"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
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.
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
This document outlines ten key guidance points that designers of procedures should address at all stages of its development, implementation and review:
1. What is a work procedure?
2. Ensure a procedure is needed
3. Involve the whole team
4. Identify the hazards
5. Capture work-as-done
6. Make it easy to follow
7. Test it out
8. Train people
9. Put it into practice
10. Keep it under review.
An explanation of the discipline of Human Factors and Ergonomics (HFE) and the sub-discipline of human-centred design are also provided.
I am interested in what colleagues here think about the proposed patient safety specialist role?
Can this development make a difference? Or will it lead to safety becoming one person's responsibility and / or more of the same as these responsibilities will be added to list of duties of already busy staff?
Can these specialist be a driver for culture change including embedding a just culture and a focus on safety-II and human factors?
What support do trusts and specialists need for this to happen?
Some interesting thoughts on this here:
The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’.
A key action associated with this is a proposal to create Patient Safety Specialists within each NHS organisation in England. The strategy explains that ‘giving everyone in the NHS a foundation level understanding of patient safety is critical, but we also need experts to lead on safety in their own organisations’.NHS England and NHS Improvement have published draft Patient Safety Specialist requirements for public consultation.
Patient Safety Learning welcome any increase in patient safety capacity and expertise in the NHS and have provided specific feedback on the draft requirements for this role. In our response we identify several areas where we believe these can be improved, including the following points:
Patient Safety Specialists having a clear and direct reporting line to a named executive director on the Board with an assigned patient safety role and to a non-executive director with a similar role.
Ensuring that the requirements identify key relationships for the role holders not identified in the draft document: Medical Examiners, Coroners, Healthcare Safety Investigation Branch, Governors, Non-Executive Board Members, HR Directors and NHS Resolution.
Including a requirement that Patient Safety Specialists should demonstrate that they have the right skills and experience to work with patients, families and their carers on patient safety issues. They should also show that they can support their organisation to engage effectively in co-production with these groups.
The need to strengthen the requirements for the individuals holding these roles to have knowledge and experience of: Investigations, Complaints, Just Culture, Systems Thinking and Human Factors.
Giving consideration to how Patient Safety Specialists will engage with frontline staff, who are notable by their lack of reference in the draft requirements.
The occurrence of adverse events due to unsafe care is likely 1 of the 10 leading causes of death and disability in the world.
In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable.
Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths.
Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs.
Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines.
In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events.
Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15%.
Working with early adopters
To test the PSIRF, NHS Improvement are first working with a small number of early adopters who are using an introductory version of the framework in their organisations.
This testing phase will be used to inform the creation of a final version of the PSIRF which is anticipated to be published in Spring 2021.
At that point, other providers of NHS funded care in England who are not early adopters will also begin adopting the new framework. All NHS organisations are expected to have transitioned to using the new framework from Autumn 2021.
Introductory version of the PSIRF
While NHS Improvement are not asking organisations other than the early adopters to transition to the PSIRF, they will help providers outside of the early adopter areas to plan for this change. They have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2021.
Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework.
This book offers practical guidance and evidence for a broad range of related improvement methods, concepts and interventions developed and implemented by the NES primary care team, or as a direct result of fruitful partnerships between academic, professional, public or regulatory institutions across the UK and internationally.
It is organised into five interlinked parts, each with a number of related chapters.
Part I provides an overview from an organisational systems perspective
Part II focuses on the role of patients, clinicians and staff
Part III is concerned with the role of learning, education and training
Part IV outlines human error theory and the types and causes of some common patient safety incidents in primary care, while considering how they may be prevented or related risks mitigated or reduced
Part V focuses on outlining the evidence for, and providing good practice guidance on, a wide selection of improvement methods that can be applied by primary care teams.
There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed.
Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues.
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Source: Harvard Law, 17 February 2020
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.
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.