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As trusts consider clearing the waiting list, there is an absence of objective approaches to prioritisation. There are 40 million variations of operative type and the NHS elective waiting list may reach more than 10 million. A coronavirus second wave may cause further delays and expansion of the waiting list. This blog from hub topic lead Richard Jones describes a proven approach to prioritising the waiting list built around individualised risk-adjustment for each patient and evolved from the core POSSUM methodology that is widely used for individual risk assessment pre-operatively. A significant backlog of elective surgical cases has built up during the COVID-19 crisis. The freeze on elective surgery has produced a waiting list that may take years to clear. In the US, the CDC has issued guidelines that "facilities should establish a prioritization policy committee consisting of surgery, anesthesia and nursing leadership to develop a prioritization strategy appropriate to the immediate patient needs". According to the CDC, this committee should work around 'objective priority scoring'. The MeNTS (Medically-Necessary, Time-Sensitive Procedures) instrument is a clever attempt to deliver this scoring, responding to availability of resources and the situation around COVID-19. However, the key challenge is that that the list needs to be prioritised in a way that reflects patient needs and ensures their safety. This is not something that MeNTS can deliver. It also is built around COVID-19 related limitations on resources and this will vary in significance depending on the hospital location and where it is in the journey out of lockdown. The risks of mortality and complications for a patient are a complex combination of the severity of the procedure and the physiological variables of the patient. As an example, a 55-year-old undergoing a radical laproscopic prostatectomy has a risk of mortality of 1.6%. However, if the patient has low blood pressure, that risk triples. If the patient also has low sodium then the risk is 10 times higher [C2-Ai insights]. The spectrum of different operations and key physiological variables creates at least 40 million potential combinations and hence risk. This is hard to manage with one patient but trying to prioritse a group of 5, 10, 100, 1,000 or even 10,000 becomes unmanageable. New patients will be joining the list while others leave following their procedures and so triage of the list will not be a one-off event. The list will need to be populated and triaged intelligently and in a consistent way repeatedly at least until there is a return to ‘normality’. There is evidence that some trusts are attempting to build their own systems for prioritisation. This may be possible around matching operative type and resource availability but the efficiency of these systems overall should be a concern. Best intentions are fine but, when reviewed later, the ability to correctly prioritise patients to minimise harm and mortality is likely to be limited if not flawed. C2-Ai’s COMPASS Surgical List Triage system is an example of a system that can support evidence-based triage and individualised risk assessment of patients, while supporting the objectives of the CDC. It supports clinical decision making across all phases from crisis back to steady state. It has been developed by the creator of the POSSUM system and is built around the world’s largest patient data set (140 million records from 46 countries) through the support of NHS Digital. The underlying algorithms are constantly refined against new and existing data sets to ensure relevance and accuracy. The Surgical List Triage tool combines the mortality and complication risks from the different patients to derive the prioritisation. The system carries out bulk assessments using individualised risk assessments for each patient. These reflect the operative type and their physiology to calculate the risk of mortality and complications, as well as providing a detailed breakdown of potential complications with percentage probability with a simple click. This system also suggests patients that should be reviewed for potential optimisation before any procedure. The physician can click on the link to see the detailed risks for the patient to support their decision making. The system can be used regularly to maintain the logic and integrity of the elective surgical list. This is superior to the potentially fragmented approach where parts of the list are manually considered in isolation as this cannot support effective optimisation of the whole list and the absence of any supporting evidence means the triage will vary enormously. COMPASS SLT is an evidence-based approach that supports optimal ordering of the list and clinical decision making that reduces avoidable harm and mortality. This in turn reduces variation, and cost while freeing bed capacity and also allowing the list to be tackled more quickly. When a patient comes in for the operation, an individual risk-assessment can be done using the COMPASS Pre-Operative Risk Assessment app. This provides a final check on whether the patient’s condition would justify optimising their condition before their procedure. However, it also details the most likely post-procedural complications individualised for the patient and their condition. That allows the treatment pathway to be tailored to that patient as well as recruiting the patient into their own recovery. For example, knowing that chest infection is the highest risk for a patient supports a conversation with them to stress the need for them to get up and about on the day of the operation. As an aside, the risk of mortality and complications can also be used as a strong element in showing informed consent has been obtained from the patient. In combination, these tools can provide a platform to support effective and ongoing triage of the list while reducing harm and unnecessary costs. The systems are currently in use in 12 trusts in the NHS. How are you prioritising waiting lists? We'd be interested to hear and share how you and your trust are dealing with the backlog.

This article describes the qualitative methodology developed for use in CIRAS (Confidential Incident Reporting and Analysis System), the confidential database set up for the UK railways by the University of Strathclyde. CIRAS is a project in which qualitative safety data are disidentified and then stored and analysed in a central database. Due to the confidential nature of the data provided, conventional (positivist) methods of checking their accuracy are not applicable; therefore a new methodology was developed – the Applied Hermeneutic Methodology (AHM). Based on Paul Ricoeur’s ‘hermeneutic arc’, this methodology uses appropriate computer software to provide a method of analysis that can be shown to be reliable (in the sense that consensus in interpretations between different interpreters can be demonstrated). Moreover, given that the classifiers of the textual elements can be represented in numeric form, AHM crosses the ‘qualitative–quantitative divide’. It is suggested that this methodology is more rigorous and philosophically coherent than existing methodologies and that it has implications for all areas of the health and social sciences where qualitative texts are analysed.

Most healthcare professionals are familiar with Datix incident reporting software. But how and why has Datix become associated with fear and blame? Datix’s former chief executive and now chairman of Patient Safety Learning, Jonathan Hazan, looks at why this has come about and what needs to be done to improve incident reporting. This year I’m seeing many more complaints on Twitter from healthcare professionals about the misuse of incident reporting. The threat “I’m going to Datix you!” is coming up time and time again and people are complaining about being “datixed” inappropriately. One Twitter user recently said: “Datix has been used as a verb so many times on my feed today that my head might explode”. Datix has become associated with fear, retribution and blame. But how has this come about and what can be done to change it? Datix as a company has seen many changes since I stood down as chief executive in 2015. The most noticeable is a change of name to RLDatix, reflecting the acquisition in 2018 of Canadian rival RL Solutions. Some things, however, have not changed. Healthcare professionals still complain about the length and complexity of the Datix forms. They still complain about the lack of action from the incident reports they submit. They still complain about getting into trouble as a result of reporting an incident themselves (particularly reports about staffing levels). And they still complain about the threat of someone else including them in an incident report as a means of coercion: “If you don’t do this, I’m going to Datix you.” All of these factors are also common to incident reporting systems from other suppliers, but because Datix has the lion’s share of the UK market, they have contributed to an overwhelmingly negative sentiment about Datix. The issues The problem with complicated and contradictory forms is that Datix gives local administrators complete freedom to design the forms themselves. This results in forms that get longer and longer over time, as new people need to collect new information. The best forms I’ve seen are very short and contain the date, the time, the reporter’s details and free text boxes for a description of what happened and what action was taken. The very best forms I’ve seen have an additional free text box: “Your safety ideas”, asking the reporter if they can think of any ways that this type of incident could be avoided or mitigated in the future. It’s a good way to encourage people to think about safety; however, it does rely on someone at the other end of the report actually listening and responding. The issue with the lack of feedback is that it relies on someone following up, investigating and then reporting back on the incident. Or if the incident isn’t going to be investigated, the reporter should be sent an explanation. If reporters don’t get any feedback and can’t see any changes made as a result of reporting, they’re going to stop reporting. This is not a problem with the incident reporting software, but an issue of the system within which it is used. The issue of the threat and fear of reporting is more deep-seated and harder to change. It’s partly linked to the other two issues – if incident reporting has no positive outcomes, it’s seen only as a burden and a tool for punishment. It’s also a symptom of a culture of fear, bullying and a lack of resources, where stressed managers want to discourage the reporting of incidents as they don’t have the time or resources to do anything about them. There are constant calls for culture change. But culture change is difficult and it’s hard to know where to start. We can, however, take incremental actions that contribute to a shift in culture. Culture change One example is the former Calgary Health Region in Canada, which had a culture where incident reporting was being used for performance management, with managers reprimanding staff who reported incidents. Recognising this was having a bad effect on staff and patients, Calgary Health Region reconfigured Datix so that the managers couldn’t see information that would identify the reporters. This didn’t change the culture overnight, but it gave staff confidence that they could report incidents in an environment free from punishment. Coupled with the setting up of a separate central department responsible for safety and investigations, this set the organisation on the long road to culture change. An excellent write up of the system that Calgary implemented can be found here. Would that system work here in the NHS? Yes it would help, but it doesn’t go far enough in a system where incident reporting has got such a bad name. We need something much more radical. What if we were to abolish incident reporting completely? Automated incident reporting systems This doesn’t mean we have to remove investigation and learning from the patient safety toolkit. It does mean that we can obtain information about incidents from places other than manually input incident report forms. The technology already exists to do this. We can monitor a hospital’s IT systems in real time to see if an incident had happened or for signs that an incident was about to happen. There would be no need to replace existing incident management systems, just the method of getting the incidents into the systems and a change to the processes around them. Such an automated incident reporting system already exists – again, in Canada – at The Ottawa Hospital. The hospital devised rules, called e-triggers, that automatically create an incident record based on certain criteria in other hospital IT systems. One such trigger might be a return to the emergency department within three days. The creation of the incident record also sends a notification to a clinician to review the record and answer some simple questions to determine if a follow up or investigation is needed. You can read some of the results from the system in this BMJ Quality & Safety paper. Although they haven’t done away with incident forms completely, this is a step in the right direction. I don’t know of anyone who has done anything similar here in the NHS, but I believe this system would go a long way towards the goal of eliminating the threat of “I’m going to Datix you”. A call to action Set up triggers to automatically send potential incidents from other IT systems into existing patient safety reporting systems. Software suppliers should take the lead on this. Simplify current incident report forms so they are as quick as possible to complete. Give clear guidance on what incident reporting should and should not be used for, with assurances that no one will get into trouble for reporting an incident or being included in an incident report. Do you have any ideas on how we can improve incident reporting and prevent the threat of “I’m going to Datix you”? Please join the discussion on the hub. Further reading: Patient Safety Spotlight Interview with Jonathan Hazan, Chair of Patient Safety Learning Nursing can help end the travesty of ‘Datix abuse’ Why Investigate? Blog series Root cause analysis: Why we need to change the focus Patient Safety Incident Response Framework

This short video, by Understanding Patient Data,  shows people talking about why it's important to use patient data, and why we need to better explain the benefits and safeguards.

An honest account from a junior doctor on moving from paper to electronic observation charts and why user testing should be done before rolling it out in hospitals. Paper observation charts are now a thing of the past where I work. Gone are the days of charting your patients’ blood pressure and pulse in the tiniest of boxes. So small you could barely see the date and time of day at the top. Often, the chart looked as if it had been filled in by a spider with inky feet, sometimes it was sticky from medication that had been spilt on it (or sometimes worse). It would be passed from one clinician to another, a little ragged round the edges. Nurses had to remember when to do the next set of observations according to the National Early Warning Score (NEWS). As for auditing observations to ensure we were adhering to national guidance for the whole hospital… forget it. We had been use to this for years. But now we have a new chart in town… e-obs. This is going to solve all our problems. At the click of a button you have a clean, legible, fully completed observation chart. Each patient would have followed the NEWS escalation as the ‘electronic system’ would remind the nurse to complete the next set of observations at the correct time. Auditing would be a few clicks away. How many patients are scoring 5 or more? Who and where are the sickest patients? Which wards are not adhering to national policy? It is all there. This is a terminal case of ‘work as imagined’. Firstly, lets clear this up. Just because a patient is scoring a NEWS score of over 5 does not mean they are the sickest of patients. Many patients who are deteriorating, especially the younger population, score lower than 5. Patients in acute kidney injury often do not score at all but may require a trip to the intensive care unit. Do not be fooled by the NEWS score. NEWS is but a number. We must look holistically at our patients and not rely on looking at just numbers. I would like to share something that happened the other day that highlights some of the pitfalls of using an electronic observation system. I am a junior doctor on an elderly care ward. One of my patients became acutely unwell at 10pm on a Sunday evening. He couldn’t breathe, his NEWS was 9, he looked and sounded awful. I thought he was going to die. The medial emergency team came. They gave him suction, the chest physiotherapist came, they changed his antibiotics. He got a little better. His NEWS went down to 4. How did this happen? Surely, he didn’t suddenly get this unwell. He was doing well the day before. I looked at his observations. They were documented beautifully on the screen. Very clear. However, he hadn’t had his obs taken for 12 hours despite his last NEWS score was 3 (this means obs need to be taken again 4–6 hours later). Why didn’t the electronic system alert the nurses to take the obs? This is a forceable function of the system? This is why we changed to an electronic system in the first place… to prevent this type of harm from happening. So, what happened? The patient had been scoring 0 for the last few days. This means that obs can be taken every 12 hours. The patient then scored 3. His oxygen saturations had dropped. As he was ‘stable’ the nurse then changed the profile of when the next set of observations were taken. Instead of the default setting of 4–6 hourly, they had set it for 12 hourly again. This is against national guidance. Profile changes are taught to the nurses and doctors when being inducted to the e-obs system. This is important to know especially if the patient is dying, off the ward or having a blood transfusion, post op etc... This means that the patient will get their observations taken at the right time depending on what is going on. Instead, the nurse had changed the profile so that the patient received less monitoring. What was the reason for this? Was it because he had been so stable before, that they thought he didn’t require more frequent observations? Was it due to ward pressures – they didn’t have time to do that frequency of obs? What ever the reason. Its against national guidance and this ‘safe system’ has allowed us to do so. There is also another problem at play here. Take another example. A patient is receiving 12 hourly observations. They are stable. What happens when the patient may ‘look unwell’ or they complain of pain or breathlessness? You take another set of observations. The trouble is. They are not due. The system won’t let you ‘log them’. Not only is this frustrating, it also takes away intuition and assessing your patient from the bedside. We cannot be complacent. Looking at numbers on a screen is not an indicator on how well your patient is. Paperless, automated systems are brilliant. They will revolutionise healthcare, it will make care safer. We have to be mindful that these are early stages. There will be problems along the way. I just wish that there was some user testing before they rolled e-obs out. Healthcare staff will take short cuts, will do unexpected things, won't always realise these consequences. Yes, it would have cost money, it would have taken time but, if they had user tested this with real staff, perhaps this man may not have suffered?

Healthcare is advancing at a quicker rate than ever before. With the introduction of Artificial Intelligence (AI), you can now get a cancerous mole diagnosed with a mobile device. The reliance on technology has never so great. With technology predicted to replace as much as 80 per cent of a physician’s everyday routine, we must question what the new threats posed to patient safety are? This article, written by CFC Underwriting, explains some of the pitfalls of the new technology. CFC is a specialist insurance provider. and a pioneer in emerging risk.

The Patient Experience Journal (PXJ) is a peer-reviewed, open-access journal published in association with The Beryl Institute. PXJ is committed to disseminating rigorous knowledge and expanding the global conversation on evidence and innovation on patient experience. Grounded in their core principles, PXJ engages all perspectives, with a strong commitment to patients included.

For the past two years, Scalpel Ltd have been building technologies that improve patient safety in surgery. We have found a lack of understanding of why we need to invest in patient safety. In this blog I discuss surgical errors and the urgent need to invest in patient safety.

On a day to day basis, the NHS Digital Clinical Safety team are involved in several wide-ranging and very different projects. As you know, clinical safety should be part of everything the NHS do. Every project, every programme, every deployment. Clinical safety should be considered, understood and implemented to the highest calibre. So as you can imagine, we are a busy team. For those manufacturers with systems in use, we deal with live incidents, upgrades, further geographical or functionality deployments. For those creating new systems we are supporting them in their clinical risk management process, running hazard workshops, creating hazard logs and writing the supporting documentation.  We are constantly reviewing and peer reviewing, assessing compliance and marking against the standard requirements. We assist suppliers and health organisations to self-audit their compliance against the standards so they may improve their clinical safety position.  We are assessing new and emerging apps and mobile health solutions to ensure they are going through the same standard of assessment as the traditional computer-based systems and we are providing representation across the NHS to ensure clinical safety remains paramount to the work being done.  One of the biggest branches of our role is training delivery. We know first-hand the importance of having a team that are educated and confident in clinical risk management.

We are NHS Digital’s Clinical Safety team and I’d like to tell you more about who we are, what we do and why we do it.  We are a team of 14 people, split between Leeds, London and Exeter. We are a mixture of clinicians and engineers with varying backgrounds and experiences. It’s our job to make sure that the risk of harm to patients as a result of health IT is the lowest it can possibly be. We are responsible for the production of two standards, designed to support and guide both the manufacturers of health IT and those organisations who deploy it. By ensuring these standards are in place and supporting people to comply with them, we can keep the risk of patient harm to a minimum. Of the two standards, one (DCB 0129) is relevant to those responsible for the manufacture of health IT and the other (DCB 0160) is related to the organisations that will be deploying and using the IT. Both standards are mandatory under the Health and Social Care Act 2012. When a health IT manufacturer designs a system, they must cdo so with clinical safety at heart. Any system that needs to connect to SPINE must go through an assurance process to make sure it is as safe as it can be to be deployed. Part of this assurance process is clinical safety. The clinical safety stage of assurance involves the assessment of the system for compliance to DCB 0129. DCB 0129 guides the manufacturer in their clinical risk management provision. It outlines their clinical safety responsibilities, such as: They must nominate a person responsible for clinical safety. This person must be a suitably qualified and registered clinician. They must produce a log of all the potential hazards associated with the system that could impact the patient. They must produce a safety case that will detail the risk analysis of each hazard and specify what controls and mitigations have been put in place to ensure as far as possible that these hazards will not occur. The same kind of responsibilities are outlined in DCB 0160 with regards to those taking on and deploying the health IT. They must be sure they have understood all the hazards identified by the system manufacturer and have made their own provisions to reduce the risk as far as possible. This should also be detailed in the same format and standard of documentation that is expected from the manufacturers under DCB 0129. We work closely with both the manufacturers and the organisations to support them with their compliance to these standards. Before a system can be deployed for the first time, it must receive a Certificate of Authority To Release (CATR) from NHS Digital that evidences their compliance to the standard. The approval for this certificate to be given is granted by the Clinical Safety team within our weekly Clinical Safety Group (CSG) meetings once we are happy with the evidence presented. Once the CATR has been granted, the manufacturer is free to deploy the system at the intended organisation within the defined scope of the CATR. In most cases, if they wish to deploy further, or add any additional functionality, they would have to come back to CSG to get the CATR upgraded. Having this process in place ensures that clinical safety is given a respectable amount of thought and consideration. This provides us with a confidence that the risk of harm to patients is kept at a minimum. We are also involved in live service incidents. If something happens with the IT once it has been deployed, we make sure the incident has been properly assessed with regards to risk of harm to the patient.

Drugs.com is the largest, most widely visited, independent medicine information website available on the internet. Their aim is to be the internet’s most trusted resource for drug and related health information. They are trying to achieve this aim by presenting independent, objective, comprehensive and up-to-date information in a clear and concise format for both consumers and healthcare professionals. The Drugs.com UK database contains drug information on over 1,500 medications distributed within the United Kingdom.

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ECRI Institute's Top 10 Patient Safety Concerns for 2020 features new topics, with an emphasis on concerns that have the biggest potential impact on patient health across all care settings. However, the number one topic on this year's list is one revisited from 2019: missed and delayed diagnoses. ECRI’s list of patient safety concerns for 2020: 1. Missed and delayed diagnoses—Diagnostic errors are very common. Missed and delayed diagnoses can result in patient suffering, adverse outcomes, and death. 2. Maternal health across the continuum—Approximately 700 women die from childbirth-related complications each year in the U.S. More than half of these deaths are preventable. 3. Early recognition of behavioural health needs—Stigmatisation, fear, and inadequate resources can lead to negative outcomes when working with behavioural health patients. 4. Responding to and learning from device problems—Incidents involving medical devices or equipment can occur in any setting where they might be found, including ageing services, physician and dental practices, and ambulatory surgery. 5. Device cleaning, disinfection, and sterilisation—Sterile processing failures can lead to surgical site infections, which have a 3% mortality rate and an associated annual cost of $3.3 billion. 6. Standardising safety across the system—Policies and education must align across care settings to ensure patient safety. 7. Patient matching in the EHR—Organisations should consistently use standard patient identifier conventions, attributes, and formats in all patient encounters. 8. Antimicrobial stewardship—Over prescribing of antibiotics throughout all care settings contributes to antimicrobial resistance. 9. Overrides of Automated Dispensing Cabinets (ADC)—Overrides to remove medications before pharmacist review and approval lead to dangerous and deadly consequences for patients. 10. Fragmentation across care settings—Communication breakdowns result in readmissions, missed diagnoses, medication errors, delayed treatment, duplicative testing and procedures, and dissatisfaction.

The use of health technology has grown exponentially in the past few decades, and the proliferation and complexity of this technology has led to new risks to patient safety. The Institute of Medicine (IOM) discussed this issue in their report, Health IT and Patient Safety: Building Safer Systems for Better Care, and concluded that achieving better health care requires “a robust infrastructure that supports learning and improving the safety of health IT.” In an interview for the Institute for Healthcare Improvement (IHI), Executive Director and patient safety expert Frank Federico describes the keys to success for using health technology safely. He discusses some common safety risks such as clinical alarm safety (now a Joint Commission National Patient Safety Goal), poor training and support systems for new users of technology, and workarounds.

Liverpool is leading the way in the use of smartphone technology to deliver and monitor care in people’s homes. The city is the first to introduce a digital system with almost all domiciliary care providers – giving instant information about 9,000 vulnerable residents to their families and professionals. The use of an app allows care providers and families to see when a visit is carried out by a carer, for how long and how the person responded.The effect is better informed families and care managers and improved care. Liverpool is the only authority in Europe to be using the technology across its city, with all but one of its 18 domiciliary care providers using everyLIFE PASSsystem. It was made possible through a grant of one million Euros of European Union funding secured through the EU STOPandGO programme of which the Innovation Agency, the Academic Health Science Network for the North West Coast was a key partner.