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Content ArticleNHS trusts have often reported emergency department doctors having low levels of satisfaction and high rates of burnout, leading to a high turnover. In 2017, Brighton and Sussex University Hospitals (BSUH) and Western Sussex Hospitals merged to form University Hospitals Sussex NHS Foundation Trust. The Trust found that the organisation of shifts at Royal Sussex County Hospital (RSCH) and Princess Royal Hospital (PRH) and lack of flexibility were adding to the strain already felt by doctors working in the high pressure emergency department. To combat the pressure consultants and other doctors were under, the Trust implemented a system to help improve rota design and flexible working. The hope was that the system would help the trust retain and recruit staff, whilst saving locum costs and improving patient care.
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Content ArticleIn recorded interview, Roger Kline, research fellow at Middlesex University, and Anton Emmanuel, Head of Workforce Race Equality Standard (WRES), discuss 'No more tick boxes', progress on WRES and the need to address race equality as an organisational improvement metric.
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Content ArticleNurses work long hours and play a critical role in keeping patients healthy. Many nurses feel that fatigue “comes with the territory” of such a high-stress, high-impact job. But what’s really at risk when a nurse is fatigued? This blog by US insurance company Nurses Service Organization (NSO) looks at the impact of nurse fatigue on patient and staff safety. It suggests several strategies to address the issue: Designing schedules and organising work to reduce nurse fatigue Developing a fatigue management plan Educating staff on sleep hygiene and the effects of fatigue on nurse health and patient safety Providing opportunities for staff to express concerns about fatigue and taking action to address those concerns Making sure extended shifts have adequate staff support and rest periods
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Content ArticleThis blog by Carl Heneghan, Professor of Evidence-based Medicine at the University of Oxford and Clinical Epidemiologist Tom Jefferson, looks at safety and regulatory issues associated with Essure, a permanent contraceptive implant. Essure anchors inside the fallopian tubes and reacts with the tissues, causing them to become inflamed and scarred. The resulting scar tissue then blocks the tubes off, intending to prevent fertilisation. The devices are about 4cm long and contain a stainless steel, nickel and titanium inner coil and an expanding outer coil containing iron, chromium and tin. Essure has been shown to cause allergic reactions, lifelong inflammatory reactions and internal injuries. The authors examine how Essure came to be approved for use in the USA, the UK and the rest of Europe, highlighting regulatory failings and conflicts of interest with the medical tech industry. They also highlight how pressure from women harmed by Essure resulted in its use being banned in several countries. The blog then describes ongoing efforts to access UK data on reports of adverse events due to Essure that are held by the Medicines and Healthcare Regulations Agency (MHRA). Freedom of Information requests for this data have been denied.
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Content ArticleThe National Institute for Clinical Excellence (NICE) updated their guidance for continuous glucose monitoring (CGM) in 2022, recommending that CGM be available to all people living with type 1 diabetes. This review in the journal Diabetes, Obesity and Metabolism aimed to compare regulatory standards for CGM in the UK and Europe, with those applied in the USA by the Food and Drug Administration (FDA) and in Australia by the Australian Therapeutic Goods Administration (TGA). It describes the processes in place and highlights that the criteria applied in the UK for assessing accuracy do not translate into real-life performance. The authors offer a framework to evaluate CGM accuracy studies critically and conclude that FDA- and TGA-approved indications match the available clinical data, whereas CE marking indications applied in the EU can have discrepancies. They argue that the UK can bolster regulation, but that this need to be balanced to ensure that innovation and timely access to technology for people with type 1 diabetes are not hindered.
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Content ArticleThis Patient Safety Advisory from the Pennsylvania Patient Safety Authority provides an overview of the issues associated with healthcare worker fatigue. It outlines fatigue risk mitigation practices that are being used in healthcare and other industries, including comprehensive fatigue risk management programs.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Lucy and Rebecca talk to us about their experience as Patient Safety Incident Response Framework (PSIRF) early adopters. They discuss how PSIRF puts patients at the centre of incident investigations, and the challenges and opportunities they have faced in implementing PSIRF at West Suffolk NHS Foundation Trust.- Posted
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Content ArticleSentinel Event Alerts from the Joint Commission identify specific types of sentinel event (a patient safety event that results in death, permanent harm or severe temporary harm), describe their common underlying causes and suggest steps to prevent them occurring in the future. This Sentinel Event Alert looks at the well-documented link between health care worker fatigue and adverse events. It looks at: The impact of fatigue Contributing factors to fatigue and risks to patients Actions suggested by The Joint Commission for healthcare organisations
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Content ArticleFatigue has increasingly been viewed by society as a safety hazard. This has lead to increased regulation of fatigue by governments. The most common control process has been compliance with prescriptive hours of service (HOS) rule sets. Despite the frequent use of prescriptive rule sets, there is an emerging consensus that they are an ineffective hazard control, based on poor scientific defensibility and lack of operational flexibility. In exploring potential alternatives, we propose a shift from prescriptive HOS limitations toward a broader Safety management system (SMS) approach. Rather than limiting HOS, this approach provides multiple layers of defence, whereby fatigue-related incidents are the final layer of many in an error trajectory. This review presents a conceptual basis for managing the first two levels of an error trajectory for fatigue.
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Content ArticleEating disorders are often seen as an illness that affects young women, but research estimates that one in four people with eating disorders are male. As a result, boys and men with eating disorders most often live in silence with the double stigma of having a mental health condition that is not recognised in their gender. In this BBC documentary, former England cricketer and TV presenter Andrew "Freddie" Flintoff goes on a personal journey into the eating disorder he has kept secret for over 20 years–bulimia. He discusses his own experience and meets specialists and young men with eating disorders across the UK.
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Content ArticleThe Healthcare Leadership Model (HLM) was developed to help leaders in the health service become better at their day-to-day role. The model is useful for everyone from board members to managers because it describes the things you can see leaders doing at work and demonstrates how you can develop as a leader. This webpage describes how the HLM works and provides a link to the free self-assessment tool.
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Content ArticleThis study in The Journal of Nursing Administration aimed to investigate the relationship between sleep deprivation and occupational and patient care errors among staff nurses who work the night shift. A cross-sectional correlational design was used to evaluate relationships between sleep deprivation and occupational and patient care errors in 289 hospital night shift nurses. The study found that more than half (56%) of the sample reported being sleep deprived. Sleep-deprived nurses made more patient care errors. Testing for associations with occupational errors was not feasible because of the low number of occupational errors reported.
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Content ArticleIn this YouTube video, Jerika T. Lam, Associate Professor at Chapman University, School of Pharmacy, offers insights on patient safety from a pharmacist’s perspective. As someone who works in a clinic that serves marginalised and underserved communities, she describes the important role pharmacists can play on a healthcare team alongside doctors and nurses to ensure patients get the appropriate medications with minimal drug interactions.
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Content ArticleThis report by the thinktank Public Policy Projects makes a series of recommendations to national government, local government, care providers and technology providers which, if implemented, will aid in the digitisation of the care sector for the benefit of people being supported and cared for, the social care workforce, and the NHS. Digital transformation across the adult social care sector is happening at a rapid pace. Despite being initially slower to adopt technology than colleagues working in the NHS and other health settings, since the start of the Covid-19 pandemic the care sector has been quick to adopt digital social care recording (DSCR) systems, alongside a range of transformative assistive and support technology. In the face of the immense strain on England’s social care system, due to an ageing population combined with chronic funding and workforce challenges, the effective implementation of the right technology could support the people providing care and support and those in receipt of support and provides an opportunity for a better quality of life.
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Content ArticleThis study in JAMA Health Forum aimed to assess the costs of inpatient falls and cost benefits associated with the Fall TIPS (Tailoring Interventions for Patient Safety) Program. The authors carried out an economic evaluation across a large cohort of 900,635 patients. The average total cost of a fall was $62 521 ($35 365 direct costs), and injury was not significantly associated with increased costs. The Fall TIPS Program was associated with $22 million in savings at study sites across the five year study period. The findings of this study indicate that implementation of cost-effective, evidence-based safety programs was associated with lower cost and care burdens associated with inpatient falls and are a step toward safer, more affordable patient care.
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EventuntilIn this research chat, Care Opinion welcomes back Dr Lauren Ramsey of Leeds University to discuss her recent paper: Exploring the sociocultural contexts in which healthcare staff respond to and use online patient feedback in practice: In-depth case studies of three NHS Trusts. Research chats are informal and friendly and last 30 minutes. For the first 15 minutes, Care Opinion CEO James Munro discusses the paper with Lauren and then invite comments and questions via the chat box (or in person if you prefer!). Anyone can come along—you don't need to be academic and you don't even need to read the paper beforehand. So do join us! Register
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Content Article
In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on a recent discussion about hysteroscopy and patient safety at a conference in January 2023, hosted by the Association of Anaesthetists. -
Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) aims to improve patient safety by supporting staff to access critical information about patients at their bedsides in emergency situations. It defines critical information as ‘information about patients that needs to be accessed rapidly and accurately to ensure correct care is delivered when it is required’. In this investigation, critical information was considered through a focus on patient identifiers (such as name and date of birth) and decisions relating to whether someone is recommended to receive cardiopulmonary resuscitation (CPR) if their heart stops (cardiac arrest). The reference event for this investigation was the care of a patient in a hospital who was found unresponsive in bed. A short time later, he stopped breathing and his heart stopped. Help was immediately sought from the ward staff and a team gathered around the patient’s bed, where they confirmed the patient’s identity and noted that a decision had been made that he was not recommended to receive CPR if his heart stopped. As a result, CPR was not started. Around 10 minutes later, a nurse who had previously been caring for the patient returned from their break and recognised that the patient had been misidentified as the patient in the next bed. The patient whose heart had stopped was recommended to receive CPR. CPR was immediately started, but despite this, the patient died.
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Content ArticleThe Association of Anaesthetists established a working group to help anaesthetics trainees with safe sleeping patterns. In this blog, Dr Emma Plunkett, consultant anaesthetist and chair of the working group, talks more about new initiatives to fight fatigue and why it’s important to monitor the impact of tiredness in the national training surveys.
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Content ArticleFatigue is a workplace hazard that affects the health and safety of patients, health care providers and the community. This blog from health tech company Cerner looks at the importance of managing fatigue in healthcare staff. The author suggests a three-step approach to lessen fatigue: Shift the culture of safety to include recognising and dealing with fatigue. Operationalise fatigue reduction measures within the organisation. Promote fatigue self-management through preventative strategies.
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The Psychologically informed policy and practice development (PIPP) project investigated current workplace concerns, barriers to change and opportunities for development and growth, and was a collaborative project run by the Royal College of Emergency Medicine, UK Research and Innovation and the University of Bath. This document details specific evidence-based recommendations relating to four key areas identified as prioritised targets in emergency care workforce development: An environment to thrive in Cultivating a better culture A tailored pathway of care Enhanced leadership The recommendations are detailed, supported by evidence, existing guidelines and new empirical data, and are specific to the needs of the emergency care specialty. -
Content ArticleIntegrated care systems are now legally responsible for leading a localised approach that brings multiple aspects of the healthcare system closer together, and for working better with social care and other public services. However, this is not a new aspiration, so why should it be any different this time? The Nuffield Trust hosted a series of roundtables to discuss concerns with stakeholders and experts to try and understand how to ensure the aims are achieved. This report summarises these findings and offers ways forward as the new era gets underway.
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Content ArticleThis primer article by the Agency for Healthcare Quality and Research (AHQR) looks at the impact of fatigue and sleep deprivation on patient safety. Fatigue is the feeling of tiredness and decreased energy that results from inadequate sleep time or poor quality of sleep. Fatigue can also result from increased work intensity or long work hours. The article outlines the current context for discussions in the US around mitigating the potential risks of sleep deprivation among healthcare workers, highlighting measures that can be put in place by healthcare organisations including employing optimal practices for scheduling, planned napping and ensuring appropriate spaces are available for rest breaks.
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Content ArticleFatigue in anaesthesia practice is often ignored or accepted as the norm due to persistent, high-intensity work demands and expectations. This document produced by the American Association of Nurse Anesthesiology (AANA) aims to provide guidance to healthcare professionals, healthcare facilities and nurse anaesthesia programs regarding sleep deprivation and fatigue. It provides evidence-based information that promotes fatigue management and work-life balance.
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Content ArticleThis systematic review in BMJ Open synthesised evidence on the impacts of insufficient sleep and fatigue on health and performance of physicians in independent practice, as well as on patient safety. The authors also assessed the effectiveness of interventions targeting insufficient sleep and fatigue. The authors found that fatigue and insufficient sleep may be associated with negative physician health outcomes, but concluded that current evidence is inadequate to inform practice recommendations.
