"The book describes how a process oriented management system, already well established in other safety critical industries, can be used in the healthcare industry to ensure patient safety. The principles of the management system are rooted in Safety 2 and the book gives practical. detailed instructions on how to create such a system, with processes that map out 'work as done'. The book also explains how healthcare differs from other industries and describes how to implement a safety management system within a healthcare organisation. Leadership, culture and learning also have central roles to play in patient-safe care and the author explains how the management system must work with these three elements.
Aside from this, I particularly like the practical nature of the book and the way you give detailed instructions so it can serve as a manual for creating and implementing a management system, based on learning from other industries and the principles of Safety 2. I've seen other people advocate for the use of a safety management system in healthcare, but you have taken it much further than that. I've certainly not seen anyone giving such detail on the practical steps to take to create one."
Chairman at Patient Safety Learning. Chief Executive at Perfect Ward
This document aims to achieve the following:
➤ Outline the data received, the severity of reported patient harm and the timing and source of reports
➤ Provide feedback to reporters and encourage further reports
➤ Provide vignettes for clinicians to use to support learning in their own Trusts and Boards
➤ Provide expert comments on reported issues
➤ Encourage staff to contact SALG in order to share their own learning.
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
Part I illustrates why improving safety is so difficult and complex, and why current approaches need to change.
Part II looks at some of the work being done to improve safety and offers examples and insights to support practical improvements in patient safety.
Part III explains why the system needs to think differently about safety, giving policymakers an insight into how their actions can create an environment where continuous safety improvement will flourish, as well as how they can help to tackle system-wide problems that hinder local improvement.
The pilot included five key elements:
Conducting semi-structured interviews with a sample of clinical and non-clinical staff who had been directly involved in a patient safety incident, adverse event or medical error in University Hospitals Leicester and Nottingham University Hospital to explore the impact this had on them and the type of support they would have liked to receive. These were transcribed and thematically analysed to identify core themes.
Developing a three-tier second victim support programme and including training peer supporters (tier 2).
Piloting of the model.
Evaluating the pilot by interviewing staff who had accessed the peer support.
A final report which included recommendations based on findings from the scoping project.
The findings of this paper show that safety lapses in primary and ambulatory care are common. About half of the global burden of patient harm originates in primary and ambulatory care, and estimates suggest that nearly four out of ten patients experience safety issue(s) in their interaction with this setting. Safety lapses in primary and ambulatory care most often result in an increased need for care or hospitalisations. Available evidence estimates the direct costs of safety lapses – the additional tests, treatments and health care – in primary and ambulatory care to be around 2.5% of total health expenditure. Safety lapses resulting in hospitalisations each year may count 6% of total hospital bed days and more than 7 million admissions in the OECD.
All healthcare leaders, providers, patients and the public should wrestle with a fundamental question: How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky?
Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?”
“The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.”
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Source: Hospital News, 3 December 2019
Anniversaries are special. They acknowledge events from personal to the historic. I just celebrated an anniversary that met both those criteria: 25 years of marriage. I did so in a place marking the centennial of its designation as a national park – a true American wonder – the Grand Canyon.
It goes without saying that the place is gobsmacking: it literally takes your breath away. It is no easy feat to navigate the options for what can be done while you are there – the food, the views, the trails, the crowds, the mules! To make the trip really monumental however, visitors and staff need to keep safety in mind. Just as clinicians, patients and families do while they are in the hospital. They need to get informed, prioritise activities and trust judgment to manage risk.
Distributing good, freely available information
The Grand Canyon Visitor’s centres and trail heads provide a cornucopia of maps, pamphlets and booklets highlighting options for activities. Making information and data available is key to keeping a visitor to the Canyon free from harm. Similar to trail maps noting loose rocks, unmaintained walkways and mudslide potential, the US Pennsylvania Patient Safety Authority (PSA) models the important mission of transparency by sharing what they learn about threats to safety. The organisation has been collecting and analysing adverse event and other data for 15 years. The Authority disseminates it not only to generate action within their state, but throughout healthcare. Their new open access journal, Patient Safety, continues down a trail established by the PSA newsletter. This work will help all of us progress by providing insights to manage both unseen and known obstacles to safety.
Grand Canyon National Park offers a wide array of choices for visitors. If you only have a day or two in the region, prioritising what hike to take and when to go takes some planning. Just as in safety where the options, tools and improvement goals can become overwhelming. It is crucial to have a method to sort things out. In both instances there is so much to do! Recently the US Veterans Administration (VA) health system published a paper on the process they use to prioritise efforts in their system. They summarised an approach that rests on a foundation of learning practices that could be helpful for all of us to consider in moving forward.
Trusting your gut
My husband in his college days hiked down the Canyon to the Colorado river and back up three separate times. Those treks gave him experience that enabled him to know when “worry” was worth listening to as we ventured down a rugged, steep, trail during our visit. We went down and came back up into the Canyon safely. A recent study from the US, published in JAMIA Open, looked at the accuracy of nursing judgement as a barometer for patient deterioration. The “Worry Factor” proved to be a darn good signal – over 75% of deterioration situations were correctly identified by nurses ahead of time.
Then there are the others
Do you ever wonder “what the ???” when you see people doing something in a park – there are signs everywhere NOT to do ... but they do it anyway? Scampering up rocks behind the safety railing, feeding squirrels, trudging down a rocky trail in flip flops! Safety messages are posted all over the park in an effort to keep Grand Canyon visitors safe. Of course, humans being human, don’t always follow the advice due to arrogance, language issues or a myriad of factors – the distraction caused by the beauty and awe of the place being one of them. Same goes for healthcare. Unintended consequences of process and environment complexity can derail efforts to keep patients safe. Bureaucracy can undermine efforts to keep large systems resourced to provide high quality care delivery, as we heard in a recent examination of the US Indian Health Service. Despite efforts to monitor opioid prescribing practices of physicians, the behaviours are notoriously persistent. Transparency and accountability for failure, while heralded as core attributes of safe care, are not always available to patients.
Patient safety and life are both grand adventures that we can navigate through the effective use of information, prioritisation and sound judgment. I hope you all have as good a partner in your journeys as I have had in mine.
NHS Improvement are asking NHS organisations to identify, by June 2020, at least one person from their existing employees as their patient safety specialist. Training for these specialists will be based on the national patient safety syllabus being developed with Health Education England.
Working with representatives from a few NHS trusts, patient safety partners (patient and public voice representatives) and clinical commissioning groups, NHS Improvement have drafted the requirements for a patient safety specialist to help organisations identify the most appropriate person(s) for the role.
You can download the draft requirements here.
NHS Improvement are inviting comments and feedback on this through their survey which can be accesed via the link at the bottom of this page. Consultation closes 12 March 2020.