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Found 221 results
  1. Content Article
    The Thirlwall Inquiry was set up to examine events at the Countess of Chester Hospital following the trial and subsequent convictions of Lucy Letby for the murder and attempted murder of babies at that hospital. This report was commissioned by the Thirlwall Inquiry. It summarises key themes from responses to a questionnaire sent by the Inquiry to all other NHS trusts with maternity and neonatal units in England. With the evidence and submissions phase of the Inquiry now closed, the Nuffield Trust publish it here in the form submitted to the Inquiry as of April 2024. Overarching themes For almost all the areas covered in the questionnaire there were existing regulations, mechanisms or guidance in place in the NHS. Within neonatal services there were additional reporting routes and requirements to take into account over and above those which apply across the NHS as a whole. In a small number of areas (for example use of CCTV) we found limited guidance. The infrastructure within trusts affected the processes they have in place to manage safety and risks. For example, there was variation between trusts in the availability of electronic systems to support access to medical records, medicines management and storage facilities, the maturity of systems for data collection, reporting and triangulating information, and ease of access to the ward for parents. However, policies, structures and processes on their own are not sufficient to ensure services are safe and effective. A wide body of research indicates that culture and leadership are critical, and a positive culture is needed for systems and processes to achieve their aims. Where there is variation in how trusts manage issues, this will reflect a combination of the circumstances of the organisation and the leadership approach to addressing issues. Some organisational circumstances are unique, but there are many factors affecting the whole NHS, or neonatal care specifically, for example resource and workforce pressures. Culture and leadership at an organisational level are also impacted by national leadership and management of the NHS. In some cases the quantity of guidance, reporting requirements, number of external regulators, and the frequency with which these change, leads to a risk that responding to external scrutiny takes precedence over learning and action within the organisation.
  2. Content Article
    Researchers reviewed literature on the causes of stress and anxiety among nurses, midwives and paramedics. They recommended that senior leaders, managers and clinicians improve working conditions and shift from individual interventions only (such as mindfulness or resilience training) to include a focus on system-level culture change.
  3. Content Article
    In this article Steven Shorrock argues that understanding the complexities and nuances of human work is critical if we are to improve how work really works. In healthcare, as clinicians and other healthcare professionals navigate their roles, they encounter a diverse array of situations that create goal conflicts, dilemmas and other challenges. One way to explore these is via micro-narratives. These are short stories based on personal observations and experiences. One method to capture these is via simple written postcards. Postcards from Work (Healthcare Edition) delves into these experiences. A sample of the cards is shown within the article.
  4. Content Article
    More information about "Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox)"
    Claire Cox, Patient Safety Lead at Kings College Hospital NHS Foundation Trust, shares a recent technique she used to explain the difference between 'work as imagined' and 'work as done'. Claire's example (a pathway for a patient coming to A&E, who also has a mental health issue) highlights the safety risks of competing guidance and the importance of co-production moving forward. The phrase work as imagined vs work as done is often used within patient safety but it's not always an easy concept to explain. I recently tried a new tactic to bring the realities of this concept to life, and show why it is so important to address these issues - in this case relating to a mental health pathway in A&E. My aim was to explain how some of the policies we try to use don't actually work well together in practice when we have a patient come to A&E with a both a mental and physical health problem. I started off by printing every piece of policy, guidance, standard operating procedure, related documentation on the trust intranet, HSIB reports, NICE guidance and anything I could find from the wider NHS. I pinned it across the walls in the meeting room. There were more than 150 items relating to how we should care for the patient in these circumstances. We put the pathway that we 'imagined' at the top, like a process map along the wall. We then placed all of the policies and documents below the pathway at the relevant points. Then I got the staff to tell me what actually happens. It became clear very quickly that the policies contradict each other. In trying to follow two policies, you couldn't actually adhere to either one properly. It was impossible for staff. Once we did that exercise, participants in the room could see how the people writing policies did not perhaps understand how 'work is done'. So it was decided that any new policy that encompassed this mental health pathway for A&E would be co-written by patients, families and the staff doing the work. Importantly, this would include all staff involved - admin, clinical and management. Once that had been written it would go through stages of testing to make sure it was working well and to incorporate necessary flex in the system when unexplained or unintended things happen. We would look at and test the vulnerabilities within that system or process. The exercise took time and effort but it was an effective way to show people the challenges and barriers to safe care in a specific context. My advice to others trying to do the same would be to get it all out, expose it, make it as visible as possible. Sometimes you have to be the one to put the writing on the wall. Related reading Postcards from work: Exploring archetypes of human work through micro-narratives Work as is done, work as imagined Electronic observations – how safe is it? Proxies for work-as-done: a blog series by Steven Shorrock, Humanistic Systems Share your thoughts What did you think of Claire's example? Could you see this working in a different area of healthcare?Do you have any tips or techniques to share that could help others explain the challenges they face on the ground to large groups of people? Share your thoughts by commenting below (sign up here first for free), or get in touch with our content team at [email protected]
  5. Content Article
    To improve the safety and quality of healthcare, we try to understand and improve how healthcare providers accomplish patient care "work." This work includes synthesising information from a patient's history and physical examination or from a handoff, performing tests or procedures, administering medications and providing information so that patients can make the best choices for themselves. Sometimes this work flows very well and everyone is pleased with the results, but sometimes this work does not unfold in the way that was anticipated. This article, originally published in Pennsylvania Patient Safety Advisory, argues that efforts to improve healthcare work will not succeed without recognising that there is a difference between a theoretical construct of "work-as-imagined" and the reality of "work-as-done".
  6. Content Article
    Disruptive behaviours have been shown to have a significant negative impact on staff collaboration and clinical outcomes of patient care. Disruptive episodes are more likely to occur in high stress areas such as the Emergency Department (ED). Having the structure, process, and skills in place to effectively address this issue will lower the likelihood of preventable adverse events. This study assessed the status of disruptive behaviours and staff relationships in the ED setting. It concluded that disruptive behaviours in the ED have a significant impact on team dynamics, communication efficiency, information flow, and task accountability, all of which can adversely impact patient care. EDs need to recognise the significance of disruptive behaviours and implement appropriate policies and protocols to address this issue.
  7. Content Article
    More information about "Reviewing ‘work as done’ to prevent wrong site anaesthetic blocks: An interview with Marsha Jadoonanan, HCA Healthcare UK"
    Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.
  8. Content Article
    The Safety Case is a regulatory technique that requires organisations to demonstrate to regulators that they have systematically identified hazards in their systems and reduced risks to being as low as reasonably practicable. It is used in several high-risk sectors, but only in a very limited way in healthcare. This multisite case study in BMJ Quality and Safety examined the first documented attempt to apply the Safety Case methodology to clinical pathways. The study found that the Safety Case approach was recognised by those involved in the Safer Clinical Systems programme as having potential value. However, it is also fraught with challenge, highlighting the limitations of efforts to transfer safety management practices to healthcare from other sectors.
  9. Content Article
    In rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
  10. News Article
    Britain’s top family doctor is calling for a “black alert” system to be introduced in general practice so that doctors can warn when surgeries are dangerously over capacity. It comes as a report reveals that almost half of GPs can no longer guarantee safe care for millions of patients, as a shortage of medics means they are unable to cope with soaring demand. Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners (RCGP), which represents 54,000 family doctors across the UK, wants a patient safety alert system introduced that is modelled on the operational pressures escalation levels (Opel) warnings – known as “black alerts” – already used by hospitals. It would enable practices and GPs to flag unsafe levels of workload, triggering support from their local health system. GP surgeries would be able to temporarily suspend non-priority activities – including some regular health checkups, certain routine but mandatory staff training and non-urgent paperwork – during periods of excessive workload. This would allow surgeries to reprioritise routine and non-urgent activity and ensure patient safety is prioritised. Hawthorne said: “General practice is a safety-critical industry yet GPs have none of the mechanisms that other safety-critical professions, such as the air traffic industry, have in place to protect them. “Our number one priority is the safety of our patients, but GPs are doing more and more to try to meet the rising demand for our services. When you’re fatigued, you’re more likely to make mistakes and our survey shows that many GPs are no longer able to guarantee that the care they are providing to their patients is as safe as it could be.” Read full story Source: The Guardian, 17 October 2023
  11. Content Article
    The publication of a new single, shared improvement approach, ‘NHS Impact’, is an exciting milestone. It reflects recognition, at the highest level in the English NHS, that improvement principles need to be part of the mainstream approach to the challenges facing the sector. Penny Pereira, Q’s Managing Director, considers the new approach, its potential impact and what it means for members and others working to improve health and care in England and beyond.
  12. Content Article
    Hosted by Don Berwick and Kedar Mate, Turn on the Lights is a podcast that aims to improve healthcare worldwide by shedding light on healthcare issues through thought-provoking conversations. By demystifying healthcare problems, it hopes to activate both the public and healthcare professionals to help us accelerate changes leading to health and healthcare improvements worldwide. The discussions cover various topics such as healthcare delivery, health equity, quality, and social justice. The podcast features solutions from around the world and encourages listeners to take action.
  13. Content Article
    This study, published by Health Expectations, aimed to understand what people were doing during the first wave of the pandemic to protect the safety of their health, and the health of others from COVID‐19, and the resilience of the healthcare system.
  14. Content Article
    NHS Impact ‘improving patient care together’ is the term NHS England is using for the new single, shared NHS improvement approach. This includes the five components which form the ‘DNA’ of all evidence-based improvement methods, which underpin a systematic approach to continuous improvement: Building a shared purpose and vision. Investing in people and culture. Developing leadership behaviours. Building improvement capability and capacity. Embedding improvement into management systems and processes. When these 5 components are consistently used, systems and organisations create the right conditions for continuous improvement and high performance, responding to today’s challenges, and delivering better care for patients and better outcomes for communities. Delivery and continuous improvement review Information about the delivery and continuous improvement review. Resources and materials Access improvement resources including good practice pathways and guidance documents. Real-time data Access real-time data to support improvement activities. Urgent and emergency care improvement These resources provide guidance and support to drive continuous improvement in urgent and emergency care services. Elective care improvement These resources provide guidance and support to drive continuous improvement in elective care improvement. Primary care improvement These resources provide guidance and support to drive continuous improvement in primary care improvement.
  15. Content Article
    This blog on the Sling the Mesh website provides an overview of research by Professor Carl Heneghan, Director of the Centre for Evidence-Based Medicine at Oxford University, into regulatory issues relating to pelvic mesh. It outlines issues uncovered by Professor Heneghan and his colleagues, including the fact that clinical trial data was not required in the regulation of mesh and that early evidence of complications was ignored in the approval of subsequent devices.
  16. Content Article
    In this article, Professor Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), outlines an NES research project which aimed to critically review the safety-related content, language and assumptions of a small but diverse range of health and care safety learning reports, policies, databases and curricula. The following information sources, which were in the public domain or volunteered by care organisations, were selected for review: NHS Board Adverse Event Learning Summaries Ombudsman Reports on Complaints Data from incident reporting and learning systems National and organisational management of adverse events policies Organisational incident investigation reports National and international patient safety curricula The study identified the following issues in the information reviewed: Omitting the ‘systems approach’ Using the language of blame and human failure Overlooking the ‘local rationality’ principle Engaging in counterfactual reasoning Misunderstanding key concepts Related reading: HSIB: Learning Response Review and Improvement tool
  17. Content Article
    Earlier this month, 13 leaders shared thoughts in NEJM Catalyst on how healthcare organisations can get more strategic around patient safety and quality improvement - an area that has seen renewed attention after COVID-19-related setbacks. Several themes emerged across leaders' responses, namely the need for more proactive approaches to mitigate risk and intervene, rather than reviewing and assessing harms after they occur.  University Hospitals nurses are leading the charge to do just that by embracing the adoption of artificial intelligence to make daily safety huddles more actionable. Read the full article, published by Becker's Hospital Review via the link below.
  18. Content Article
    Each year, the Joint Commission gathers information about emerging patient safety issues from stakeholders and experts in different fields of healthcare. This information forms the basis of the Commission's National Patient Safety Goals, which are tailored to specific programs. You can download the 2023 National Patient Safety Goals (NPSGs) for the following programs, as well as easy-to-read summaries: Ambulatory Health Care Chapter Assisted Living Community Chapter Behavioral Health Care and Human Services Chapter Critical Access Hospital Chapter Home Care Chapter Hospital Chapter Laboratory Chapter Nursing Care Center Chapter Office-Based Surgery Chapter
  19. Content Article
    Clinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation. Findings There is no specific guidance for ED clinicians on the identification of suspected non-accidental injuries and what to do if they suspect an infant has a non-accidental injury. There may be barriers to routinely escalating cases of children with a potential non-accidental injury to paediatric (child specialist) and safeguarding teams. Delays in the availability of information about potential safeguarding concerns add to the pressures on ED staff when making decisions about infants with potential non-accidental injuries. There remain concerns about, and an inconsistent approach to, sharing safeguarding information between organisations. The Emergency Care Data Set (ECDS) gathers information about ED attendances and includes a field for when such attendances are related to safeguarding. The ECDS safeguarding information collected is not currently utilised within the NHS and there is minimal quality assurance in place to ensure that it is reliable. Risk factors for non-accidental injuries which do not meet the criteria to be included on the Child Protection – Information Sharing system (the electronic system designed for information sharing between the NHS and social services) are not included in a patient’s summary care record and may therefore remain unknown to clinicians. The investigation identified mechanisms which could enable safeguarding information that is not currently available to ED clinicians, to be made available through existing national and regional digital systems. Safeguarding teams are often located physically distant from EDs. This can create a barrier to communication and liaison with the team. Safety recommendations HSIB recommends that the Royal College of Emergency Medicine, working with relevant stakeholders, develops guidance to support clinicians in the diagnosis and management of non-accidental injuries. HSIB recommends that NHS England, working with relevant stakeholders, reviews the utility of the safeguarding data in the Emergency Care Data Set and agrees a process for assuring the quality of any data to be captured. Safety observations HSIB makes the following safety recommendations: It may be beneficial if there was an electronic system available for clinicians to view any safeguarding information to assist in decision making. It would be beneficial if the safeguarding operating model, to be tested through pathfinders, included a response time for advice when sought by professionals such as emergency department clinicians It may be beneficial if safeguarding teams are either physically located near to, or make efforts to promote their visibility in, emergency departments.
  20. Content Article
    This long read by the Nuffield Trust looks at priority areas where further development and action could help improve the effectiveness of virtual wards. It outlines different models for virtual wards and looks at how to ensure effective system oversight. It also highlights the need to ensure the workforce is equipped to run virtual wards effectively and safely.
  21. Content Article
    This document by the Joint Commission provides an overview of the issues faced by healthcare workers who are negatively affected by their involvement in a patient safety incident—second victims. It highlights the prevalence of second victims, summarises the key problems they face and outlines recommendations to ensure staff receive adequate support from healthcare organisations when they are involved in an incident.
  22. Event
    This conference focuses on improving practice and patient safety to reduce Extravasation Injury, ensuring front line clinicians are aware of the risk of extravasation and how to recognise, treat and escalate extravasation injuries when they do occur. This conference will enable you to: Network with colleagues who are working to reduce Extravasation Injury Learn from outstanding practice in recognizing, treating and escalating extravasation injury Reflect on national developments and learning Ensure vesicants are administered in the safest way Develop your skills in training frontline staff to recognize evolving injuries Understand how you can implement preventative measures Identify key strategies for improvement Educate patients to raise alarm and improve consent procedures Develop protocols to support practice Understand the role and competencies of the NHS trust lead for extravasation Ensure effective treatment, and early intervention in severe wounds Learn from case studies in cancer, maternity, radiology and paediatrics Ensure you are up to date with the latest legal cases Self assess and reflect on your own practice Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email [email protected] for discount code.
  23. Event
    until
    This webinar by the Institute for Safe Medication Practices in the US is aimed at: Pharmacists, physicians, nurses Medication safety officers Quality professionals Risk managers Leaders in pharmacy and nursing Pharmacy and anaesthesia technicians Although most medications in healthcare today have a wide margin of safety, there remains some which can cause serious harm or death if they are misused. To reduce the risk of error with these “high-alert” medications, special precautions and high leverage strategies should be implemented to avoid serious patient safety events. Numerous organizations have taken steps to identify these medications, but many are still less than confident that they have taken all the necessary precautions against serious patient harm. Join the ISMP faculty as we focus particular attention on the potential safe use risks with heparin, concentrated electrolytes, and magnesium using the results from ISMP’s National Medication Safety Self Assessment® for High-Alert Medications. Faculty will review specific safety characteristics of each these important drug classes, describe self-assessment findings related to the use of these medications, and discuss the necessary practice strategies for harm prevention when using these high-alert medications. Register for the webinar 3.00pm Eastern Time (US and Canada), 8.00pm GMT
  24. Event
    until
    Infection is a leading cause of childhood deaths, but many of these deaths are avoidable with timely treatment. The national Before Arrival at Hospital Project (BeArH), funded by the National Institute for Health Research (NIHR), explored what happens to children under five years of age with serious infections before they are admitted to hospital. The aim of this research was to explore what helps children get help quickly and what might slow this process down, so that lessons could be learned for the care of this group of children in the future. This forum will be led by Professor Sarah Neill, Dr Damian Roland and Natasha Bayes. To join the research forum and hear the findings of this important research project from the study team, email [email protected] for the Microsoft Teams link.
  25. News Article
    Nine months ago, Boris Johnson praised staff at St Thomas’ for saving his life. Now, a senior intensive care nurse at the London hospital has warned that patient care is being compromised because of staff shortages and a failure to plan for the second Covid wave. Dave Carr, an intensive care charge nurse, is one of many NHS workers desperate for the public to know what is going on inside their hospitals at a time when misinformation and scepticism about the virus are rife. “The public needs to be aware of what’s happening. This is worse than the first wave; we have more patients than we had in the first wave and these patients are as sick as they were in the first wave. Obviously, we’ve got additional treatments that we can use now, but patients are still dying, and they will die,” said Carr. As a representative for the union Unite, Carr feels emboldened to speak out. But across the NHS, many more staff claim they have been threatened with disciplinary action or even dismissal if they put their head above the parapet. In Devon, one nurse working on a Covid ward said safety standards had slipped at her hospital, but she feared for her job if she was identified by name. “The infection control restrictions are more relaxed. Before, we had to use a separate entrance but now we don’t, and some doctors feel they don’t have to obey the infection control protocols and are still unsure of how to properly remove the PPE,” she said. Read full story Source: The Guardian, 1 January 2021

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