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Patient Safety Learning

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  1. Content Article
    Patient care inevitably raises issues of safety. Safety measures can never be failsafe, but they can always be improved. The aim of this publication is to offer guidance to boards on helping to bring about these improvements. The publication was developed by Monitor for NHS foundation trusts, though its principles apply equally to other NHS settings. It draws on evidence and best practices from UK pilot sites, and also taps the experience of healthcare providers in other developed countries who use similar principles and approaches. The field research and work with the UK pilot sites took place between October 2009 and March 2010.
  2. News Article
    One of Britain’s three high-security hospitals – where notorious people including Ian Huntley and Charles Bronson have been detained – is so understaffed that neither workers nor patients are safe, a damning new report has found. Rampton Hospital in Nottingham faces severe staff shortages, leading workers to restrain patients and lock them away in their rooms and putting patients at risk of self harm, according to the Care Quality Commission. In a report looking into the hospital, inspectors – who rated the hospital as inadequate – said there were around half the staff needed on one ward. In one example of those at the hospital being at risk, a patient self-harmed with glass from their watch, while another was able to harm themselves with a CD while they were confined to their room. One deaf patient was secluded several times on another ward for “being loud”, according to the CQC. “We spoke with people in the learning disabilities services who told us they sometimes get locked in their room from dinner time until the next morning,” the report said. “They told us that they don’t like being locked in their rooms.” Read full story Source: The Independent, 17 January 2024
  3. News Article
    People trying to buy illicit synthetic opioids and sedatives online to treat pain, anxiety and insomnia increasingly risk taking a different drug that has caused dozens of deaths among heroin users, a leading expert has warned. Nitazenes – synthetic and extremely powerful drugs implicated in fatalities of chronic powdered heroin users in Birmingham, Bristol and London in recent months – have been detected in illicit supplies of tablets being sold as diazepam and codeine that appeal to a wider market. New figures released to the Guardian by the National Crime Agency reveal 65 people have died from taking nitazenes in the past six months – more than two a week, while detections in drug supplies have increased more than fivefold in the last two years. “[Nitazenes] are being mixed into heroin but it is also in fake diazepam, fake codeine and the person buying the tablets online is a very different kind of user to a heroin user,” Dr Caroline Copeland, the director of the National Programme on Substance Abuse Deaths said. “It means the risk is much wider.” Read full story Source: The Guardian, 17 January 2024
  4. Content Article
    In 2017-18, the Department of Health & Social Care (DHSC) implemented a new operating model and delivery body for NHS procurement known as NHS Supply Chain (to replace the previous, fully outsourced model which was also called NHS Supply Chain). The new body was responsible for procuring products, warehousing, and delivering goods on behalf of the NHS. NHS Supply Chain (Supply Chain) estimates that the NHS collectively spends approximately £8 billion annually on buying medical equipment and consumables, from gloves and paper to stents and prosthetic hips.
  5. Content Article
    When a family loses a loved one in unclear or unexplained circumstances, there is one thing that family members need above all else: answers. How did their loved one die, and could their death have been prevented? The Coroner Service is there to answer these questions. But in his annual report published in December, the chief coroner Judge Thomas Teague revealed the extensive delays now occurring in the coroners’ courts. In April 2021 more than 5,000 families waited over a year for the coroner to complete their investigations. This was a staggering increase on pre-pandemic figures, with 2,278 cases having lasted more than 12 months in 2019. And while figures from April 2022 suggest the backlog is gradually reducing (with 4,568 cases taking more than 12 months), it is clear that far too many families are still facing agonising delays, sometimes lasting several years.
  6. News Article
    Health experts have warned “we must act now” as measles cases have soared across the country amid an increase in unvaccinated children. There were 1,603 suspected cases of measles in England and Wales in 2023, new statistics from the UK Health Security Agency (UKHSA) show. MMR cases have increased significantly in the last two years - in 2022, there were 735 cases, and just 360 the year before. On Friday, Birmingham Children’s Hospital said it had become inundated with the highest number of children with measles in decades. The hospital treated more than 50 children for the disease in the last month. Professor Sir Andrew Pollard, Chair of the UK Health Department's Joint Committee on Vaccination and Immunisation, warned that unless more children are vaccinated there will be an increase in hospital admissions and even deaths. He told The Independent: “The main reason for this new outbreak is the increase in unvaccinated children in the last few years. “Vaccinations have decreased below 90 per cent and this is dangerous. The vaccine is powerful if we use it, and it will protect our children. “We must act now and the increased cases are a warning that there will be consequences if we don’t. There will be children with severe infections, brain damage and even death.” Read full story Source: The Independent, 15 January 2024
  7. Event
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    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour class will focus upon using SEIPS Surgery. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these sessions by clinical subject experts. The class will be limited to a small group to ensure in-depth learning. Register
  8. Event
    until
    The Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour class will focus upon using SEIPS Surgery. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these sessions by clinical subject experts. The class will be limited to a small group to ensure in-depth learning. Register
  9. Content Article
    Coercive or restrictive practices such as compulsory admission, involuntary medication, seclusion and restraint impinge on individual autonomy. International consensus mandates reduction or elimination of restrictive practices in mental healthcare. To achieve this requires knowledge of the extent of these practices. This study is the most comprehensive overview of rates of coercive practices between countries attempted to date. 
  10. Content Article
    After an extreme traumatic event there are things that you can do to help yourself, and your colleagues, to move on. Fiona Day, medical and public health leadership coach and chartered coaching psychologist, Stacey Killick, consultant paediatrician at Glan Clwyd Hospital, and Lucy Easthope, professor in practice at Durham University’s Institute of Hazard, Risk, and Resilience and adviser on disaster recovery give their tips in this BMJ article.
  11. News Article
    At least half of all integrated care systems lack a plan to defend the services they oversee from a cyber attack, HSJ has discovered. Integrated care systems are responsible for bolstering the cyber resilience of the organisations in their area. This includes having a “system-wide plan for maintaining robust cyber security”. However, research by HSJ has found that only ten ICSs would confirm they had such a plan. Twenty-six ICSs admitted they did not have a plan in place, while six systems did not respond to HSJ’s inquiries. See the end of the story for the full list. Of those without a plan, only 10 said they were developing one. NHS England had initially asked each ICS to submit draft cyber security strategies by the end of May, before sending final versions by the end of September but is now thought to be drawing up new timelines. Some regions appear particularly exposed. All four ICSs in the North East and Yorkshire region admitted they did not have a cyber security plan, while no ICS in either the London or South East region could confirm they did. An NHSE spokesman told HSJ it was “vital” that ICSs have “robust plans in place to manage the specific cyber risks in their local areas to protect patient data and systems”. Read full story (paywalled) Source: HSJ, 15 January 2024
  12. News Article
    Ministers are facing calls to tackle the NHS’s chronic lack of staff as figures reveal that the bill for hiring temporary frontline workers has soared to more than £10bn a year. Hospitals and GP surgeries across the UK are paying a record £4.6bn for agency personnel and another £5.8bn for doctors and nurses on staff to do extra “bank” shifts to plug gaps in rotas. Widespread short staffing has increasingly forced the service in all four home nations to hand colossal sums to employment agencies to hire stand-in workers. In England alone, the bill for agency staff, particularly nurses and GPs, has risen from £3bn to £3.5bn over the past year – a 16% rise. Wes Streeting, the shadow health secretary, said years of neglect of the growing NHS staffing crisis by Conservative governments had obliged “desperate” hospitals to spend “huge” sums on agency staff, including doctors who can cost more than £5,000 to hire for a single shift. The Royal College of Nursing said the levels of agency spending were “staggering”. It would be cheaper to employ more nurses as staff instead of having tens of thousands of vacancies, the general secretary Pat Cullen said. The NHS in England currently has 42,306 vacant nursing posts. Read full story Source: The Guardian, 16 January 2024
  13. News Article
    More than 7,000 Covid-related hospital admissions could have been prevented in the UK in the summer of 2022 if the population had received the full number of jabs recommended, according to research in The Lancet. Some 44% of the UK population was under-vaccinated, with younger people among the most likely to skip doses. In a first, health records for everyone over five in the UK were analysed. The same approach could now be used to understand other diseases. The entire population of the UK is 67 million, and all those over the age of five had their anonymised electronic health data analysed for The Lancet study. With about 40,000 severe hospital admissions related to Covid during that summer, the research estimates that more than 7,000 - 17% - would have been avoided if everyone had taken up the offer of the vaccine and booster doses for which they were eligible. Read full story Source: BBC News, 16 January 2024
  14. News Article
    A record 420,000 patients had to wait more than 12 hours in A&E last year, analysis has shown. The latest NHS England figures revealed a 20% increase on 2022 in people facing lengthy delays after a decision to admit them to hospital from the emergency department. In 2023, 419,560 people – or one in 15 A&E patients – faced “trolley waits” of 12 hours or more, according to the Liberal Democrats, who compiled the analysis. It marks by far the highest number since records began in 2011, and amounts to an average of 1,150 patients a day. Ed Davey, the party leader, criticised the “appalling delays” and accused Rishi Sunak’s government of “ignoring the suffering of patients and driving our health service into the ground”. Significant waits in A&E have been linked to excess deaths and increased harm to patients, as their condition could deteriorate before they are admitted or given a bed on a ward. Davey said: “Every year A&E delays are getting worse and worse under this Conservative government as hospitals are starved of the resources and staff they need. These appalling delays are leaving often vulnerable and elderly patients waiting for hours on end in overcrowded A&Es." Read full story Source: The Guardian, 14 January 2024
  15. News Article
    More than 8,500 patients in England were being treated on virtual wards in the run-up to Christmas, figures have revealed, as the NHS moves to ease pressures on hospital capacity. However, experts said the so-called hospitals at home are not a “silver bullet to solve the crisis in health and social care”. Figures published by NHS Digital revealed some 8,586 patients were treated virtually in December 2023, up from 7,886 in November. The snapshot was taken on 21 December 2023, meaning it is likely those patients spent Christmas on a virtual ward rather than an actual hospital. Virtual wards allow patients to receive care in their own homes, with clinical staff using apps or wearable technology to monitor them remotely. Professor Sir Stephen Powis, NHS national medical director, said the “rapid expansion” of virtual wards beds and patients “is a real NHS success story”. He added: “This not only frees up vital hospital beds for those who need them most but ensures patients can recover in the place they are most comfortable with support from families, carers and friends, and while occupancy has been growing rapidly as NHS teams make the most of all bed capacity available, we want to see continued growth right across the country so as many patients as possible can benefit." However, Wendy Preston, the head of nursing practice at the Royal College of Nursing (RCN), said “virtual wards aren’t a silver bullet to solve the crisis in health and social care”. “Whether they’re in a physical bed or on a virtual ward, patients still need to be able to see a nurse,” she added. “But there are over 40,000 nursing vacancies across the NHS, and social care is chronically understaffed. Run effectively, virtual wards can relieve pressure, but on every single shift nursing staff are fighting an uphill battle to care for too many patients. “If the UK government wants to turn around the state of the NHS and deliver the ‘hospital level’ care at home that patients expect, nursing staff need to see game-changing investment in the workforce.” Read full story Source: The Independent, 15 January 2024
  16. News Article
    The scale of the crisis in social care is laid bare as figures show that dementia patients occupy a quarter of all beds in the NHS. People living with the disease often go into hospital after falls or infections as well as for acute medical or surgical problems. Dementia patients often experience longer hospital stays than the average patient and can be delayed leaving wards due to a shortage of care in the community. At any one time in the NHS, one in four hospital beds are occupied by people living with dementia, according to the National Institute for Health and Care Excellence, which says stays on wards can trigger distress, confusion and delirium for patients. Doctors must carry out a discharge assessment of patients to ensure they are healthy before they can leave hospital. Medics assess a dementia patient’s care needs outside of hospital and discharge can be delayed if these are deemed not adequate. Demand for social care continues to rise as the population grows older but there is a shortage of workers in the sector. Skills for Care estimated that, in 2022/23 an average of 9.9 per cent - or 152,000 - roles in adult social care in England went unfilled. This was the equivalent to 152,000 vacancies - down by 11,000 from the previous year, although vacancies remain high compared to the wider UK economy. Services are so overstretched that people are left struggling without vital support to carry out everyday tasks in their own homes, and lives are being blighted. Read full story Source: The Independent, 14 January 2024
  17. News Article
    An unprecedented medicines shortage in the NHS is endangering lives, pharmacists have said, as unpublished figures reveal that the number of products in short supply has doubled in two years. A treatment for controlling epileptic seizures was the latest to be added on Wednesday to a UK drugs shortage list that includes treatments for conditions ranging from cancer to schizophrenia and type 2 diabetes. Causes of the crisis are thought to include the plummeting purchasing value of the pound since the Brexit referendum, which reduces the NHS’s ability to source medicines abroad, and a government policy of taxing manufacturers. According to Department of Health and Social Care (DHSC) figures provided to the British Generic Manufacturers Association, there were 111 drugs on a shortages list on 30 October last year and 96 on 18 December, with supply notifications issued for a further 10 treatments to NHS providers in the UK since then. It amounts to a 100% increase in shortages compared with January 2022, with pharmacists and health charities claiming the conditions of some patients were deteriorating as a result. Delyth Morgan, the chief executive of Breast Cancer Now, said her organisation had been contacted over the past 12 months by several patients unable to source the medicines they needed to control the spread of their disease. She said: “Last year many people shared with us, via Breast Cancer Now’s helpline, that they’d been facing difficulties accessing their hormone treatment including letrozole, anastrozole and tamoxifen, causing them huge worry and anxiety. Trying to track down a treatment by travelling to a number of different pharmacies is an added burden for patients at an already difficult time. “It may also sometimes be that certain brands of drugs are out of stock and people may have to switch to another brand or different drug. In the worst case someone may have a period of time without the medication, a drug which could help reduce the risk of their breast cancer coming back or spreading.” Read full story Source: The Guardian, 14 January 2024
  18. News Article
    People who go abroad for weight-loss surgery, and then need urgent medical care back in the UK, cost the NHS more than it costs to carry out the operation itself, according to new research. A study featuring five London hospitals recorded the details of 35 people who had suffered complications after travelling abroad for gastric surgery during 2022. The data, shared with the BBC's Disclosure programme, shows the patients suffered from a range of symptoms including severe malnutrition, vomiting, sepsis, hernias and haemorrhaging. Five of them needed feeding tubes inserted, while the average stay in hospital was 22 days. The interventions at the five hospitals for the 35 patients cost the NHS a total of £560,234, or £16,006 per patient, in 2022. The equivalent amount would have covered the cost of about 110 bariatric surgeries in UK hospitals. Consultant bariatric surgeon Omar Khan, one of the lead authors of the study, said the paper was intended "to try and quantify" the effect on the NHS of increasing numbers of people going abroad for weight-loss surgery - sometimes known as bariatric tourism. "We know that the waiting lists in the NHS are unfortunately long. We also know that there are new units, particularly in Turkey, which have been set up to cater for an international market," he explained. "We focused on patients with major complications, patients who were severely ill. They had leaks from the stomach, they had bleeding, they had infections. A significant portion required further surgery and some required revisional surgery." Read full story Source: BBC News, 15 January 2024
  19. News Article
    “Better upfront planning, training and testing” were needed in a tech launch which was tied to patient harm and service disruption, an NHS England review has found. Royal Surrey and Ashford and St Peter’s Hospitals foundation trusts went live with Oracle Cerner’s electronic patient record in May 2022 – under a programme called Surrey Safe Care – but the implementation has since been linked to incidents of patient harm, including one death, and significant disruption to trust services. Now, a lessons learned review, carried out by NHSE’s frontline digitisation team and obtained by HSJ via a Freedom of Information request, has identified 24 areas of improvement. The key lessons cited by the review are “better upfront planning, roles and responsibilities, training and testing”. It recommended that, in future implementations, trust boards should be supported by others experienced with implementing EPRs within the NHS to “aid board level decisions and ‘what questions to ask when’”, while clearer responsibilities should also be agreed upon for programme leads and EPR suppliers. The review also found the content of training must be evaluated thoroughly, while the EPR supplier should provide “upfront and continuous training”. It added the “full end-to-end testing [by] representatives from all end user groups” should be completed before go-live. It also said EPR readiness needs to incorporate “data readiness, such as data quality, and mapping how data has originally been captured [which] may impact reporting and organisational readiness”. Read full story (paywalled) Source: HSJ, 15 January 2024 Related reading on the hub: NHS England warns electronic patient record could pose ‘serious risks to patient safety’: what can we learn?
  20. Content Article
    This study evaluated the impact of narrative/story-based approaches to safety messages; e.g. injury stories on actual safety behaviour versus mechanistic instructions without use of anecdotes and ‘traditional abstract safety messages’. Story-based messages resulted in a 19% improvement in safety behaviour compared with non-narrative comms.
  21. Event
    This masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner. Identifying Information Risks across the organisation. Working with others to mitigate the risk to patients, staff and organisation. Confidence that all reasonable technical and organisation measure are in place. Giving assurance to the Board that risks have been considered, mitigated or owned. Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches. hub members receive a 20% discount. Email info@pslhub.org for discount code. Register
  22. Event
    The Patient Safety Incident Response Framework (PSIRF) arguably represents the most significant change to investigating and managing patient safety incidents in the history of the NHS. To embed PSIRF effectively within organisations, healthcare teams need to understand and utilise a range of new techniques and disciplines. Clinical audit is an established quality improvement methodology that is often overlooked by patient safety teams, but will play an increasingly important role in ensuring that PSIRF fully delivers its stated objectives. CQC reports often highlight the importance of clinical audit as a measurement and assurance tool that can raise red flags if used appropriately. Indeed, both the Ockenden and Kirkup reports highlighted the importance of clinical audit in identifying and quantifying substandard care. While SEIPS, After Action Reviews, more in-depth interviewing techniques, etc. are all receiving much fanfare in relation to PSIRF, the importance of clinical audit needs to be better understood. This short course will explain how organisations who use clinical audit effectively will increase patient safety and better understand why incidents take place. We will look at the key role of audit in understanding work as imagined and works as done and show why national audits can assist with creating patient safety plans. Change analysis and the effective implementation of safety actions are keys to PSIRF delivery and clinical audit will assist in the delivery of both. We will also demonstrate the important, but often under-appreciated role, clinical audit staff will have in the successful delivery of PSIRF. Key learning outcomes: Why clinical audit is an integral element of PSIRF. Why clinical audit staff have a vital role to play in PSIRF. How clinical audit data can help raise red flags and spot risks. Using clinical audit to better understand your incidents. Ensuring your safety actions are working. Using audit to assess your patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
  23. Event
    This virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework. But more than this, the masterclass will support staff to go beyond compliance to understand the issues and emotional component on a deeper level; to have real authentic engagement and involvement with patients and families. New frameworks such as PSIRF are now in place, but how do we not only comply with these, but go beyond compliance to have real authentic compassionate engagement and involvement with patients, families and indeed staff to make a real positive difference? Connecting new knowledge with emotions can really support long term learning, which is an important part of this masterclass. This one-day masterclass will look at the new PSIRF and the Complaints Standards Framework and through real life content, bringing the human focus for the patients, loved ones, and indeed staff to the forefront. It will support staff to explore what compassionate engagement looks like, feels like, and how to communicate it authentically and meaningfully. In a supportive and relaxed environment, delegates will have the opportunity to gain in depth knowledge of the emotional component, relate to, analyse and realise the significance of and believe in their own abilities in creating practices that not only support the PSIRF but go beyond compliance to be working in a way that supports gaining an optimum outcome for patients, families and staff, in often a less than optimum situation. Key learning objectives: Feel, analyse, and explore the presence and absence of compassionate engagement within life, trauma, and a healthcare incident and how empathy is the gateway to compassion. Seeing perspectives and understanding emotional motivations and the emotional component recognising vulnerability in others and self. Seeing the bigger picture and having an enquiring mind to understand the story and how the ‘Funnel of Life’ can impact on our ability to engage. Build confidence in the positive impact of compassionate engagement and really being authentically interested in the emotional component to be able to create an optimum outcome in often a less than optimum situation. Explore and have a good grasp of how internal unconscious belief systems, can link through to the outcomes we achieve. We know what works with compassionate engagement, but why do we so often struggle? Explore and analyse biases, judgments, and how a lack of compassionate engagement not only has the potential to cause psychological harm, but can prevent optimum outcomes for the organisation. Realise the significance of authenticity rather than feeling fearful of not doing things perfectly. Examine where can we get emotional information from to support us, even if we are not aware we are doing it! Identify the importance of an enquiring mind and a hypothesis as we try and understand the story that we are aiming to compassionately engage with. Develop understanding of Safeguarded Personal Resolution (SPR ®) to formulate compassionate engagement under PSIRF and the Complaints Standards Framework. Develop awareness on personal wellbeing and resilience. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
  24. Event
    This course is suitable for anybody who deals with complaints as part of their job role, or anybody who may have to handle a complaint. This includes dedicated complaints teams and customer support teams and managers. A highly interactive and effective workshop to improve confidence and consistency in handling complaints, we will demonstrate a simple model to facilitate effective responses, and delegates will have the opportunity to practise the use of our unique AERO approach. With complaint volumes increasing, and individual complaints rising in term of conflict and emotional impact, early resolution and de-escalation are key objectives within healthcare complaints. Mediation is a highly effective alternative dispute resolution approach, and the skills deployed by mediators provide useful tools for diffusing complaint situations arising at the point of delivery/interaction. Developing the skills and confidence to explore perspective, seek to understand the root and true cause of the patients concerns (the complaint ‘iceberg’) and introducing resolution techniques empower teams to increase the chances of achieving a resolution with less detrimental impact on their own and the healthcare team’s wellbeing. Mediation techniques also produce a clearer understanding of the complaint and why the situation escalated. The masterclass explains how mediation works and how techniques can be used effectively within local complaint resolution to develop a person-centred process (for both patient and healthcare professional). Within these key areas, the course will explore how unconscious bias plays a role in complaints and their resolution. A mediation inspired approach to complaint resolution produces invaluable insight to help reduce recurring complaint situations, develop training and development plans and support the teams on the frontline. Key objectives Improved confidence in using mediation techniques to resolve challenging customer complaints. Use of a methodology to improve consistency in successfully addressing challenging customer concerns. Personal Action plan to take back to my role and my team. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
  25. Event
    This conference will focus on measuring, understanding and acting on patient experience insight, and demonstrating responsiveness to that insight to ensure patient feedback is translated into quality improvement and assurance. Through national updates and case study presentations the conference will support you to measure, monitor and improve patient experience in your service, and ensure that insight leads to quality improvement. Sessions will include learning from patients, improving patient experience, practical sessions focusing on delivering a patient experience based culture, measuring patient experience, demonstrating insight and responsiveness in real time, monitoring and improving staff experience, the role of human factors in improving quality, using patient experience to drive improvement, changing the way we think about patient experience, and learning from excellence in patient experience practice. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-experience-insight or email frida@hc-uk.org.uk Follow on Twitter @HCUK_Clare #PatientExp hub members receive a 20% discount. Email info@pslhub.org for the discount code.
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