual safeguarding, by listening to young people and feeding back to local authorities when for example unsafe spaces in the community are identified.

The patient safety movement started almost fifteen years ago when it was energised by the release of the Institute of Medicine report “To err is human”. Despite efforts since then to improve quality and safety many believe that little progress has been made in reducing harm caused by errors, accidents and unforeseen occurrences. There is a sense of frustration with current approaches to safety (Safety I) and disappointment that more progress has not been made. Recent developments in safety science, termed Safety II, focus on resilience, adaptive capacity and complexity science and show promise for advancing the safety agenda. In this short blog Steven Shorrock gives us some tips on how to 'do safety II'.

Fake medicines and medical devices bought online can lead to serious negative health consequences. Buying from dodgy websites also increases the risk of being ripped off through credit card fraud or having your identity stolen. The #FakeMeds campaign, run by Medicines and Healthcare products Regulatory Agency (MHRA), helps you protect your health and money by providing quick and easy tools so you can avoid fake medical products when you shop online. The website includes links to: Information on the #FakeMeds campaign Register of authorised online sellers of medicine How to use self-test kits safely Yellow Card to report any suspected fake medicines or side effects Information about the CE Mark

This blog highlights: The juxtaposition of how work is carried out by healthcare staff compared to the work that policy makers are 'imagining' healthcare workers are doing. The need for healthcare staff to be part of patient safety solutions. I work in, both, the work imagined and prescribed, but practice in the world of work done. It’s interesting working in both worlds and has made me ask these questions: Why this happens? What are the consequences? How can we manage this disconnect? Real-life scenario What happened? A patient on a ward needs a nasogastric tube (NGT) for feeding and giving medication due to an impaired swallow following head and neck surgery. The nurse prints off the policy for placing an NGT from the Trust's infonet. The nurse inserts the NGT and checks the policy on how to test if it is in the correct position. The tube could be in the stomach (the right place) or it could be placed in the lungs (not a great place for medicines and feed to go!). The nurse calls the nurse in charge for support. It’s been a long time since she has placed an NGT and she wants to check she iss doing the right thing. The senior nurse arrives, before the feed is commenced. The senior nurse notices that the policy that the nurse is using is out of date. Checking the position of NGTs had changed. The senior nurse prints out the updated policy – NGT was in the correct position. This was a near miss event. So what? If an NGT is in the lung and you give medication and liquid feed there is a high chance the patient would contract fatal pneumonia at worst or a protracted stay on the intensive care unit on a ventilator at best. In both these cases, it would need to be declared to the regulators as they are classed as serious incidents. What next? This incident was one of many near misses that were collected over four shifts. This incident was discussed with the Deputy Chief of safety within that Trust. His first reaction was: "When was this? We had a Datix last year of the same incident – why has this happened again and why don’t I know?" It was true, there were a few similar incidents last year and an action plan was put in place to mitigate another incident like this happening again. All the old policies were to be removed from the infonet and replaced with the updated versions. Not only this, the Trust was now moving towards a web-based search facility that enables the clinician to have all the updated evidence for policies, antibiotic therapies, prompt charts, documentation and prescribing advice. The guide would be updated and the old policies would automatically be replaced, thus mitigating clinicians using out of date policies and procedures. The document management system was put in place to ensure it is easier to do the right thing. So, if this forcible function was in place, how did this incident happen again? Not all staff know about the new document system. Some nurses think this search facility is for doctors only. Nurses are prohibited to use their mobile phones on the ward. Clinicians not always able to get to a computer. It takes too long to update when opening the browser – therefore people are using it offline. The final point is an interesting one. Making it easy to do the right thing is one of a number of aspects that a safe system is comprised of; however, if part of that system i.e. the Wifi is not set up to support the change, that system is at risk of a ‘work around’. Work arounds are what healthcare staff do to enable them to get through that shift without immediate detriment to themselves or the patient, make swift complex decisions easily and to ‘tick the box’. Time is a precious commodity, especially when you are a frontline worker. We know the document management system will have the updated policy; we wait for the download. We wait. We wait a bit longer. Eventually it loads. Remembering it takes a long time, we save it and use it ‘offline’ for future access. By using the guide offline makes it quick and easy. We are using Trust policy; however, that policy may now be out of date. So what? Implementation of this online guide was made to make our lives easier and safer for patients and ourselves. Due to an oversight of how clinicians ‘actually’ use and interact with this change in the work environment, it could have an adverse outcome for patients. How would the safety team know this was happening? Near misses seldom get reported. Chance meetings in corridors, chance conversations overheard, a reliance on staff that may know the answer – if we ‘fixed’ the problem for that near miss, why should we report it? No harm came to the patient after all. We have a good culture of reporting in the Trust; however, our safety team are overwhelmed with incidents to investigate. The current system is set up to investigate when harm has happened rather than seeking out ways to prevent harm. I’m part of the problem, so I can be part of the solution? I would welcome any support on this. Does anyone have any solutions or strategies in place where frontline staff are involved in the reporting of near miss events and are part of the solution to mitigate them?