Search the hub

ITU handover Bedside checklists Transducing arterial lines Arterial line sampling Bedside monitoring Observations Ventilation basics Activity sheet. About the author Sam is a registered nurse who works for a Trust on the South Coast of England

View video (2:48)

This infographic sets out standardised, safe care of children and young people who are receiving or for consideration of receiving Heated humidified high flow therapy (HHHFT).

This page is dedicated to the Anaphylaxis Campaigns (AC), Making Schools Safer Project and includes all the resources that they have produced for schools; from allergy awareness presentations (for pupils) to free online e-learning AllergyWise courses.

This report builds on those of previous years to provide analysis of longer-term trends and insights into the changing NHS staff profile. It focuses specifically on the critical NHS workforce issues that have been repeatedly identified in recent years: nursing shortages, and shortages of staff in general practice and primary care. The report also explores key pressure points: student nurses the international context and international recruitment retention. The report concludes by summarising the key workforce challenges that will need to be considered in the development of the full NHS people plan. Patient Safety Learning's repsonse to the report: This report on NHS workforce trends released by the Health Foundation today includes some really interesting findings, particularly around the changes in the skills mix between nurses and clinical support staff (including health care assistants and nursing assistants). The report states that in 2009/10 there were equal numbers of nurses and support staff, with one clinical support staff member for every FTE nurse in the NHS. In 2018/19, the number of support staff per FTE nurse had risen 10% to 1.1 FTE per nurse. Looking at the numbers, this translated to the NHS employing 6,500 more clinical support staff to doctors, nurses, and midwives, compared to 4,500 more FTE nurses. While changes to ratio of nurses to clinical support staff may reflect changing patient needs, technological advances and other factors, the report also notes concerns that these may be ‘introduced in an unplanned way in response to negative factors – such as cost pressures or recruitment difficulties – rather than positive drivers of improvement’. At Patient Safety Learning we believe to achieve a patient-safe future, patient safety must be more than a priority for an organisation. It must be core to its purpose, reflected in everything that it does. This should apply to the NHS when considering changes in workforce staffing and numbers so that the impact that these may have on patient safety is considered as an intrinsic part of the decision making process. While the report notes that in many cases decisions on skill mix changes are implemented well and evidence led, it’s not clear whether patient safety has been taken into account. Our view is that these decisions should involve a explicit, evidence-based assessment of the impact on patient safety which leads to the selection of the option that offers that safest outcome for patients.

Misplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a “never event” by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them. An e-learning package, robust standardisation in staff’s approach to patient care, re-setting “red lines” to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.

Colour is a hallmark of Autumn across the US. A more spectacular set of colours, in a variety of shapes and sizes, paint the sky at daybreak every October in New Mexico. The Albuquerque International Balloon Fiesta is the largest gathering of its kind. In 2019, its 48th year, the fiesta hosted 550 hot air balloons, 650 pilots and entertained close to 900,000 visitors. The event holds a place on the bucket lists of travellers around the world. It is hard to describe the feeling of glee standing amid a mass ascension until you’ve been there amongst the early morning crowds. You might think it’s all fun, funnel cakes and floating but—like any aviation activity—ballooning entails risk. Make no mistake, the balloonists and their teams, the organisers, law enforcement, and even participants play a role in the safety of the event. Before sunrise each day, the “dawn patrol” of 8–10 hot air balloonists lift off. These experienced pilots gage the safety of the sky prior to the authorities giving the signal for the assent to begin. Only after that, does the wave after wave of multiple balloons unpack, gear up, inflate and take off from the field. Crews mull about, patiently navigating their designated space amongst onlookers and their cameras to get ready for flight. They implement standard procedures to safely gear-up for flight. Healthcare, too, prepares teams for complex situations to ensure safety through standardisation and practice. The US healthcare accreditation agency, the Joint Commission, shared insights on reducing maternal harm due to postpartum haemorrhaging that summarises best practices centered on readiness, recognition, response and reporting to support systems learning. Stanford Medicine in California recently held a series of “dress rehearsals” prior to opening a new hospital. The test of the space gave clinicians, administrators and patient advisors a chance to make sure conditions were right for a safe opening day. The fiesta organisers also deploy tactics to learn from what doesn’t go well. They use technology to gather input from crews and the public to identify areas for improvement. Traffic into the 360-acre launch site creates ineffective and potentially dangerous situations given the swell of people arriving in town. Attendees almost double the size of the city for the 10-day event. Public input gathered online helped planners to redesign this year’s park and ride shuttle system after it failed in 2018 to reliably get people to the festival. Hospitals also use information technology to learn how to improve the safety of the care experience. Researchers in Washington State developed a 4-step model built on inpatient experiences with undesirable events. They used patient and family knowledge to design informatics solutions that engage patients as contributors to safety. The model supports raising awareness of problems, encouraging prevention actions, managing emotional harms and reducing barriers to reporting .A rare situation stalled the festival this year: fog. Yes, fog is not something New Mexican’s encounter often but it shut down opening day morning—none of the balloonists could take off. This unique occurrence would have been all the more problematic had teams not heeded safety advice in this less-than-ideal situation. Practices and protocols keep patients safe too but only if they are followed. A unique set of circumstances led to the death of a patient awaiting care in a Pennsylvania emergency department. Protocols weren’t followed limiting situation awareness, communication and process completion. Balls were dropped and the results were tragic. Complex systems can manifest unintended consequences from strategies designed to protect people. Balloon fiesta has its share of mishaps. Pilots end up in the Rio Grande, drift into powerlines, bones get broken and, rarely, lives are lost. The expert crews mean well but failures happen. A nurse in Tennessee who made a medication mistake that resulted in patient death was charged criminally. While lawmakers may feel this is a just approach, it is a threat to healthcare transparency. A series of incidents involving misdiagnosis of child abuse is raising concerns in the US. While specialised paediatricians can readily identify patient conditions that indicate abuse, sometimes those judgements are made in error. The decisions made to protect children instead accuse innocent parents or family members of harm. The safe flight of those families then tumbles to the ground. The pace is back to normal in Albuquerque. Balloons still float above us in the morning and afternoon—'tis the season. They brighten the clear blue skies with the Sandia mountains as a backdrop. But you can bet that what did go wrong this year will be folded into the event planning so all that participate in the 2020 festival will be as safe as possible.