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  1. Today
  2. News Article
    NHS patients are being left unseen in pain and in some cases to die alone because shifts do not have enough registered nurses, a survey shows. The Royal College of Nursing said analysis of a survey it carried out showed that only a third of shifts had enough registered nurses on duty. The union has also gathered testimonies from nurses who talk of always “rushing” and being asked to do more; working in “completely unsafe” levels of care; and having to make “heartbreaking” decisions on who does or doesn’t get seen. Shortages mean individual nurses are often caring for dozens of patients at a time, the RCN said. It has called for limits on the maximum number of patients for whom a single nurse can be responsible. Nicola Ranger, the RCN’s acting general secretary and chief executive, said the survey showed that patients were being failed. “In every health and care setting, nursing staff are fighting a losing battle to keep patients safe,” she said. “Without safety-critical limits on the maximum number of patients they can care for, nurses are being made responsible for dozens at a time, often with complex needs. “It is dangerous to patients and demoralising for nursing staff.” Read full story Source: The Guardian, 1 July 2024
  3. News Article
    The UK nursing regulator’s new interim chief executive has stepped down just four days into the job after facing widespread staff backlash over her links to a high-profile race discrimination case. Multiple staff working at the Nursing and Midwifery Council (NMC) raised concerns to its directors over the appointment of interim CEO Dawn Broderick, who was head of HR at another trust when it was found to have discriminated against a Black employee. The Independent can now reveal Ms Broderick resigned from the NMC on Monday evening. It is the latest in a succession of controversies to hit the nursing regulator, following reports uncovered by The Independent last year. These include allegations from whistleblowers that racism within the NMC was allowing complaints against nurses to go unchecked. Staff have come forward to The Independent, warning they do not have confidence the NMC’s board will take the issue of racism seriously. Read full story Source: The Independent, 2 July 2024
  4. Content Article
    High volumes of patients are transferred every day between health and care settings. Whilst efforts have have been made over several years to improve this process through the implementation of standards and the sharing of digital information, there is more to be done. Whole system improvements are required and significant further progress can be made to improve the quality and consistency of data shared between organisations. The Professional Standards Record Body (PRSB) has published a number of standards that support the transfer of care of patients between settings.  This toolkit concentrates on the PRSB eDischarge Summary Standard, which specifies the data to be shared between secondary and primary care to support the discharge of a patient from hospitals across the UK. This toolkit does not propose a one-size-fits-all approach and recognises that health and care services are organised in different ways across the UK.
  5. Content Article Comment
    Love the infographic. It is a great group of people all focussed on improving and making it better for our patients and our staff. Well done Claire.
  6. Content Article
    This article looks at recent efforts to increase awareness of female genital mutilation (FGM) amongst healthcare professionals in the UK. Dr Victoria Kinkaid conducted a UK-wide survey to find out how much medical students knew about FGM. Results from the survey highlighted a gap in medical student education around FGM. Further exploration with the help of focus groups revealed that this knowledge gap also affected other frontline professionals with mandatory reporting duties for FGM, including teachers, midwives and social workers.  Working with her MSc supervisor, Dr Heather May Morgan, Victoria launched a four week course entitled 'Female Genital Mutilation (FGM): Health, Law, and Socio-Cultural Sensitivity' in 2022 to try and bridge this gap. This article looks at the impact of the course and how Victoria and Heather's work to increase awareness is expanding.
  7. Content Article
    Polypharmacy is a term used to describe when a patient is taking a number of medicines at the same time. This study in the British Journal of Clinical Pharmacology aimed to measure how common polypharmacy is and describe the prescribing of selected medications known for overuse in older people with polypharmacy in primary care. It was a multinational retrospective cohort study that used data from patients with a mean age of 75-76 years from six countries: Belgium, France, Germany, Italy, Spain and the UK. The results revealed a high prevalence of polypharmacy with more than half of the older population being prescribed at least five drugs in four of the six countries. Whilst polypharmacy may be appropriate in many patients, the authors found worryingly high usage of PPIs and benzodiazepines. The study's results support current efforts to improve polypharmacy management across Europe.
  8. News Article
    The agonising pains came midway through Dr Rageshri Dhairyawan’s third cycle of IVF, ten years ago. “I felt as if a heavy metal shovel was scraping away at the lining of my abdomen,” she recalls. “It was like nothing I’d ever felt before,” she says. Her fear was ovarian torsion — “when the ovaries become so big from all the follicle stimulation that they twist on their stalk, which is excruciating and needs to be repaired surgically because the ovary becomes starved of oxygen.” Her husband rushed her to A&E where she was given morphine, then admitted to a gynaecology ward. As a scan revealed no ovarian torsion, “It was thought the hormones had flared up my endometriosis.” Dhairyawan was in so much pain she couldn’t move, and yet she recalls being treated as though she was an attention-seeker “trying to get strong opioids through dishonest means” and “as a nuisance for pressing my buzzer”. It was as if, she says, “I didn’t have something they thought was very serious so why was I still there? I just remember not wanting to feel like more of a nuisance because I knew what being a nuisance on a ward can look like — I’d been a doctor for ten years.” Dhairyawan’s husband demanded pain relief for her. She left hospital shaken. “It massively changed me,” she says. “The experience of not being listened to as a patient, not being taken seriously — it really shocked me. Because I thought, I’m a senior doctor, I know exactly how the NHS works, I know my medical condition, I now what to ask for. And I still can’t speak up and advocate for myself.” Read full story (paywalled) Source: The Times, 2 July 2024
  9. News Article
    NHS trusts are signing up to deliver efficiency savings of up to 9% of costs, HSJ has found. The Queen Elizabeth Hospital King’s Lynn has a cost improvement programme of nearly £30m in 2024-25, equivalent to 9% of spending, which is three times higher than the amount it delivered last year. Trusts and commissioners were last month issued with new financial targets as NHS England attempted to bring down a £3bn forecast deficit for local organisations. A spokeswoman told HSJ the trust had already identified three-quarters of the £30m, and said “we believe that there are further efficiencies in our system, which would see us go further than the 3.1% achieved last year.” She added: “All cost-saving initiatives go through a robust process to make sure that they will not impact patient safety or clinical care provided by the trust.” Read full story (paywalled) Source: HSJ, 1 July 2024
  10. Yesterday
  11. Community Post
    Patients are increasingly being asked to access online systems to: request prescriptions or make medication requests access healthcare records and test results make appointments communicate health concerns sign consent forms. These developments can have a positive impact but they can also carry potential challenges, as highlighted in this recent blog - Digital-only prescription requests: An elderly woman sent round the houses. We'd like to hear your experiences of using online systems in healthcare. Have they made things easier? Does it feel like your care is more joined up for it? Have any of these changes been challenging? If so why? Comment below (sign up first for free) or contact us directly at content@patentsafetylearning.org to share your experience.
  12. Content Article
    Medicines reconciliation is the process of compiling a complete list of a person’s current medicines. When a patient registers at a new primary care setting, medicines reconciliation contributes to patient safety and continuity of care. This article in The Pharmaceutical Journal explores how to optimise the multidisciplinary team and involve pharmacy technicians in the process, using four case scenarios. The article aims to help those working in community pharmacy teams to: identify potential risks and appropriate management strategies for new patients with complex medication needs, including those with chronic conditions and those requiring specialist care. understand the importance of timely referrals, communication with specialists, and adherence to guidelines in ensuring safe and effective medication management. recognise the significance of interdisciplinary collaboration and patient-centred approaches in addressing the diverse healthcare needs of patients, particularly those from other cultural backgrounds. You can access this article by signing up for a free account with The Pharmaceutical Journal.
  13. News Article
    'PAs' - who have just two years training - are being used to treat NHS patients, but doctors are concerned about patient safety, reports Sarah Graham. PAs, or physician associates, are a relatively new type of health professional, first introduced in the UK in 2003 and increasingly used across the NHS to provide care to patients, including at GP surgeries. They undergo two years of postgraduate training (compared with the ten years of medical training needed to become a GP). There are now more than 3,000 PAs working in the NHS. The Government has said it wants to increase the number to 10,000 by 2037, but the scheme has become controversial following a series of reports of patients being misdiagnosed, some with fatal consequences. As far as Dave Hay knew, he was seeing a GP. It was 2022 and he’d started having bouts of dizziness, brain fog and fatigue. “It was having an impact on my work and everyday life, so I called my local surgery to make an appointment. I saw someone who wasn’t my usual doctor, but she introduced herself as Dr Smith,” says Hay, 57, a scientist from Yorkshire. “I explained my symptoms. She didn’t do any kind of examination – didn’t check my ears or my vision – and just said, ‘look, I don’t think there’s anything seriously wrong with you, but come back if your symptoms get worse’,” he says. Two weeks later Dave, now 57, a scientist from Yorkshire, felt worse. It was only later, during a chance conversation with the practice nurse, that Dave learned he hadn’t been seeing a GP at all. “I was at a routine appointment and explained what had happened,” Dave says. “The nurse asked who I’d seen and said, ‘that’s not a doctor, that’s a PA’. I had no idea what a PA was.” When Dave arranged an appointment with one of the named GPs, she diagnosed depression and anxiety, because of issues at work and a recent family bereavement. “She looked at my medical history and asked some much more targeted questions, pieced it all together, and recommended talking therapy and antidepressants,” Dave explains, who is now well. However, he does feel that he was misled and waited longer for the right treatment because the PA did not explain her actual role, which they are supposed to do. Read full story Source: iNews, 1 Jul7 2024
  14. Content Article
    The Independent Healthcare Providers Network (IHPN) have launched a toolkit to support independent healthcare providers to further improve multi-disciplinary team (MDT) working in the sector.  MDT working is an established practice in many areas of healthcare, including in the independent sector, and for patients with complex care needs such as cancer, MDTs are viewed as the gold standard for care. 
  15. Content Article
    East Lancashire Hospitals NHS Foundation Trust share their guide on human factors. It describes what human factors is and why it is so important alongside example case studies of how human factors is being used within the Trust.
  16. Content Article
    This blog is part of a series written by Dr Charlie*, taking a closer look at some of the patient safety issues affecting people lives today. In this blog Dr Charlie describes how their homeless friend Robbie* has struggled to access the care and clarification he needed around his liver abscesses. Dr Charlie explains how important it is for healthcare professionals to take into account individual circumstances if they are to provide people with the information and care they need. *not their real name
  17. News Article
    Doctors are warning the UK medical regulator that wider use of physician associates in the NHS may risk patient safety and lead to greater inequalities in care in deprived areas that struggle to recruit GPs. The government’s plan to recruit 10,000 physician associates – healthcare professionals supervised by doctors – has angered many clinicians who consider the roles ill-defined and a potential threat to patient safety. The General Medical Council (GMC) is to regulate physician and anaesthesia associates, who also work under doctors’ supervision, from December. The doctors’ union, the British Medical Association, last week announced it was seeking a judicial review of the GMC over the “dangerous blurring of lines” between doctors and medical associate professions. It argues physician and anaesthesia associates need regulating, but not by the GMC. Other professional membership organisations want clarification of associates’ roles. The Royal College of General Practitioners (RCGP) told the GMC that regulation is a “significant step forward”, but the scope of practice needs to be urgently developed. Read full story The Guardian, 30 June 2024
  18. News Article
    The latest release of data from the Royal College of Nursing's Last Shift Survey shows the urgent need for investment in the nursing workforce and safety-critical nurse-to-patient ratios enshrined in law. New analysis finds more than 11,000 members reveals just a third of shifts had enough registered nurses. Chronic staff shortages mean individual nurses are often caring for 10, 12, 15 or more patients at a time. The RCN are now calling for safety-critical limits on the maximum number of patients a single nurse can be responsible for. Our survey found that 1 in 3 hospital shifts were missing at least a quarter of the registered nurses they needed. In A&E settings, significant numbers of nurses reported having more than 51 patients to care for. Across all settings, 80% of respondents said there aren't sufficient nurses to meet the needs of patients safely. RCN Acting General Secretary and Chief Executive Professor Nicola Ranger said: “Without safety-critical limits on the maximum number of patients they can care for, nurses are being made responsible for dozens at a time, often with complex needs. It is dangerous to patients and demoralising for nursing staff. “When patients can’t access safe care in the community, conditions worsen, and they end up in hospital where workforce shortages are just as severe. This vicious cycle fails staff and patients – it can’t go on. “We desperately need urgent investment in the nursing workforce but also to see safety-critical nurse-to-patient ratios enshrined in law. That is how we improve care and stop patients coming to harm.” Read full story Source: RCN, 1 July 2024
  19. Content Article
    A fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.
  20. Last week
  21. Content Article
    Online reporting tools are a key component of professional accountability programmes as they allow hospital staff to report co-worker unprofessional behaviour. Ethos is a whole-of-hospital professional accountability programme that includes an online messaging system, which has now been implemented across multiple Australian hospitals. This study examined reported unprofessional behaviour that staff indicated created a risk to patient safety. It included 1310 Ethos submissions reporting co-worker unprofessional behaviour between 2017 and 2020 across eight Australian hospitals. The findings indicate that unprofessional behaviour was associated with risks to patient safety. Co-worker reports about unprofessional behaviour have significant value as they can be used by organisations to better understand how unprofessional behaviour can disrupt work practices and lead to risks to patient safety.
  22. Content Article
    Children are at higher risk of medication errors due to the complexity of drug prescribing and administration. Intravenous (IV) paracetamol overdose differs from overdose by ingestion as there is no enteral absorptive buffering. This study outlines the first national UK data focusing on paediatric IV paracetamol poisoning. The data show that unintentional IV paracetamol overdose appears to occur more frequently in young children. A significant proportion of errors were calculation errors, which were often 10-fold errors. While these errors have the potential to cause serious harm, thankfully most cases were asymptomatic. Errors with IV paracetamol might be reduced by electronic prescribing support systems, better communication regarding administration and consideration of whether other routes are more appropriate.
  23. Content Article
    The Patient Safety Movement Foundation offers a unique educational opportunity for healthcare professionals around the world to expand their knowledge in the theory and practice of patient safety. Building on the World Health Organization Global Patient Safety Action Plan, the fellowship aims to develop future leaders particularly from lower middle and middle income countries. The programme combines a year-long curriculum developed by patient safety experts in a variety of areas, taught via monthly live virtual classroom sessions. Fellows complete monthly readings on specific topics, actively participate in discussions on the interpretation of theory and methods, and its implication to practice. Fellows submit monthly reflections on their learning as well as a longer reflection at the end of the fellowship. Applied learning is achieved by completing a hands-on improvement project that explores and advances issues of patient safety in each fellow’s respective professional environment. Fellows are encouraged to publish the outcome of their project and present at conferences. Fellows are driven by a deep passion for patient safety, often sparked by first-hand encounters with patient harm events, and a desire to improve care outcomes in their home communities and workplace settings. They become part of a global social movement for patient and healthcare worker safety. Information on how to apply can be found in the link below.
  24. News Article
    Hackers behind a London hospital attack recently published records that include personal information about pregnant women, newborns, cancer patients, people suffering from schizophrenia and thousands of others across the UK and Ireland, revealing the breach was far more widespread than authorities have previously indicated. An analysis of the data trove by Bloomberg News found that it contains tens of thousands of medical records on patients from more than 400 public and private hospitals and clinics. Among the records are some 40,000 highly sensitive documents sent by doctors requesting biopsies and blood tests for individual patients in all regions of the UK and some hospitals in Ireland. A breach of the kind faced by Synnovis was inevitable, according to Saif Abed, a former NHS doctor and expert in cybersecurity and public health. “The NHS has some of best patient safety and cybersecurity standards in the world,” Abed said. “They are just immensely poorly enforced.” Abed said that there was a lack of mandatory cybersecurity audits on any contractors providing services to the NHS, which meant those contractors could have substandard cybersecurity practices that could in turn leave the NHS vulnerable. Read full story Source: Bloomberg UK, 26 June 2024
  25. Content Article
    This paper reviews the key perspectives on human error and analyses the core theories and methods developed and applied over the last 60 years. These theories and methods have sought to improve our understanding of what human error is, and how and why it occurs, to facilitate the prediction of errors and use these insights to support safer work and societal systems. Yet, while this area of Ergonomics and Human Factors (EHF) has been influential and long-standing, the benefits of the ‘human error approach’ to understanding accidents and optimising system performance have been questioned. This state of science review analyses the construct of human error within EHF. It then discusses the key conceptual difficulties the construct faces in an era of systems EHF. Finally, a way forward is proposed to prompt further discussion within the EHF community.
  26. Content Article
    Few previous studies evaluating the benefits of diagnostic decision support systems have simultaneously measured changes in diagnostic quality and clinical management prompted by use of the system. This report describes a reliable and valid scoring technique to measure the quality of clinical decision plans in an acute medical setting, where diagnostic decision support tools might prove most useful.
  27. Content Article
    Clinical safety is about keeping patients safe. It applies not only to us in the NHS, or social care organisations, but to you when building healthcare software. The law requires you to ensure your software is clinically safe, which means minimising the potential for harm to patients. This page on the NHS Digital website explains what you need to know about clinical safety when building healthcare software.
  28. Content Article
    Read the latest case studies from the National Guardian’s Office.
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