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In the late eighties, I attended a presentation on the future of the UK Medtech sector presented on behalf of the government by KPMG. The main message being the government’s desire for the industry to focus on research and development whilst transferring manufacturing to China! What relevance does this have to patient safety? Fast forward some twenty years and I am presenting the case for adoption of one of our most successful unique patented patient safety products (successful global use at this point around the 5 million patient level) to one of the largest NHS trusts. The difficulties faced by industry The trust we presented to operates a clear policy that industry should not even provide literature on products to any clinician unless procurement permission is given. We complied with this policy and were invited in to present after an anaesthetist had highlighted that the trust had experienced patient injury from the current standard practice of using rolls of tape to secure patients' eyes during anaesthesia to protect from hazards and prevent the eyes from drying out causing potentially serious harm. Our product literature carries an endorsement from the Association of Perioperative Practice who clearly state that the practice of using tape to address these issues is “not recommended and that Eyepads fit for purpose should be used”. The meeting is attended by a man from procurement and a Sister from the trust with many years of experience in her role. I present the product case and pass samples to the Sister. Within a minute of handling the product she dismisses the product as “expensive nonsense”! The man from procurement proclaims the session over and we part company. The anaesthetist that initiated the meeting was not present and was not allowed to take her desire to try our solution any further. This story is reflective of not only our experience but typical of the path we and other Medtech companies encounter in attempting to introduce new innovative patented solutions to the NHS UK companies. The drive towards ever cheaper manufacturing adoption by the NHS is led by NHS supply chain, dominating the tendering market for products with multiple manufacturing sources. The NHS is now globally recognised as a procurement-driven market, focussed on reducing costs through purchasing and negotiating lower pricing. An organisation that issues “zero inflation pricing increase” policies. This can be very effective and is certainly a major driving factor in the success of the multitude of Chinese manufacturing companies supplying the NHS. A market that has produced a multitude of failed schemes for the adoption of new technologies in favour of sourcing ever cheaper, often poor quality products. But we did not jump on that bandwagon and instead chose to continue working with the best patented technological solutions emerging. We recently had the pleasure of working with Helen Hughes and Patient Safety Learning on a webinar presenting one such product. We introduced this product over a year ago and immediately engaged with the latest NHS Accelerated Access Collaborative innovation adoption scheme. In the webinar I described how this and all of our other efforts had failed to make any serious impact other than producing great results with a small band of community health nurses. Then COVID-19 strikes and almost overnight procurement is bypassed. There is a priority in addressing shortages of products perceived as vital in maintaining care levels in the impending increased demand due to COVID-19. This leads to the successful sale of several hundred of our units. However, when the government moves to address the issue through large scale purchase of the product, our solution is dismissed and offered no part of the contracts awarded in a process that was uncannily like the experience described above. A culture of cost cutting and fear Management of the NHS is an enormous undertaking. However, I would suggest that many years of focus on cost cutting has delivered a culture of fear and apathy toward the adoption of the amazing new technologies that can transform care. The plethora of schemes for innovation adoption that we have engaged with over the years have failed, often at the outset, simply due to inadequate funding and planning. During this period industry has also had to bear the substantial increased costs of product and staff regulatory changes. When I engage with some of these schemes, I cannot understand why there are so many companies in the mix pitching products and services that have nothing to do with healthcare, but offer instead procurement or management “more efficient management” tools! Some trusts appear to be more concerned with this aspect than the actual delivery of healthcare. One trust insists that we supply our products through a third-party purchase company because the product they buy is not listed on NHS supply chain. They have now ceased to order after the third-party supplier entered administration, owing us several thousand pounds! In November we will launch a new patented product with patient safety benefits, invented by two operating department practitioners (OPDs) in Liverpool. We will manufacture the product in the UK and manage global marketing from the UK. However, we are currently focused on marketing the product overseas; engaging with NHS procurement is not a priority. I know other companies have that same view. It’s recognised that efficient procurement is an important element of NHS management, largely developed from the political direction in the Eighties on cheaper globalised manufacturing policies. Unfortunately, whilst to some degree it has been very successful in cutting costs, patient and staff safety has on occasion been compromised. There is now a culture of cost cutting with procurement completely focused on this. Call for action NHS adoption of new beneficial technologies is woefully inadequate and remains largely under the control of procurement services often disinterested in it and unqualified to manage it. For patient and staff safety to benefit, I would like to see: Simplified fast-tracked product assessment procedures managed by appropriately qualified staff. The removal of products and services designed for healthcare management from the assessment of products directly involved in improving healthcare outcomes. Our current structures are simply not fit for this purpose.

This easy reference guide has been produced because: Some aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable. This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive. However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients. This is version 2 of the aide memoire, which includes additional advice on situations where providers can continue to safely use more complex local polices. Other changes were minor refinements of language and use of capital letters to emphasise application to checks before first use.

Key points: Outpatient hysteroscopy (OPH) is a procedure carried out in the outpatient clinic that involves examination of the inside of your uterus (womb) with a thin telescope. There are many reasons why you may be referred for OPH, such as to investigate and/or treat abnormal bleeding, to remove a polyp seen on a scan or to remove a coil with missing threads. The actual procedure usually takes 10-15 minutes. It can take longer if you are having any additional procedures. You may feel pain or discomfort during OPH. It is recommended that you take pain relief 1-2 hours before the appointment. If it is too painful, it is important to let your healthcare professional know as the procedure can be stopped at any time. You may choose to have the hysteroscopy under general anaesthetic. This will be done in an operating theatre, usually as a day case procedure. Possible risks with hysteroscopy include pain, feeling faint or sick, bleeding, infection and rarely uterine perforation (damage to the wall of the uterus). The risk of uterine perforation is lower during OPH than during hysteroscopy under general anaesthesia. Join the conversation on the hub about hysteroscopies.

This annual report, by the All-Party Parliamentary Thrombosis Group, recognises that the 2018 survey of Trusts and CCGs shows, like the year before, many areas of best practice and provision of written and verbal patient information are well established across the country. However, there is evidence of decline in a number of areas, even within those areas that have met their targets. While the NHS is facing a number of pressures across the organisation, including financial constraint and capacity issues, it is crucially important that VTE prevention and management remains a focus, particularly given the increasing rate of admissions and the rising elderly population. VTE risk assessment is an excellent way of helping to improve patient safety, while also lowering overall cost.

We have all heard of the terrible stories of nurses going to the coroner’s court. These stories have been fed to us by our seniors, our mentors, our lecturers since we were students. "If you don’t document properly, you will end up in the coroner’s court, you might even get struck off!" These stories strike the fear of god into you. No one wants to go to coroner’s court, no one wants to be criticised for the work they have spent years training to do. No one wants to be publicly humiliated. This is my story of what happened when I attended a coroner's hearing on a patient who was in my care. I was a band 6 at the time. It was a usual day on the medical ward. Busy. I had a bay of six patients. Three of them were fit for discharge, but no community placement for them to go to, two medical patients and one who was a surgical patient. The surgical patient was under the medics and the surgeons. He came with abdominal pain; he was waiting for a surgical review. Many patients are under numerous teams on the medical ward. One of my roles is to ensure that they get seen by each team every day to ensure a plan for treatment. Today was no different. The patient was seen by the medical team who said "await surgeons". I chase up the surgeons, but they are in theatre. From experience I know that they will be out of theatre by late afternoon – so hopefully I can catch them then. In the meantime, the surgical patient becomes unwell. His blood pressure drops, his NEWS of 5 from 0. He is tachycardic. I call the medics who attend – they want me to call the surgeons… no answer. Intensive care team arrive – to this day I’m not sure how they knew to come, perhaps one of the medics called them? The intensive care doctors I hear raging down the phone at a poor surgeon who is in theatre. The surgeon comes to the ward and soon realises the gravity of the situation. There are discussion that are being had away from the bedside – I’m not sure what was being said or plans that were being made. I was not part of the process. I’m busy doing observations every 5 minutes as requested, plus trying to look after my other five patients. All of a sudden we are going to theatre. I’m still unsure what’s going on. What’s he going there for? The patient looks really scared. I bet I look scared too! I help wheel him down to the operating theatre. As soon as we arrive in the anaesthetic room he has a cardiac arrest. We try and resuscitate him to no avail. I went back to the ward; bewildered, sweating from doing chest compressions, confused and with tears in my eyes. I have a quick cup of tea and I’m back out on the ward again. Three months later my manager asks to see me in the office. ‘What have I done wrong?’ When anyone asks for you to come to the office, its usually bad. They ask if remember the surgical patient who arrested a few weeks back. Of course, I do. I had been thinking about it ever since. I had been worrying about it. I felt it was my fault. They tell me that the case is going to the coroner's court and I was to be called as a witness. I cry. That’s me done then. I’m going to be struck off. I’m going to be found out that I am a rubbish nurse. My manager was amazing. They had experience in these hearings. They explained the whole process. From what would happen from now until the end of the hearing. That afternoon I was contacted by the Trust investigation team. They were lovely too. They asked me exactly what happened and help me write a statement. They put me at ease. It was made clear that what happened was not my fault and that they want to find out what happened to prevent it happening again. The next week or so I had contact with the Trust legal team. I had never spoken to a legal team before in my life. I did feel as if I was a criminal at first. The legal team were also brilliant. They spoke through the actual process; who was in the room, the layout of the room, what questions I might be asked, what the outcomes often are. They gave me advice on how to answer questions; answer what you know as fact, not opinion. If you don’t know, say you don’t know. Be honest. I had two further meetings with the legal team and the investigating team. This was to check I was ok, to make sure I was supported. For what could be an extremely stressful period of my career, was made so much easier by people taking the time out just to check I was ok. I carried on working throughout this period and working with confidence. The hearing came. I knew what to expect. I knew the layout of the room. I knew the patient’s relatives were in the front row, I knew I had to swear an oath, I knew I had support from my Trust. I was able to speak freely – even the bad bits; no covering up or making excuses for others. I was asked what happened that day. I was honest. I didn’t know what was going on. I didn’t know what was wrong with my patient. I was not used to caring for surgical patients. Admitting that I ‘didn’t know’ was awful. I should know, shouldn’t I? When I was saying this, I could feel the eyes of the patient's widow bore into me. I had let my patient down and I had failed. The coroner asked me many questions related to escalation of care to seniors, the policy, my adherence to the NEWS policy – to which I had followed. My part was over in a flash. The next was the surgeon, who got most of the grilling. Why was he not there, where was his documentation, why did he not come when asked repeatedly? It wasn’t his fault either. He was in theatre with another patient. He can’t be in two places at once. I felt really sorry for him. I hope he got the same support I did. The outcome of the hearing was to issue a regulation 28. This ensures that a report is sent to the government by the Trust as the coroner believes that action needs to be taken can to prevent future preventable deaths. So, what happened then? I went back to work and carried on as usual. The ward where I worked no longer takes surgical patients. They made a new unit called the ‘surgical assessment unit’ where surgical nurses care for this cohort of patients. I wanted to share this – yes, there are many issues surrounding this, but the point I wanted to get across is that the investigation team, my manager and the legal team supported me through this difficult time. I am not sure if other Trusts have this level of support for staff attending coroners court.

Five tips: People aren't machines Push the button Differeing shapes and sizes Stamina and repetition Look around

This is a template that can be used by health professionals carrying out medicines reconciliation.

The implementation of the SCORE survey had two objectives: Support teams across a wide range of health and care settings to improve their safety culture and quality of care. Increase the knowledge and understanding of the role safety culture plays in the delivery of high-quality care. Top tips for adoption: The approach concentrated on the quality of the process. Word of mouth and recommendation was key. Awareness-raising of safety culture regionally generated interest. Public and patient involvement should be part of the process. Some teams have involved patients in their debriefing or improvement planning.

What can I learn? This web page gives you information on: the friends and family test patient insight group an animation on how the quality framework works.

What can I learn? Practical guidance and examples of best practice in the design of infusion devices How design can be used to change and make safer the use of infusion devices in practice. Principles that can be widely applied to the design of other technologies

What can I learn? Patient experience remains the weakest of the three arms of quality; it doesn’t get the same attention as safety and clinical effectiveness and still tends to be seen as a nice add-on. This needs to change. Don’t measure, unless you’re willing and able to improve. Start small, but start. Don’t be focussed on the barriers. Measure well. Feedback responsibly, link it to improvement. Don’t worry about unleashing high patient expectations that can’t be met.

Prompt cards can be used by all members of the Emergency Department Team. If used correctly they will improve patient safety and reduce human factor errors. Prompt Card Version 3.0.pptx

My much loved daughter-in-law, Mariana Pinto, died on 16 October 2016. She was 32. Her tragic and unexpected death raised many questions for us about standard practice by psychiatric services and about patient safety. The evening before she died, Mariana was taken by ambulance to her local A&E department, escorted by four police officers, and handcuffed for her own safety. She was psychotic – delusional, paranoid, violent and very distressed. She had attacked her husband (my son) who had visible bite marks, scratches and bruises. It was a first episode and totally out of character. She had not eaten or slept for several days. In A&E she was brought food and drink but spat it out, believing it to be poisoned. She kept trying to escape from the cubicle. The police stayed, stating that she was extremely vulnerable. Eventually she agreed to take a sedative – but not before she had held it under her tongue for some time, and only after we, her family, were able to persuade her that she should take it. Once she was finally sedated, she was given various tests to rule out any physical cause, and a mental health act assessment. This was done with her and her husband together. There was no attempt to see him separately. She was deemed competent to make decisions about her care, and as she wanted to go home, was discharged, with a referral to the local Crisis Team, who we were told would receive the referral at 8 am the following morning and would arrange to visit. The psychiatric team operate within A&E but for a separate mental health trust. This same trust runs the Crisis Team. It is deemed outstanding by the Care Quality Commission (CQC). The following morning, there was no contact from the Crisis Team. My son rang them at midday to ask when they would visit. They said normally between 5 and 7 pm on Sundays and to ring back if he needed to. He rang back at 3.30 pm stating that she had deteriorated rapidly and asking for the visit to be brought forward. He was told that it could not be. At 4.00 pm Mari ran out of the open door to the roof terrace and jumped off it. She did not survive her injuries. The Coroner gave a narrative verdict, making it clear that Mariana did not know what she was doing, though her actions were deliberate. She also gave a Prevention of Future Deaths Report. Whilst the trust is obliged to reply, there is no statutory obligation to demonstrate that the actions they have promised have actually been taken. There was no attempt at any risk assessment. There was no attempt to check that my son could speak freely (he could not – it was a studio apartment). There was no attempt to call the emergency services on his behalf, and no attempt to check he had been able to do so. None of this is regarded as negligent or especially problematic. Since her death the Crisis Team do visit on Sunday mornings. We also found out that the number we were given to call was for service users already allocated a key worker, rather than a more general number – but as my son spoke to senior staff on each call, this should not have made a difference. After her death we raised the following questions: Surely given the bite marks and bruising, her husband should have been allowed to give his information to the psychiatric team separately? No, it turns out that while this would have been good practice, it was not negligent. Surely, given that her family knew and loved her, we should have been asked post sedation if she seemed like herself (she did not). No, it turns out that this is not seen as necessary. It’s not even regarded as good practice. Surely, given that she was paranoid and had told the police that she did not trust her husband, her husband should have been given private space to discuss the discharge and rehearse what to do if things went wrong once the sedative wore off? And surely we should have been told that the Crisis Team is not instead of calling 999 in an emergency. And efforts made to help us to decide if the situation was an emergency. No, it turns out that while this would have been good practice, it was not negligent. The mental health trust has now introduced a written discharge template for care and contingency planning. We have been told that the circumstances of Mariana’s death were unusual and could not have been foretold. That may be. But there are still lessons to be learnt. To improve patient safety in mental health crisis and to learn from deaths, we need to change standard practice. It should become standard to: See family and friends separately if someone is paranoid, to understand the family’s concerns, learn more about the patient and work together to consider how best the patient can be kept safe and helped. Provide written care and contingency plans to patients and their family Use one number for a Crisis Team helpline, with clear policies to offer help and support to service users and to their carers, and proper protocols in place to assess risk and intervene if someone is at immediate risk of harm. Make it very clear to patients that a referral to a Crisis Team is not a substitute for calling 999 in an emergency (where there is an immediate risk of harm to the patient or others) and to distinguish between a crisis and an emergency. Other professionals have a role in this too: On discharge, the A&E staff (who were very kind and very concerned) could invite the family to come back if the situation deteriorates, making it clear that it was an emergency, was a legitimate use of 999 and of A&E, and that the Crisis Teams are not for emergencies. The police could do the same, if they are trusted by the family (in many cases they are not).