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Patient Safety Learning

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  1. Content Article
    During the last 4 years, three infants have presented with finger-tip injuries secondary to entrapment in woollen/synthetic mittens. The accident happened at home in one case but the other two occurred in different neonatal units. Spontaneous amputation of the terminal phalanx of the index finger occurred in two patients but in the other there was complete healing. This problem may be avoided by restricting the use of mittens, by changing their design, and by a greater awareness of this hazard. Related reading on the hub: Knitted items – potential for harm to babies? (2018) Notes from a Patient Safety Education Network discussion on a similar incident. (This is a group for UK hub members involved in patient safety education/training in their organisations and members of the hub can join by emailing support@PSLhub.org.)
  2. News Article
    To help patients with high-risk pregnancies receive care at hospitals that are staffed and equipped to deliver care appropriate to their needs, the Department of Public Health will require licensed birthing hospitals to use a system called Levels of Maternal Care. The system classifies hospitals based on their capacity to meet the needs of patients with a range of potential complications during childbirth. The impetus is the rising levels of severe maternal morbidity, large racial disparities in outcomes, and concerns that higher-risk patients who deliver in hospitals that over-estimate the level of care they are able to provide are more likely to experience complications. Levels of care describe a hospital’s physical facilities, capabilities and staffing, indicating its ability to serve people giving birth across a range of medical needs. For example, Level 1 is appropriate for low-risk patients with uncomplicated pregnancies, including twins and labor after cesarean delivery. To that group, Level II adds patients with poorly controlled asthma or hypertension and other higher-risk conditions. Subsequent levels include patients at increasingly high risk of complications, up to Level IV, which is appropriate for patients with severe cardiac disease, those who need organ transplant and others. Established by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine in 2015, the classification system is one tool used by states across the country to improve maternal health and birthing outcomes. Read full story Source: Betsy Lehman Center. 17 January 2024
  3. Content Article
    Meeting cancer performance targets is a challenge for many trusts with waiting times for diagnosis and treatment growing since the pandemic. But this is a worrying time for patients as well, and they would welcome quicker turnaround of results and diagnosis. Cutting time out of this pathway would benefit everyone but are there ways to do this which do not compromise patient safety? An HSJ webinar, in association with SS&C Blue Prism, addressed this important question and tried to find ways trusts could reduce waiting times.
  4. Content Article
    This project aimed at understanding and tackling the barriers to sufficient hydration, breaks and refreshment facilities for NHS staff. Sherwood Forest Hospitals NHS Foundation Trust was keen to introduce the Royal College of Nursing's (RCN) rest, rehydrate and refuel initiative, and did so through a project led by one of the chief nurse clinical fellows. First, staff were surveyed to understand the current situation and any barriers they may face. This was followed by a trial on two pilot wards, before roll our of a trust-wide campaign.
  5. Content Article
    Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients. The aim of this study published by Jama Internal Medicine was to determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalised adults transferred to an intensive care unit (ICU) or who died. The results showed that diagnostic errors were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.
  6. News Article
    People living in the most deprived parts of the country are more than twice as likely to be in poor health as those living in the most affluent, a new report has revealed. People in Liverpool are almost three times more likely to be in poor health than those in Oxfordshire, and twice as likely to be economically inactive, research by the cross-party IPPR Commission on Health and Prosperity found. The researchers found a “stark divide” in health and wealth throughout the UK was leaving many “bad health blackspots”, with people more likely to be out of work. Overall, people living in the most deprived parts of the country are more than twice as likely to be in poor health as those living in the most affluent – and are around 40% more likely to report economic inactivity. Read full story Source: The Independent, 18 January 2024
  7. News Article
    Patients have suffered cardiac arrests while waiting in A&E departments or in ambulances queueing outside because Scottish hospitals are overwhelmed, doctors have warned. At least three cases in which patients’ hearts stopped beating while they were waiting for care have been reported to the Royal College of Emergency Medicine in Scotland. Some of the incidents, the college said, may have been preventable. One frontline doctor told The Times that a patient with heart problems had died waiting in a queue of ambulances outside an emergency department. Staff could not take the patient inside because there was no capacity. JP Loughrey, vice-president of the college and an A&E consultant in the west of Scotland, said that people who should be in resuscitation rooms with a team of experts and equipment to monitor their vital signs were instead lying in ambulances outside hospital buildings. He also said that tensions were growing between frontline staff and NHS managers in large hospitals because doctors and nurses, who were already struggling to cope, were under increasing demands to work harder to process more patients. Read full story Source: The Times, 19 January 2024
  8. Event
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    Airedale’s digital journey: Revolutionising healthcare Starting in 2006, Airedale NHS Foundation Trust digitized patient services, introducing remote health assessments for prisoners. Facing funding challenges for successful pilots, 2010 saw the establishment of the Digital Care Hub with Rachel Binks serving as a key consultant. In 2014, the 24/7 Goldmine service emerged, supporting those in their last year of life with telephonic and video assistance. Goldmine, now a decade strong, is acclaimed for enabling patients to spend their final days at home, supported by grateful families and caregivers. Expanding beyond end-of-life care, MyCare24 was born in 2023 through a joint venture, enhancing service delivery and marketing capabilities nationwide. Airedale NHS Foundation Trust’s digital journey signifies innovation, compassion, and a commitment to reshape healthcare for the future, ensuring tangible, positive impacts on patient care. Register
  9. Event
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    Fundamentals of Emergency Medicine Education is a 2-day, 17-hour course that provides participants with the knowledge and skills to become effective educators in emergency medicine. Through a dynamic and interactive format, the course focuses on best practice, strategies, updates, and educational innovations to optimize the educational environment in your Emergency Department. This course is designed for faculty at any career stage who work with trainees and are seeking a comprehensive foundation in medical education. The goal of this course is to teach fundamentals of medical education to improve the teaching and learning in your department. Register
  10. Event
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    The Patients Association and NHS England’s Worry and Concern Group is holding a webinar on pilot studies testing ways to incorporate inpatients’ views of their illness and worries and concerns in the assessment and recognition of acute illness and risk of deterioration. The webinar brings together patients and clinicians to review: The work done during the Worry and Concern pilots The experience of patients and clinicians who took part in the pilot studies How to ensure patient involvement in the design of a nationwide worry and concern programme. The panel is: John Bamford, Patient Safety Partner Kayleigh Griffiths MBE, member of National Worry and Concern Steering Group Jane Murkin, Deputy Director Safety & Improvement – Nursing, NHS England Prof Damian Roland , Honorary Professor of Paediatric Emergency Medicine, University of Leicester John Welch, Consultant Nurse, Critical Care & Critical Care Outreach, University College London Hospitals NHS Foundation Trust. Prof Roland will review experiences with the new national Paediatric Early Warning System (PEWS). The webinar is free and on Zoom. Register online
  11. Content Article
    This podcast features Dr Alan Fletcher National Medical Examiner and Suzy Lishman, Senior Advisor on Medical Examiners at the Royal College of Pathologists discussing what the changes to death certification processes and new requirements to be introduced with the statutory medical examiner system will mean for medical examiners, medical examiner officers and others involved in death certification.
  12. Content Article
    This study published in the BMJ evaluated the effect of chair placement on length of time physicians sit during a bedside consultation and patients’ satisfaction. The study concluded that chair placement is a simple, no cost, low tech intervention that increases a physician’s likelihood of sitting during a bedside consultation and resulted in higher patients’ scores for both satisfaction and communication.
  13. Community Post
    Article in the Big issue:
  14. News Article
    A “national call to action” has been made by the UK Health Security Agency (UKHSA) after a worrying surge in the spread of measles in London and the West Midlands. Professor Dame Jenny Harries, chief executive of the health board, told BBC Radio 4’s Today programme that people have “forgotten what measles is like”, and that children can be unwell for a week or two with symptoms including a nasty rash, high fever and ear infections. She added that the virus is highly infectious, with health officials warning that serious complications can arise that include hospitalisations and death. This comes as official figures show uptake of the measles, mumps and rubella (MMR) vaccine is at its lowest point in more than a decade. Read full story Source: The Independent, 19 January 2024
  15. News Article
    The mother of an 11-year-old Aberdeenshire girl with Long Covid has launched a legal action against their health board, in what lawyers claim is the first case of its kind in Scotland. Helen Goss, from Westhill, is seeking damages from NHS Grampian on behalf of her daughter, Anna Hendy. The action claims the health board is responsible for "multiple failings" in Anna's treatment and care. The claim alleges failings were avoidable, that they caused Anna "injury and damage", and led to her condition worsening. Anna became unwell after contracting Covid in 2020. The action alleges a number of failings by the health board. These include claims that requests for Anna to be referred to the specialist paediatric services of immunology and neurology were refused. It also claims no further help was offered after Anna was diagnosed with Chronic Fatigue Syndrome (CFS) and Paediatric Acute-onset Neuropsychiatric Syndrome (PANS). And it says these failings "could have been avoided had NHS Grampian followed contemporary guidance on diagnosis and treatment". Read full story Source: BBC, 19 January 2024
  16. News Article
    A hospital trust has been breaching national guidance by excluding some long waiters from its reported waiting list figures, in a move experts warned could put patient safety at serious risk. The practice appears to have helped Sandwell and West Birmingham Hospitals report zero patients waiting more than two years for treatment during most of last year. Its policy means cases that unexpectedly “pop up” as two-year waits in its datasets are temporarily removed. The trust will then review whether the cases are data errors or genuine two-year waits, and if genuine, aim to provide treatment within a month. If not treated within a month, the cases would be added back to the reported waiting list the following month. Rob Findlay, an expert on RTT waiting lists, said the implications of the SWBH policy are far more serious than simply reporting incomplete numbers for a month. He said allowing a month to deal with the pop-up without declaring it “relieves them of pressure to solve the problems that are causing patients to be lost in the first place”. He added: “Some patients – the hospital would never know – might never pop up and be lost from the waiting list forever. “[This is] a serious patient safety issue which could potentially have a significant impact on how long patients are waiting for treatment.” Read full story (paywalled) Source: HSJ, 19 January 2024
  17. Content Article
    This animation was created to highlight the specific issues for people with learning disabilities in relation to psychological trauma.
  18. Content Article
    Learn how to become a health systems analyst and use the science of ergonomics to improve patient safety and transform day-to-day working practices. Safety scientists play a major role in preventing unintended harm across many high-consequence industries, improving overall wellbeing and changing the culture of workplaces. Staffordshire University MSc in Human Factors for Patient Safety will teach you how to design applied solutions for health and social care settings. The course is ideal for existing health professionals – from both clinical and non-clinical backgrounds - who want to specialise in care safety, risk, improvement and system transformation and advisory roles. These highly transferable skills are also relevant to many other sectors. Find out more from the link below. Start date: 28 April 2024
  19. Content Article
    The Royal College of Physicians of Edinburgh has released a statement on their position on the specific role of the physician associate.
  20. Content Article
    The systems engineering initiative for patient safety (SEIPS) is a framework to help us understand outcomes within complex socio-technical systems, like healthcare. SEIPS has developed over a number of academic papers and offers a range of tools that can help an investigator to understand why things happen. Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when planning and undertaking patient safety investigations.
  21. Content Article
    Plans to increase their number in England to plug workforce gaps have been criticised – but their work is valued by hospital colleagues. Sammy Chan is very proud to be a physician associate, despite the controversies. “I find it particularly rewarding because I get to build relationships with patients,” she said. Chan works in respiratory medicine, mainly in outpatients. As well as more routine monitoring of patients and booking scans, she has been trained to perform chest drains and to insert pleural catheters. “While it’s quite emotionally challenging, it’s nice to be a constant presence on their journey,” she said. Chan is one of 40 physician associates employed at the Royal Berkshire foundation trust in Reading. Introduced nearly two decades ago, physician associates have some medical training but are not doctors. They can take medical histories, carry out physical examinations and help develop treatment plans – but cannot prescribe medicine or order X-rays. The NHS aims to increase the number of physician associates working in England from about 4,000 to 10,000 to help plug widespread gaps in the workforce.
  22. News Article
    Senior doctors are urging MPs to reject government plans to regulate “physician associates”, whose growing use in the NHS has divided the medical profession. The British Medical Association has said that allowing the General Medical Council (GMC) to regulate physician associates (PAs) would “blur the lines” between doctors and non-doctors. Many medics are opposed to the increased use of PAs, who they fear patients will wrongly see as doctors, even though they do not have a medical degree. They have expressed concern that letting the GMC – which regulates doctors – regulate PAs from April, as ministers plan, is “potentially dangerous” because it could confuse the public, diminish the status of doctors, and leave patients at risk of being treated by someone without the appropriate skills. The BMA is running advertisements in the Guardian and on social media asking MPs on a Commons committee examining the plan to vote against it when they consider it on Thursday. “PAs are not the same as doctors, and blurring the lines can have tragic consequences for patients who think they have seen a doctor when they have not,” the adverts say. Read full story Source: The Guardian, 18 January 2024
  23. News Article
    The publication of a final report into the infected blood scandal has been delayed until May. The chairman of the public inquiry, Sir Brian Langstaff, said more time was needed to prepare "a report of this gravity". Victims and their families were initially told they would learn the findings in autumn last year. That date was pushed back until March, and the inquiry has now confirmed the further delay to 20 May 2024. "I am sorry to tell you that the report will be published later than March. That is not what I had intended," added Sir Brian. "When I reviewed the plans for publication, I nonetheless had to accept that a limited amount of further time is needed to publish a report of this gravity and do justice to what has happened." It is thought about 30,000 people were infected with HIV and hepatitis C through contaminated blood products in the 1970s and 1980s. More than 3,000 have died in what has been described by MPs as the worst treatment disaster in NHS history. Read full story Source: BBC News, 17 January 2024 Further reading on the hub: UK Infected Blood Inquiry
  24. News Article
    Large regional variations in the risk of death from cancer by the age of 80 have been revealed in research by Imperial College London based on NHS data for England. Analysis of the figures by The Independent shows the risk of dying is highest in northern England cities, while men and women living in the London boroughs had the lowest chance. Although the risk of dying from cancer has decreased across all areas of England in the last two decades, it is now the leading cause of death in England, having overtaken cardiovascular diseases. The Less Survivable Cancers Taskforce has that warned Britain has some of the worst cancer survival rates among the world’s wealthiest countries. It ranked the UK 28th out of 33 countries for five-year survival rate for stomach and lung cancer; for pancreatic cancer the UK was 26th, and it was 25th for brain cancer. Read full story Source: The Guardian, 13 January 2024
  25. Content Article
    This paper addresses the fundamental discipline theoretic question of whether situation awareness is a phenomenon best described by psychology, engineering or systems ergonomics. Each of these disciplines places a different emphasis on the notion of what situation awareness is and how it manifests itself. Each of the perspectives is presented and compared with reference to studies in aviation and other domains.
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