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Found 202 results
  1. News Article
    The government has rejected an urgent call by MPs to bring in a new licensing regime for non-surgical procedures such as Botox injections, chemical peels, microdermabrasion and non-surgical laser interventions. Ministers also rejected recommendations by the House of Commons Health and Social Care Committee to make dermal fillers available as prescription only substances—as Botox is—and to bring in specific standards for premises that provide non-surgical cosmetic procedures. The government also rejected several recommendations aimed at tackling obesity—including a dedicated eating disorder strategy, annual health and wellbeing checks for every child and young person, and restrictions on buy-one-get-one free deals for foods and drinks high in fat, salt, or sugar. Read full story Source: BMJ, 2 February 2023
  2. Content Article
    Who we are The Quality Network for Inpatient Working Age Mental Health Services (QNWA) was first established in 2006 as AIMS (Accreditation for Inpatient Mental Health Services), which later specialised to AIMS-WA (Working Age), before becoming a quality network in the summer of 2020. The Network was founded to promote better standards of care within mental health inpatient wards following the publication of findings from the National Audit of Violence 2003-2005, which highlighted the concerning high prevalence of violence on acute wards, but also concluded that examples of good practice were going unrecognised. The Network is one of around 30 quality networks, accreditation, national clinical audit, and research and evaluation projects organised by the Royal College of Psychiatrists (RCP) Centre for Quality Improvement (CCQI). The CCQI works with more than 90% of mental health service providers in the UK to assess and improve the quality of care they provide. Since the first set of QNWA standards were published in September 2006, the Network has grown to include over 140 member wards. A full list of member wards and their current accreditation status is available to view on the RCP's website. What we do QNWA is a not-for-profit, run by quality improvement staff and steered by clinicians and patient and carer representatives. The purpose is to support and engage wards in a process of quality improvement whereby they are reviewed against a set of specialist standards for acute inpatient wards for working age adults. The accreditation process provides recognition for wards who meet a set threshold of standards and who are deemed to be operating at a level that achieves accreditation. Upon becoming a quality network in 2020, the developmental membership option was introduced. Unlike accreditation membership which works on a three-year cycle and results in an accreditation decision, the developmental membership works on an annual basis and there is no threshold of standards for services to meet. This allows services to familiarise themselves with the standards and review process before attempting to gain accreditation and to concentrate on any areas of improvement. The eighth edition standards were published in May 2022 and aim to reflect the changes in working practices and legislation over the last two years in addition to placing greater emphasis on equality, diversity and inclusion, as well as sustainability in mental health services. Standards for Acute Inpatient Services for Working Age Adults - 8th Edition (1).pdf QNWA promotes the sharing and learning of best practice through peer-led review visits and helps wards to action plan against areas of future improvement. The Network serves to identify areas of achievement and areas for improvement in individual services, through a culture of openness and enquiry. The model is based on engagement rather than inspection and this is achieved by facilitating and encouraging quality improvement through a supportive network of members and rigorous peer-review process. Membership benefits QNWA members benefit from having their service reviewed by expert acute inpatient colleagues and are also invited to attend tailored training events, special interest days and conferences. Some of the key benefits of being a QNWA member are listed below: The QNWA discussion group currently has over 400 members, who can ask questions and share knowledge and examples of best practice. This is the mailing list which is used to keep members up to date about upcoming training, peer reviews, special interest days and events, etc. Members also have exclusive access to Knowledge Hub – an online group to connect, network and share knowledge. One of the main benefits of being a QNWA member is being able to visit and peer-review other member wards. If staff wish to attend peer-review visits, they must first attend a peer-reviewer training session. These are free to attend and take place online every two months. Once trained, staff will have the opportunity to visit acute inpatient mental health wards across the UK; this is an excellent opportunity for professional development, to contribute to the peer-review process, and to facilitate networking and the sharing of best practice. The Network aims to hold 1–2 special interest days per year on a range of topics suggested by our members. Additionally, the Network holds an annual forum, with speakers, workshops and poster presentations. All QNWA members receive up to two free places to attend online events; face-to-face events are offered at a subsidised rate. Contact us If you are interested in becoming a member or would like to know more, please contact the QNWA team at QNWA@rcpsych.ac.uk
  3. Content Article
    NatSSIPs2 consists of two inter-related sets of standards: The organisational standards are clear expectations of what Trusts and external bodies should do to support teams to deliver safe invasive care. The sequential standards are the procedural steps that should be taken where appropriate by individuals and teams, for every patient undergoing an invasive procedure. The NatSSIPs2 have evolved to have less emphasis on tick boxes or rare ‘Never Events’ and now include cautions, priorities and a clear concept of proportionate checks based on risk. We recognise that ‘teams’ change or may be newly formed on the day of a procedure, and therefore require clear processes. NatSSIPs2 should form the basis of improvement work, inspections and curricula. Key principles in NatSSIPs2 include: The concept that NatSSIPs2 will help achieve of the triple goals of improved patient safety, better team-working and enhanced efficiency. The categorisation of invasive procedures into major or minor procedures, each requiring different checks which are proportionate to the risk of harm. The benefit of ‘Standardisation, Harmonisation, and Education’ across invasive specialty processes. The need to consider human factors with systems thinking, culture, psychological safety and team-work to underpin NatSSIPs2 implementation. An update of the WHO Five steps to safer surgery of Team Brief, Sign In, Time Out, Sign Out and Handover/Debrief to include three more steps to make the Sequential Standards (Steps): Consent and Procedural verification; Safe use of implants; and Reconciliation of items (to prevent retained foreign objects). ‘The NatSSIPs Eight’ should be in place for every relevant patient. That checks performed by an engaged team enable communication and save misunderstandings, reduce risk, provide clarity and set expectations The central role of the patient as a participant in safety checks. The need for a learning safety system supported by insight, involvement and improvement. A structure of People, Processes and Performance within the organisational standards The requirement for adequately resourced organisational leadership and support for safety. The NatSSIPs2 have been written by practising clinicians, from across the four UK nations, across disciplines, professions and organisations, with patient and organisational input and published by the Centre for Perioperative Care. They incorporate safety science and learning from all UK nations’ patient safety strategies and major reports and investigations. Are you a healthcare professional interested in learning more about NatSIPPs? On the hub we host the National NatSIPPs Network, a voluntary group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. You can join by signing up to the hub today. When putting in your details, please tick ‘National NatSIPPs Network’ in the ‘Join a private group’ section’. If you are already a member of the hub, please email hello@patientsafetylearning.org.
  4. Content Article
    At Patient Safety Learning we seek to harness the knowledge, insights, enthusiasm and commitment of health and social care organisations, professionals and patients for system-wide change and the reduction of avoidable harm. The scale of this challenge remains immense. Each year, millions of patients suffer injuries or die because of avoidable harm in healthcare. The World Health Organization (WHO) states that in high-income countries 1 in every 10 patients is harmed when receiving hospital care.[1] In the UK, the NHS pre-Covid estimate was that there were around 11,000 avoidable deaths annually due to safety concerns, with thousands more patients seriously harmed.[2] In 2022 we have seen positive new patient safety initiatives, such as the launch of the NHS Patient Safety Incident Response Framework (PSIRF), the creation of a Patient Safety Commissioner for England and efforts to increase awareness of medication safety issues as part of this year’s World Patient Safety Day. However, much more work is needed to tackle the complex systemic causes that result in the persistence of avoidable harm in health and social care. More inquiries, but are lessons being learnt? This year we have seen two new major reports that detail more shocking cases of avoidable harm in maternal and neonatal care in the NHS. In March the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published its final report, which made a range of recommendations for improving care and safety in maternity services across England.[3] Subsequently, in October the report of the investigation into maternity and neonatal services at East Kent Hospitals NHS Trust was published, revealing a series of serious patient safety failings at the Trust between 2009-2020.[4] Added to this, there is now an ongoing review into maternity services in Nottingham, which could prove to be the largest maternity scandal to date, exceeding 1,500 cases.[5] The findings of these inquiries echo concerns highlighted in many reports in the last decade. Time and time again we see the same themes emerging – the failure to listen to patients; a corrosive blame culture and the lack of an effective regulation and organisational leadership and governance.[6] At Patient Safety Learning, we believe that the Department of Health and Social Care and NHS England need to recognise these system-wide issues and consider them in their wider context – not simply issue individual responses to each new report with a commitment to ‘learn lessons’. There also needs to be a more rigorous approach to ensuring that the recommendations of these inquiries and reviews are implemented. In our report ‘Mind the implementation gap’, published earlier this year, we make the case that there needs to be transparent performance monitoring of the implementation of recommendations to ensure that these actions are translated into evidenced patient safety improvement.[7] Implementing the NHS Patient Safety Strategy NHS England has initiated a number of new activities in 2022 as it continues to implement the NHS Patient Safety Strategy. The most noteworthy has been the publication of detailed guidance for the new Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s new approach to developing and maintaining effective systems and processes for the purpose of learning from patient safety incidents. All organisations are expected to transition to this by Autumn 2023. This is a potentially very significant change in approach and culture and over the past 12 months we have shared a range of resources in relation to this, including: Patient Safety Management Network discussions about the new systems-based approaches to learning. Examples of the application PSIRF, such as in relation to pressure ulcers. An interview with Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England. There has also been ongoing work to develop and rollout the Learn From Patient Safety Events (LFPSE) service, a new national incident reporting system for the NHS. In the latter half of this year, specialist staff working in patient safety and local risk management system leads have raised with us concerns about the development and implementation of LFPSE. Many have said that they did not feel they were being listened to and we have supported them in highlighting their concerns with NHS England. Subsequently, in recognition of these concerns, there has been changes made to the taxonomy requirements for the new system and an extension of the implementation deadline from March to September 2023. July 2023 marks four years since the publication of the NHS Patient Safety Strategy. Over the next year we will be looking more closely at the implementation of this to date, considering where progress has been made and where improvement is required. Highlighting topical patient safety issues Over the course of the past year, we have continued to use the hub to share learning and campaign for improvements in patient safety. Throughout the year we have continued to highlight topical patient safety issues, both directly and through shining a light on the work of others, including: Kath Sansom highlighting 10 problems with NHS England’s specialist mesh centres. The risks posed to patient safety by rejected GP referrals for investigations and outpatient treatment. The Surviving in Scrubs campaign to call out the sexist and misogynist culture within healthcare. Concerns about the ability of staff to speak up on patient safety concerns, reflected in the results of this year's NHS Staff Survey. Hope Virgo pointing to the need to confront barriers to accessing support in the healthcare system for people with eating disorders. A doctor examining the link between Covid-19 and cardiovascular disease. Keith Conradi setting out why healthcare needs to operate as a safety management system. We also launched our Patient Safety Spotlight interview series this year, interviewing staff and patients working to improve patient safety, about their role and what motivates them. You can read all the interviews so far on the hub. Safety for All campaign Patient Safety Learning has been working in partnership with the Safer Healthcare and Biosafety Network on several different activities in 2022 as part of the Safety for All campaign. This campaign highlights how poor staff safety standards and practice impact adversely on patient safety and vice versa. It promotes the need for a systematic and integrated approach to improve safety practice for staff and patients across the health and social care so that the sum is greater than the parts. As part of this we have: Published the report ‘Mind the implementation gap: The persistence of avoidable harm in the NHS’, which calls for system-wide action in healthcare to transform our approach to learning and improvement. Held a Parliamentary reception on the 29 June, hosted by Dean Russell MP, where we launched a new good practice support guide for staff involved in serious safety incidents. Held a Conference on 7 December at the Royal College of Physicians with a range of panel sessions and speakers, including the new Patient Safety Commissioner for England, Dr Henrietta Hughes. We will be sharing resources from our recent Conference and undertaking more work as part of this campaign in the new year. Patient safety standards We consider that one of the primary reasons for the persistence of avoidable harm is that healthcare does not have or apply standards for patient safety in the way that it does for other safety issues. The standards it does have are insufficient and inconsistent. We believe that by adopting and implementing comprehensive patient safety standards, organisations will be able to deliver safer care and embed a commitment to patient safety throughout their work. This would also enable patients, leaders, clinicians, the wider public and regulators to assess their progress and performance in improving patient safety. Based on our original research and policy document ‘A Blueprint for Action’, Patient Safety Learning has developed a set of unique patient safety standards centred around seven key foundations for patient safety:[8] Leadership and governance Culture Shared learning Professionalisation of patient safety Patient engagement Data and insight Delivery of patient safety services. The seven foundations are supported by 26 specific patient safety aims. In total, there are 144 identified standards, based on 20 years of research, as well as learning from inquiries, policy, and good practice from healthcare. This year we have begun working with several organisations to implement these standards as part of their organisational safety improvement strategies and will be taking this work forward in the new year. You can read more about our patient safety standards on our website. Continued growth of the hub This October the hub, our free award-winning platform for patient safety, officially turned three years old. To date, the hub has received over 565,000 visits and had over 1.1 million page views. It now has over 3,300 members from 80 countries working in over 1,000 different organisations, and offers 7,500 knowledge resources, viewed by people from 221 countries. In addition to the rich content of patient safety topics, some of which we mentioned earlier in the blog, this year we have also seen significant growth in our community networks. The Patient Safety Management Network – an informal voluntary network created by and for patient safety managers – continues to go from strength to strength, providing a weekly drop-in session with guests to talk through issues of importance, offering peer support and creating a safe space for discussion. This now has over 800 members. the hub also now hosts the National NatSSIPs Network, a group of over 400 UK healthcare professionals involved in the implementation of NatSSIPs/LocSSIPs in their organisation. If you are interested in joining one of the networks or would like to set up your own network on the hub, please do get in touch at info@pslhub.org. Looking forward to 2023 This has been another seriously challenging year in health and social care. While many of the restrictions associated with the Covid-19 pandemic have been scaled back, infections from the disease remain a serious issue and healthcare systems across the world are continuing to deal with the strains and pressures both created and exacerbated by the pandemic. Going into the new year we will continue to be an independent voice speaking up for patient safety and seek to work in partnership with others to share learning and create safer healthcare. References WHO, 10 facts on patient safety, 26 August 2019. NHS England, The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients, July 2019. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. The Independent, NHS could face biggest maternity scandal ever as Nottingham probe expected to exceed 1,500 cases, 30 November 2022. Patient Safety Learning, Will lessons be learned? An analysis of systemic failures in the East Kent maternity report, 17 November 2022. Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, April 2022. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019.
  5. News Article
    The US Joint Commission will hold a safety briefing with healthcare organisations at the start of every accreditation survey starting in 2023, the organisation has said. Site surveyors and staff members preselected by the healthcare organisation will conduct an informal, five-minute briefing to discuss any potential safety concerns — such as fires, an active shooter scenario or other emergencies — and how surveyors should react if safety plans are implemented while they are on site. The change takes effect 1 January 2023 and applies to all accreditation surveys performed by the organisation. Read full story Source: Becker's Hospital Review, 13 December 2022
  6. Content Article
    Commissioned by the Department of Health and Social Care (DHSC) in February 2020, the Independent Investigation into East Kent Maternity services published its report last month highlighting patient safety failings in maternity and neonatal care services from 2009–2020 at two hospitals: Queen Elizabeth The Queen Mother Hospital at Margate and the William Harvey Hospital in Ashford. This is another devastating report detailing cases of serious avoidable harm and preventable deaths in the NHS, stating that it found that: “... those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.”[1] It is a harrowing read, with its findings echoing many of the problems we have seen highlighted in other maternity care inquiries and reports in recent years, such as the Morecambe Bay Investigation and the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.[2] [3] The aspects of this report specific to maternity and neonatal care have recently been explored in more detail by charities such as Sands, Tommy’s, Baby Lifeline and Birthrights.[4] [5] [6] [7] In this article, we will analyse this report from a broader patient safety perspective, focusing on five key themes that are consistent with many other serious patient safety inquiries and reports in recent years: Failing to listen to patients. Still not learning from investigations. Poor behaviour and a corrosive blame culture. Lack of effective leadership for patient safety. Absence of an effective regulatory framework. Having considered each of these issues in their wider context, we will then consider the recommendations made by this report, what we think needs to happen to prevent similar scandals in the future and the need for a fundamental transformation in our approach to patient safety. Failing to listen to patients A common theme that comes up repeatedly in inquiries and reports into serious patient safety failings is a failure to listen to patients when they raise concerns about care. At Patient Safety Learning we believe that patient engagement is key to improving patient safety and identify this as one of the six foundations of safer care in our report, A Blueprint for Action.[8] Patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. It is clear from the East Kent Maternity services investigation that too often this was not the case, with it stating that: “An overriding theme to have come from the listening sessions is the tendency of midwives and doctors to disregard the views of women. In fact, in a significant number of cases, the Panel found compelling evidence that women and their partners were simply not listened to when they expressed concern about their treatment in the days and hours leading up to the birth of their babies, their concerns often dismissed or ignored altogether. In at least some of these cases, the Panel was able to draw a connection between that failure to listen and an adverse outcome.”[1] The report highlights cases of patients being dismissed or ignored in a range of separate ways: being excluded and marginalised immediately after serious events, an unwillingness to engage with families in investigations, failures to explain risks and ensure patients were informed, and distressing incidents showing a basic lack of kindness and compassion. It also highlights that these issues only received full investigation thanks to the tenacious campaigning efforts of patients and family members themselves, noting that: “In common with other investigations, the trigger for regulatory scrutiny and the commissioning of this Independent Investigation came from individual families who had been failed by the Trust. It was their persistence and determination to get to the truth that has led us to where we are now. It is disappointing that families continue to have to do this to substitute for ineffective safety monitoring by trusts and regulators.”[1] There are no detailed recommendations in the report relating to improvements in this area, apart from a proposal for the DHSC to consider “bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies”.[1] However, nationally this is acknowledged by the NHS as an area for improvement, with the importance of patient engagement and involvement set out in the NHS Patient Safety Strategy.[9] The NHS also published last year a new Framework for involving patients in patient safety to guide improvements in this area.[10] Although this includes a number of commendable ideas, translating these principles into practice remains the key challenge. This requires resources, commitment and a willingness to proactively seek the insights of those with lived experience to be successful. Healthcare needs to restore the trust of patients and families so they can be assured that safety is a core purpose with their voices and experience being heard and ensuring that lessons are learned and applied to prevent future harm. We are closely monitoring the implementation of the framework and await the subsequent evaluation of its impact on patients and families and safety improvement. Still not learning from investigations Patient safety incident investigations are an important source of patient safety learning, providing an opportunity to identify what went wrong and the actions needed to prevent a similar incident taking place in the future. However, too often in the NHS we still see examples of investigations not resulting in learning and improvement. This is a theme that also emerges from the East Kent Maternity services investigation, with it stating: “Safety investigations were often conducted narrowly and defensively, if at all, and not in a way designed to achieve learning. The instinct was to minimise what had happened and to provide false reassurance, rather than to acknowledge errors openly and to learn from them.”[1] The report noted that investigations could be inadequate, failing to identify where practice could be improved and that, as mentioned in the previous section, there was a reluctance to involve families in these processes. This problem is not specific to East Kent, with poor quality investigations also being a major theme in the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust published earlier this year. Describing the approach to root cause analysis (RCA) investigations at Shrewsbury and Telford, it said: “It also identified that there was no culture of shared learning, that the RCAs often focused on the wrong issues, lacked system wide actions and focused instead on non-specific actions such as ‘share report widely’ and ‘learn from events’. There was no documentation that action plans were completed and recommendations often focused on individuals, rather than recommendations for system changes.”[3] There are no detailed recommendations in the East Kent report about the need for improvements in safety investigations. However, this issue was picked up in the review of maternity services at Shrewsbury and Telford as an area for improvement, with it emphasising that “families must be involved in the investigative process and that lessons must be learned and implemented in a timely way to prevent further tragedies”.[3] NHS England has also identified the need for improvement in patient safety investigations. This year they have published a new Patient Safety Incident Response Framework (PSIRF), setting out their approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.[11] This new framework makes a welcome acknowledgement of the importance of engaging patients and families as part of the investigation process and ensuring that investigations result in a clear understanding of the causal factors of harm and actions needed to deliver safety improvements. As with new initiatives around patient involvement, it is too early to say whether PSIRF will bring about significant changes to address the issue of poor-quality investigations highlighted in both the East Kent and Shrewsbury and Telford reports. It proposes a complex innovation in the NHS’s approach to incident investigation and review. We believe that its success will depend on having the right leadership and resources to support this transition, enabling organisations to move towards a learning culture with quality improvements designed and implemented to prevent future harm. This should ultimately be the judge of PSIRF’s success. Poor behaviour and a corrosive blame culture It is vital that organisations have an open and fair culture that enables patient safety issues to be raised, discussed and addressed. However, the presence of a blame culture, which results in people covering up errors that lead to avoidable harm rather than report them, comes up as a consistent theme in major patient safety scandals. This has been highlighted in the Mid-Staffordshire Inquiry in 2013, the Independent Medicines and Medical Devices Safety Review in 2020 and most recently in the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust.[12] [13] [3] This is also a key concern in the East Kent Maternity services investigation. The report notes that a poor culture existed between obstetricians and midwives at the Trust, that there was a fear of speaking up about patient safety issues, a reluctance to listen to staff concerns and a bullying and blame culture when things went wrong. It appears that some of these issues were recognised internally at the Trust, but that efforts to tackle this proved ineffective: “The Panel was told that there were “about three” cultural change programmes at the Trust that failed because of a lack of direction and leadership, and that the Trust paid lip service to cultural change but this was not sufficient. There was not enough commitment or engagement from leaders of the organisation.”[1] “A consultant told the Panel: “The Trust thinks if you send someone on a three-day training course in human factors, that their personality will change forever but that’s not going to happen.” Another clinician expressed having limited confidence in the behaviour and competence of certain obstetricians.”[1] Poor behaviour was not restricted to clinicians but also seen at senior leadership and governance levels too: “The Panel further heard of poor behaviours of non-executive directors at the Trust Quality and Safety Committee: “The behaviour of the non-executive directors was appalling, rude, bullying. It was shameful.”[1] In our report published earlier this year, Mind the implementation gap: The persistence of avoidable harm in the NHS, we highlighted that despite similar issues of blame culture coming up in multiple patient safety scandals over the past 20 years, currently the NHS still only has an outline of proposed activity to tackle this problem.[14] The importance of having a just culture that supports patient safety is highlighted as a key aim of the NHS Patient Safety Strategy, and since the publication of the East Kent report the National Patient Safety Team has recently published new examples of good practice in this area.[15] However, three years into the Strategy we are yet to see more specific and robust measures proposed to address this. For instance, there are no specific proposals around organisations publishing and reporting on goals to change culture or steps for intervention when poor behaviours are identified. This is not an issue limited to Trusts with serious patient safety scandals. The results of the NHS Staff Survey over the last three years show that too many staff still do not feel safe to speak up about errors, patient safety incidents and near misses.[16] [17] [18] Disappointingly, this report makes no recommendations on this issue, perhaps considering it beyond the scope of the investigation. However, Patient Safety Learning believes that this is a theme that must be considered a high priority in the DHSC’s response to this report. Lack of effective leadership for patient safety Issues around organisational culture, as highlighted above, are interlinked with the importance of leadership for patient safety. Good leadership can drive patient safety performance, support learning from unsafe care and put in place clear governance processes to enable this. It is another of the six foundations of safer care identified in our report, A Blueprint for Action. The East Kent Maternity services investigation consistently highlights a failure at a leadership level to identify and prevent avoidable harm to patients and deaths at the Trust, including: Governance structures that were “not sufficiently robust to allow assurance from ward to Board”.[1] An impression by regulators that the Trust did not actively look for problems and issues to be resolved but waited for them to be pointed out. Poor Board relationships between the executive and non-executive directors. Lack of external benchmarking of performance and serious incidents. The report makes two specific recommendations in relation to these issues: Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards. NHS England reconsider its approach to poorly performing trusts, with particular reference to leadership. We support both these recommendations. However, we also believe that further urgent action is needed by the DHSC and NHS in relation to the report’s leadership findings, which have much in common with other recent inquiries and reports into serious patient safety failings. We believe that there needs to be a more effective leadership and governance for patient safety in both the NHS and independent sector. There should be high standards and behaviours set for our leaders and they should be supported by specialist patient safety, organisational development and governance experts. As with the other key themes considered here, this is not a blank slate that requires new research and analysis. A useful starting point would be for the DHSC and NHS England to revisit the recommendations of the review of the Fit and Proper Person Test by Tom Kark QC and Jane Russell, published in 2019, which in its first recommendation called for: “All directors (executive, non-executive and interim) should meet specified standards of competence to sit on the board of any health providing organisation. Where necessary, training should be available.”[19] Organisations also need clear and published goals for patient safety with Board focus and effective oversight on reducing patient harm. A key part of our work around the development of patient safety standards for healthcare organisations is focused on strengthening patient safety leadership and governance in organisations as an integral part of a safety management systems approach (read more about this in the next section). Absence of an effective regulatory framework The East Kent Maternity services investigation gives a significant amount of attention to the Trust’s relationship with regulators during this period. The picture it paints is one of a system failing to act quickly or effectively in response to serious patient safety concerns, stating: “We have found that the Trust was faced with a bewildering array of regulatory and supervisory bodies, but the system as a whole failed to identify the shortcomings early enough and clearly enough to ensure that real improvement followed.”[1] The Trust was overseen by a range of different organisations, including: Care Quality Commission General Medical Council Its local Clinical Commissioning Group Healthcare Safety Investigation Branch Monitor (former NHS regulator whose functions are now part of NHS England) NHS England Nursing and Midwifery Council Royal College of Obstetricians and Gynaecologists Royal College of Midwives The report suggested that “the plethora of regulators and others served to deflect the Trust into managing those relationships and away from its own responsibility”.[1] As with the other themes highlighted in this article, these concerns about the effectiveness of the regulatory framework are not a new issue. In a 2018 report, Opening the door to change, the CQC described the current system as “confused and complex, with no clear understanding of how it is organised and who is responsible for what”.[20] Similar issues have also been highlighted in reports and inquiries such as the independent inquiry into the issues raised by Paterson and the Independent Medicines and Medical Devices Safety Review.[21] [3] The Professional Standards Authority for Health and Social Care (PSA) have also recently discussed this in their report Safer Care for All, stating: “Large-scale failures of care still occur frequently, and inquiries and reviews highlight similar themes and issues, with the system seemingly unable to prevent their recurrence. Each body looks at the problems principally through the lens of its own remit, often prejudging the nature of the solutions as a result. We need a new framework focused on safety that spans organisational and sectoral boundaries.”[22] The East Kent report makes no specific recommendations about these system-level failures. However, Patient Safety Learning believes this is another issue the DHSC must consider as part of their response to this report. We need a joined-up and effective regulatory framework for patient safety that identifies problems at an early stage and facilitates and coordinates interventions and improvements. Report recommendations Now turning to the East Kent Report’s recommendations, in his introduction Dr Bill Kirkup states that he has opted not to make a series of specific policy recommendations. Setting out the rationale for this, the report states: “NHS trusts already have many recommendations and action plans resulting from previous initiatives and investigations, and we have no desire to add to their burden with further detailed recommendations that would inevitably repeat those made previously, or conflict with them, or both. We take those previous recommendations and the resulting policy initiatives as a given."[1] Instead, it sets out four broad areas describing the deep-rooted reform required to address the issues highlighted in the report. These are summarised below: Creating a Task Force to drive the introduction of valid maternity and neonatal outcome measures for mandatory national use. Reports to be commissioned on how compassionate care can best be embedded into practice and sustained through lifelong learning, alongside commissioning reports considering the oversight of clinicians, with national agreed standards of professional behaviour and sanctions for non-compliance. Reports to be commissioned on how teamworking in maternity and neonatal care can be improved and how this can be supported in the employment and training of junior doctors. Considering a new Government bill which would place a duty on public bodies not to deny, deflect or conceal information from families and other bodies. Alongside this, Trusts should be required to review their approach to reputation management, ensure there is maternity care representation on their Boards and for NHS England to reconsider its approach to poorly performing Trusts. Action needed for a systems approach to patient safety We support these recommendations, but also note the concern highlighted by Dr Kirkup about the effectiveness of inquiry recommendations in reducing avoidable harm. He states that: “… this approach has been tried by almost every investigation in the five decades since the Inquiry into Ely Hospital, Cardiff, in 1967–69, and it does not work. At least, it does not work in preventing the recurrence of remarkably similar sets of problems in other places.”[1] We concur with the disheartening sentiment. As set out in our report earlier this year, Mind the implementation gap, such recommendations are often eagerly received, with associated commitments to learn lessons from the past, but their implementation remains inadequate and patchy and their impact left unmonitored and often unevaluated. However, as we make clear in this article, there are several overarching patient safety themes which the East Kent Maternity service investigation raises, in common with previous patient safety inquiries and reports, where there is a clear need for action. Some of these are not covered by the East Kent report’s recommendations. Given that these are system-wide issues, not specific to one specialism or type of trust, we believe that the DHSC response to this report needs to consider these in their wider context, and account for the broader trends from reports and inquiries from the last 20 years. We need a holistic and joined up approach to these issues – not simply another commitment to ‘learn lessons’ without the necessary follow through. As recently discussed in more detail in an interview with Keith Conradi on the hub, a key element of this is learning from other high-risk industries and moving towards the creation of a safety management system in healthcare, which he describes as follows: “The basics of any safety management system is to have safety objectives, so you set out what you want to achieve. This requires assessment of the hazards and risks and the mitigation to those risks and these need to be transparent. You need an assurance process that constantly monitors the safety performance of the organisation and investigates incidents when they occur. This in turn will drive learning which will further improve safety and crucially embed a safety culture amongst all staff. All of this needs to be recognised at Board level, continually stretching the organisation’s safety objectives."[23] While the NHS Patient Safety Strategy talks about moving towards “a patient safety system, across all settings of care”, in our view there is currently no overlapping approach to this and this needs to be urgently addressed.[9] At Patient Safety Learning we believe that the persistence of avoidable harm is the result of our failure to address complex systemic causes. In our report A Blueprint for Action we identify six foundations of safer care for patients and practical actions to address them.[8] Central to this is the need for a transformation in our approach to patient safety, ensuring that this is treated as a core purpose of health and social care, not one of several competing strategic priorities to be traded off against each other. Patient safety needs to be seen as everyone’s responsibility, from the DHSC, policy makers, patient safety experts, system and professional regulators, leaders, those developing and providing guidance on good practice, academics and to individual healthcare professionals. We need to operate as an effective Safety Management System with everyone working in partnership, aligned with patient safety at the core. References Independent Investigation into East Kent Maternity Services, Maternity and neonatal services in East Kent – the Report of the Independent Investigation, 19 October 2022. Dr Bill Kirkup CBE, The Report of the Morecambe Bay Investigation, March 2015. Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust, Ockenden Report: Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury and Telford Hospital NHS Trust, 30 March 2022. Sands and Tommy’s Joint Policy Unit, Responding to the independent report on East Kent maternity and neonatal services, 19 October 2022. Sands and Tommy’s Joint Policy Unit, We need a renewed approach to improving the safety of maternity services, 21 October 2022. Baby Lifeline, The East Kent Report: In summary, 19 October 2022. Birthrights, Birthrights responds to the independent investigation into East Kent maternity services, 2 November 2022. Patient Safety Learning, The Patient-Safe Future: A Blueprint for Action, 2019. NHS England, The NHS Patient Safety Strategy, 2019. NHS England and NHS Improvement, Framework for involving patients in patient safety, 29 June 2021. NHS England, Patient Safety Incident Response Framework, Last Accessed 8 November 2022. The Mid Staffordshire NHS Foundation Trust Public Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, 6 February 2013. The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, April 2022. NHS England, Safety Culture: learning from best practice, 15 November 2022. Patient Safety Learning, Results of the NHS Staff Survey 2019, 18 February 2020. Patient Safety Learning, Tackling the blame culture? NHS Staff Survey Results 2020, 22 March 2021. Patient Safety Learning, Safe to Speak up? NHS Staff Survey Results 2021, 31 March 2022. Tom Kark QC and Jane Russell, A review of the Fit and Proper Person Test, 6 February 2019. CQC, Opening the door to change: NHS safety culture and the need for transformation, 2018. The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. PSA, Safer care for all – solutions from professional regulation and beyond, 6 September 2022. Patient Safety Learning, Why healthcare needs to operate as a safety management system: In conversation with Keith Conradi, 24 October 2022
  7. News Article
    The World Health Organization (WHO) announces that the Ministry of Food and Drug Safety, Republic of Korea, has achieved maturity level four (ML4), the highest level in WHO’s classification of regulatory authorities for medical products. WHO has formally assessed the medical product regulatory authorities of 33 countries, of which only the Republic of Korea is listed as attaining this level in regulation for both locally produced as well as imported medicines and vaccines. This achievement represents an important milestone for the Republic of Korea and for the world, signifying that the Ministry of Food and Drug Safety (MFDS), the national regulatory authority for medicines and vaccines, is operating at an advanced level of performance with continuous improvement Only about 30% of the world’s regulatory authorities have the capacity to ensure medicines, vaccines and other health products are produced to required standards, work as intended and do not harm patients. WHO’s benchmarking efforts identify regulatory authorities that are operating at an advanced level so that they can act as a reference point for regulatory authorities that lack the resources to perform all necessary regulatory functions, or which have not yet reached higher maturity levels for medical product oversight. “This is a great testament for Republic of Korea’s commitment for ensuring safe and effective medicines and vaccines, and investing in building a strong regulatory system,” said Dr Mariângela Simão, Assistant Director-General, Access to Medicines and Health Products. “We hope the achievement will be sustained and also help promote confidence, trust and further reliance on national authorities attaining this high level”. Read full story Source: WHO, 29 November 2022
  8. Content Article
    This document has been developed to support providers of mental health inpatient services that are considering, actively implementing, or who are already advanced in use of vision-based patient monitoring systems (VBPMS) to create or update their protocols, policies, and governance arrangements to support safe use for the benefit of patients and staff. Its aim is to support individual healthcare providing organisations in their current or future use of VBPMS to standardise implementation approaches across the country and provide a platform for sharing learning. Particular attention has been paid to recommendations that underpin governance of the system in addition to its safe, effective, and ethical use. Recommendations from the document should be used at the discretion of each organisation to fit their specific needs and local circumstances.
  9. Content Article
    Best Practice Statements include: Holistic management on venous leg ulceration Active treatment of non-healing wounds in the community Addressing skin tone bias in wound care: Assessing signs and symptoms in people with dark skin tones Care of the person with diabetes and lower leg ulcers Post operative wound care: reducing the risk of surgical site infection You can access all of the Best Practice Statements via the link below.
  10. Content Article
    The College has established a Safer Care Committee which is undertaking the following: Developing and disseminating patient safety and risk management strategies for the speciality of Emergency Medicine. Advising and collaborating with NRLS, NICE, DH, CQC, the Royal Colleges and other national bodies who have an interest in risk management and patient safety in Emergency Departments. Developing and identifying resources for patient safety. Informing Fellows and Members of patient safety research, key publications and resources. Reviewing of significant incident reports in Emergency Medicine. To see the terms of reference and committee members e-mail safety@rcem.ac.uk.
  11. Content Article
    Dashboards include: Restrictive Practice - CAMHS Low Secure Restrictive Practice - CAMHS Medium Secure Restrictive Practice - CAMHS PICU Restrictive Practice - CAMHS T4 Restrictive Practice - D/deaf (Adults) Restrictive Practice - D/deaf CAMHS Restrictive Practice - Eating Disorders (Adults) Restrictive Practice - High Secure (Adults) Restrictive Practice - Low Secure (Adults) Restrictive Practice - Medium Secure (Adults) Restrictive Practice - Obsessive Compulsive Disorder and Body Dysmorphic Disorder Service Restrictive Practice - Perinatal Restrictive Practice - Tier 4 Personality Disorder
  12. Event
    The NHS Patient Safety Conference, in partnership with Patient Safety Learning, is a long-standing virtual and in-person event series that has welcomed over 1500 NHS professionals through its doors. In February 2021, further updates and changes were made to the NHS Patient Safety Strategy. The most significant strategy update is the new commitment to address patient safety inequalities, with a new objective added to the safety system strand of the strategy. This event series provides a timely platform to discuss these changes. Key event topics are run across 3 key pillars: Insight Adopt and promote fundamental safety measurement principles and use culture metrics to better understand how safe care is. Use new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. Introduce the Patient Safety Incident Response Framework to improve the response to an investigation of incidents and implement a new medical examiner system to scrutinise deaths. Improve the response to new and emerging risks, supported by the new National Patient Safety Alerts Committee Share an insight from litigation to prevent harm. Involvement Establish principles and expectations for the involvement of patients, families, carers, and other lay people in providing safer care. Create the first system-wide and consistent patient safety syllabus, training, and education framework for the NHS. Establish patient safety specialists to lead safety improvement across the system. Ensure people are equipped to learn from what goes well as well as to respond appropriately to things going wrong. Ensure the whole healthcare system is involved in the safety agenda. Improvement Deliver the National Patient Safety Improvement Programme, building on the existing focus on preventing avoidable deterioration and adopting and spreading safety interventions. Deliver the Maternity and Neonatal Safety Improvement Programme to support a reduction in stillbirth, neonatal and maternal death, and neonatal asphyxia brain injury by 50% by 2025. Develop the Medicines Safety Improvement Programme to increase the safety of those areas of medication use currently considered the highest risk. Deliver a Mental Health Safety Improvement Programme to tackle priority areas, including restrictive practice and sexual safety. Work with partners across the NHS to support safety improvement in priority areas such as the safety of older people, the safety of those with learning disabilities and the continuing threat of antimicrobial resistance. Work to ensure research and innovation support safety improvement. All organisations are committed to patient safety, but how do leaders ensure that they’re doing all they can to deliver safe and effective care? Join Dr Sanjiv Sharma, Executive Medical Director at Great Ormand Street Hospital for Children, and Helen Hughes, Chief Executive of Patient Safety Learning for a presentation at 9.05am. Dr Sharma will outline their ambitious patient safety transformation journey, how they are designing and delivering an innovative safety systems approach. Embedding Patient Safety Learning’s new standards for patient safety, hear how GOSH’s self assessment has informed the development of prioritised action plans, strengthened governance and leadership engagement and cross organisation collaboration. Helen Hughes, Chief Executive of Patient Safety Learning, will outline why a standards based approach to patient safety is needed and the benefits it can bring. Register
  13. Content Article
    The standards cover the following areas of care and treatment: Organisation of care Primary care Health and wellbeing Acute and chronic pain Neurological complications Cardiorespiratory complications Renal and urological complications Priapism Fever and sepsis Orthopaedic complications Gastroenterological and hepatobiliary complications Ophthalmological complications Anaemia Leg ulcerations Outpatient management Reproductive health Surgery Hydroxycarbamide Blood transfusion Iron chelation Haematopoietic stem cell transplantation Emerging therapies
  14. Content Article
    Findings Most hospitals are delivering good quality care and looking after patients well. The CQC report highlighted many examples of how hospitals are improving and continuing to improve the quality of care they offer, even though there are constraints. CQC encourages trusts to follow this good practice to improve their own services. But it also found that some trusts have blind spots about the quality of care they are delivering in a particular core service, even in some trusts rated good overall. All hospitals told us that patient safety was their top priority, but too often they did not have an effective safety culture or reliable systems to ensure this. Many of the inefficiencies we saw can be avoided, such as hospital acquired infections, or are caused by poorly coordinated care. The overarching message from CQC's inspections is that effective leadership delivers high-quality care. In hospitals rated good or outstanding, the trust boards had worked hard to create a culture where staff felt valued and empowered to suggest improvements and question poor practice. Where the culture was based around the needs and safety of patients, staff at all levels understood their role in making sure that patients were always put first.