The story of Alison Bell, and her family's uncovering of the truth about what happened to her in the care of an NHS Trust will be told by her brother Tom. He will describe the nature of the various investigations that were held into Alison's death and the role of the prevailing cultures within the public sector organisations they have dealt with; the NHS, Police, CPS and Regulatory Bodies.
This true and ongoing story shines a light on the personal, emotional and financially costly impact that public sector service cultures can have on the lives of their service-users and their own bottom-line. Tom’s lived and current experience will help us to explore the implications for our own practice and the organisations we might seek to influence, manage and lead.
In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.
The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement.
A varied approach to patient safety was evident on review of the corrective measures applied following the occurrence of a significant event. High efficacy corrective measures such as forcing functions, which can eliminate risk, were evident. However, in some cases, the corrective measures put in place to prevent recurrence were limited to low efficacy strategies such as re-education of staff. Undertakings should consider the risk management strategies applied to incident investigations and corrective measures to ensure they are robust and help prevent errors from reoccurring rather than punish.
Overall, many of the investigation reports received by HIQA were comprehensive and showed systems based approaches to reviewing incidents. Some, however, focused on human error in isolation, without consideration of human error as a symptom of system weaknesses. Undertakings should ensure a just culture is in place where individuals feel free to report errors, assured that the response will focus on what happened, rather than who failed. This was not always evident in reports received by HIQA.
Finally, it is noted that radiation incidents reported to HIQA in 2019 have involved relatively low radiation doses with limited risk to service users. The findings in this report indicate that overall the use of radiation in medicine in Ireland is generally quite safe for patients. However, radiation incidents have been reported internationally with severe detrimental effects to service users. The potential for such serious adverse events highlights the need for ongoing vigilance in relation to radiation protection and the necessity of reporting and learning frameworks. It is hoped that areas of improvement noted in this report would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland.
Key points from the survey
A safety culture is critical for the protection of staff and patients.
Psychological Safety for healthcare workers is an essential requirement of all safe health systems
People (patient & health worker) safety is inherent in healthcare and Coproduction is the foundation of all initiatives.
Measurement of what works well is essential so that there can be learning at all levels.
Reporting of clinical incidents is a vital part of learning and needs to be undertaken within a just culture which is blame-free, with clear accountability.
The COVID-19 pandemic revealed experiences of good practice and areas where health services need to improve, particularly in the protection of staff and looking after their mental wellbeing.
Crisis management is a critical part of health services management.
Managing the flow of people through the service is important to control infection.
Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that:
All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments.
Effective communication related to medical errors may foster autonomy and ultimately improve patient safety.
Error reporting better serves patients and providers by mitigating their effects.
Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to their colleagues after an adverse event occurs.
Medical errors and near misses should be reported when they are discovered. Healthcare professionals are usually the first to notice a change in a patient's condition that suggests an adverse event. A cultural approach in which personal accountability results in long-term increased reporting reduces errors.
This unique 1-day distance-learning course from Medled is delivered via Zoom by our expert trainers in a format designed to maximise learning retention and application of knowledge. You'll learn to:
Understand the concept of systems thinking and models of safety – looking beyond the individual and the flawed concept of ‘Human Error’.
Gain an introduction to human capabilities & limitations & how those influence quality and safety of care – how humans can be heroes and hazards.
Be able to unpick the nature of human fallibility and why practice does not always make perfect.
Have the knowledge to proactively contribute to the safety culture in your organisation.
Be able to recognise error-provoking conditions and influence your systems of work.
Understand the relationship between stress and performance/risk of error.
Take away a tangible model for understanding the relationship between our physiological needs and performance – do we set ourselves up to fail?
Understand strategies to optimise high-performance teamworking with ad hoc teams.
Evidence-based, utilising cutting edge safety & performance science this course is suitable for all Healthcare Professionals, both clinical and non-clinical; it is applicable to all departments and multi-disciplinary teams.
Accredited by Chartered Institute of Ergonomics & Human Factors, you'll take part in interactive actitvities and leave with practical tools to take away.
In this blog, Patient Safety Learning make the case that staff safety is intrinsically linked to patient safety. It sets out how the six foundations for safer care from the report, A Blueprint for Action, can be used to consider how making improvements to staff safety complements patient safety.
It looks in more detail at four key aspects of staff safety and how these areas are intertwined with improving patient safety:
Physical safety – considering how the Covid-19 pandemic has highlighted the importance of this in ensuring patient and staff safety is not jeopardised.
Safe staffing levels – outlining the importance of this to protect the welfare of staff and avoid creating conditions in which patient safety incidents are more likely to occur.
Psychological safety – setting out the importance of having organisational cultures that enable staff to feel secure in speaking up about incidents of unsafe care, ensuring that opportunities for learning and innovation are not shut down by a blame culture.
Support to staff after patient safety incidents – highlighting the key role that providing emotional support to health and social care staff who are involved in patient safety incidents can play in fostering an environment of openness and learning.
It concludes by setting out the activities Patient Safety Learning will undertake over the course of September to raise awareness of, and promote action for, staff safety.
1. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.
A robust safety culture is the combination of attitudes and behaviours that best manages the inevitable dangers created when humans work in complex environments.
Great leaders know how to wield attitudinal and behavioural norms to best protect against these risks.
psychological safety – that is, an environment where no one is hesitant to voice a concern and caregivers know that they will be treated with respect when they do)
organisational fairness – where caregivers know that they are accountable for being capable, conscientious and not engaging in unsafe behaviour, but are not held accountable for system failures
a learning system in which engaged leaders hear patients and front-line caregivers’ concerns regarding defects that interfere with the delivery of safe care, and promote improvement to increase safety and reduce waste.
Leaders are the keepers and guardians of these attitudinal norms and the learning system.
It has been a month since the publication of the Cumberlege Report, which detailed the harm that has happened to tens of thousands of patients over many years. Following a 2-year period of gathering evidence, listening to views and deliberation, the report made several important recommendations. Since then, it has generated only modest headlines and within healthcare circles little debate. Has there ever been such an important report that has generated such little discussion and debate following publication?
It would be easy and obvious to cite Covid as the reason for this, but surely the current pandemic is all the more reason for the importance of patient safety to be integral to our planning and priorities as we restart and reset services and look to the future.
The report made several key recommendations across a number of devices, procedures and drugs. The main themes were to:
involve patients more in their care and to listen and take their views seriously
move away from a culture of blame so that staff could speak up and voice concerns
improve data collection and incident reporting to aid learning
provide more support to patients after things have gone wrong
better address health inequalities
improve leadership and regulation.
It is one of several reports in the last 20 years that has considered patient safety scandals and sought to address this persistent and fundamental problem within healthcare. It is not just a UK problem, the OECD estimates 15% of healthcare budgets are spent on harm, much of it entirely preventable, and the remainder on rectifying or compensating for the problems created.
Within the Cumberlege report was this quote:
"I have to say 20 years later it is very frustrating how little progress we have made. It’s clear to me that we still have not got the leadership and culture around patient safety right. As long as you have that culture of people trying to hide things - then we are not going to win this."
Professor Ted Baker, Chief Inspector of Hospitals, CQC
At this time of unprecedented change, with an acceleration of acceptance and adoption of innovation and technologies like never before, surely now is the time to bring patient safety to the fore of the debate about how our healthcare services should be run and managed. If it is not deemed important now will it ever truly be important? Or will it remain forever in the camp of “too difficult” to solve?
To ensure the safety of patients we should also recognise the need for people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. Patient Safety Learning’s the hub plays an important part in this, providing a platform to share resources, stories and good practice for anyone who wants to make care safer for patients.
At PEP Health (Patient Experience Platform), we have one of the largest databases of patient comments tracking back to Jan 2018. It covers every hospital in the UK and includes every comment made by patients across social media platforms and online review sites. Our analysis of these comments demonstrates that what patients say matters and that patients provide remarkable insight and perspective. It also highlights that patient experience and patient safety are not two discrete components of “quality” but are closely interwoven and linked. For example, we hear patients commenting on issues such as repeated medicine errors, an inability to access essential services and being provided with either poor or confusing information
So, in the spirit of starting some discussion following the Cumberlege report, here are my recommendations and thoughts:
Without better, faster data to support change nothing will happen. This data needs to be a balance of quantitative and qualitative data that brings together patient safety, patient experience and the patient voice.
A patient safety commissioner can provide leadership but they cannot change the culture alone. After so long trying internally without success, we should now publicise results and be more transparent than ever before. Organisations should be benchmarked and compared against their peers.
Greater celebration and promotion should be made of successes. Best practice and learning is too slow to take hold. Teams should not only be encouraged to adopt change but be empowered to make change locally.
The patient voice must be taken much more seriously by organisations and clinicians so that in 20 years’ time we are still not publishing reports following scandals with little change to celebrate and few lessons learnt.
The Royal Society of Medicine's International COVID-19 Conference brings together thought leaders from around the world to share the key clinical learnings about COVID-19.Session 1: Respiratory effects: critical care and ventilationChair: Dr Charles Powell, Janice and Coleman Rabin Professor of Medicine System Chief, Icahn School of Medicine, Mount Sinai> Professor Anita K Simonds, Consultant in Respiratory and Sleep Medicine, RBH NHS Foundation Trust> Dr Richard Oeckler, Director, Medical Intensive Care Unit, Mayo Clinic, Minnesota> Dr Eva Polverino, Pulmonologist, Vall D’Hebron BarcelonaSession 2: Cardiovascular complications and the role of thrombosisChair: Rt Hon Professor Lord Ajay Kakkar PC, Professor of Surgery, University College London> Professor Barbara Casadei, President, European Society of Cardiology> Professor K Srinath Reddy, President, Public Health Foundation of India> Professor Samuel Goldhaber, Associate Chief and Clinical Director, Division of Cardiovascular Medicine, Harvard Medical SchoolSession 3: Impacts on the brain and the nervous systemsChair: Professor Sir Simon Wessely, President, Royal Society of Medicine> Dr Hadi Manji, Consultant Neurologist and Honorary Senior Lecturer, National Hospital for Neurology> Dr Andrew Russman, Medical Director, Comprehensive Stroke Center, Cleveland Clinic> Professor Emily Holmes, Distinguished Professor, Uppsala UniversitySession 4: Looking forwardChair: Professor Roger Kirby, President-elect, Royal Society of Medicine> Dr Andrew Badley, Professor and Chair of Molecular Medicine, Chair of the Mayo Clinic COVID research task force, Mayo Clinic> Professor Robin Shattock, Professor of Mucosal Infection and Immunity, Imperial College London> Professor Sian Griffiths, Chair, Global Health Committee and Associate Non-Executive member, Board of Public Health England> Dr Monica Musenero, Assistant Commissioner, Epidemiology and Surveillance, Ministry of Health, Uganda
The guide also provides helpful links and contact information for readers interested in learning more about the highlighted resources. The majority of DoD PSP tools and resources are available to anyone providing care in the Military Health Service. These evidence-based resources offer opportunities to make any heath care facility safer and more open to discussions to build a culture of safety.
Organisational culture represents the shared ways of thinking, feeling, and behaving in healthcare organisations.
Healthcare organisations are best viewed as comprising multiple subcultures, which may be driving forces for change or may undermine quality improvement initiatives.
A growing body of evidence links cultures and quality, but we need a more nuanced and sophisticated understandings of cultural dynamics.
Although culture is often identified as the primary culprit in healthcare scandals, with cultural reform required to remedy failings, such simplistic diagnoses and prescriptions lack depth and specificity.