Patient-Safety-Learning

This report draws on data from the National Child Mortality Database (NCMD) to investigate how illness around the time of birth affects the health of children up to the age of 10, and to draw out learning and recommendations for service providers and policymakers. This report aims to understand patterns and trends in child deaths where an event before, or around, the time of birth had a significant impact on life, and the risk of dying in childhood.

The Northern Ireland Department of Health's Mental Health Strategy Delivery Plan for 2022/23 sets out the prioritised workstreams under the 2021-31 Mental Health Strategy, which was published in June 2021, alongside a ten-year Funding Plan. It outlines governance and monitoring arrangements, actions currently in progress and actions that will be delivered at a later date. The Delivery Plan is published alongside Mental Health Strategy Co-Production/Design Principles, designed to give structure and meaning to the Department’s desire to ensure continued co-production throughout the implementation of the ten-year Strategy.

Rather than measuring how safe care is, the focus is often on measuring levels of harm in healthcare systems. This report by Healthcare Excellence Canada outlines findings from a research study which aimed to answer, “How safe is care from the perspective of patients, families, care partners, and care providers?” Through a literature review, interviews, focus groups and a World Café wthe study aimed to increase understanding of how patients and their care partners view safety. The Measuring and Monitoring of Safety Framework (MMSF) (Vincent et al., 2013b) was used to guide the study. The MMSF offers a broader, more comprehensive and real-time view of patient safety and helps shift away from a focus on past cases of harm towards current performance, future risks and organisational resilience. The report concludes that the MMSF represents a critical shift in how patients can enable safer care. Inviting patients and care partners to contribute meaningfully to safety will enhance healthcare providers’ view of harm and understanding of what it means to feel safe.

In this blog, Chris Day, Director of Engagement at the Care Quality Commission (CQC) sets out more detail on the CQC’s role in the assessment of Integrated Care Systems (ICSs). He highlights the importance of developing regulation that earns the trust of both people using services and those working in them. He outlines how the CQC will use its new responsibilities under the Health and Care Act 2022 to assess the extent to which each ICS understands the needs of its local population and whether it is working effectively in collaboration, with valued input from all health and care partners.

Fracture liaison services (FLSs) check if people who have recently broken a bone after falling from a standing height or less (a fragility fracture) might also have osteoporosis – a disease that weakens bones. They then advise on treatments to reduce the risk of another fracture, helping to improve patient outcomes. The Royal College of Physicians (RCP) estimates that at least 90,000 patients in England and Wales who should have anti-osteoporosis therapy are not receiving it. This guide by the RCP's Fracture Liaison Service Database (FLS-DB) aims to help patients and their families and carers understand what to expect following a fragility fracture. It outlines three key findings and the actions that individuals can take to ensure they receive the care and treatment they need from health services.

David Oliver is a consultant in geriatrics and acute general medicine who has worked in the NHS for 33 years. In this blog, he talks about his personal experience of running covid 'hot' wards during the different waves of the pandemic, describing the toll working in these conditions has taken on the health of him and many of his colleagues. He highlights the impact of looking after dying patients without adequate PPE, informing family members of patients' death over the phone, being responsible for many more patients than usual and witnessing colleagues die from Covid-19. The result has been burnout, mental health issues and low morale for a workforce that was already stretched before the pandemic hit the UK. David finally caught Covid-19 himself in March 2022 and he talks about how the virus—plus the cumulative effect of working under such strain for over two years—has meant he is not able to work and has been signed-off sick since mid-May.

The NHS England National Patient Safety Team has produced two podcasts to provide an overview of the background and development of the new National Maternity Early Warning Score (MEWS) tool. In the first podcast, Professor Marian Knight, University of Oxford; Professor Peter Watkinson, Oxford University Hospitals NHS Foundation Trust; and Tony Kelly, National Clinical Advisor, Maternity & Neonatal Safety Improvement Programme NHS England, discuss the development of a new national Maternity Early Warning Score (MEWS) tool. In the second podcast, Tony Kelly, Hannah Rutter, Senior Improvement Manager at MatNeoSIP NHS England, Louise Page, Consultant Obstetrician and Gynaecologist, West Middlesex University Hospital and Chelsea and Westminster Hospital NHS Foundation Trust, Anita Banerjee, Consultant Obstetric Physician, Guys and St Thomas’s NHS Foundation Trust and Katherine Edwards, Director of Patient Safety and Clinical Improvement, Oxford Academic Health Science Network discuss the the benefits of implementing the new national MEWS tool.

This annual report sets out how NHS Resolution's dispute resolution strategy has continued to drive down litigation against the NHS in England in 2021-22. 77% of claims made by patients were resolved in 2021/22 without court proceedings, continuing the year-on-year reduction for the last five years, and in line with the organisation's strategy to keep patients and healthcare staff out of court. NHS Resolution achieved this reduction through a range of dispute resolution approaches and continued cooperation across the legal market. It emphasises that the reduction in litigation has not been at the expense of a rigorous approach to investigation.

The National Infusion and Vascular Access Society (NIVAS) is a multidisciplinary organisation made up of healthcare professionals with a special interest in vascular access and IV therapy.  This white paper by NIVAS lays out evidence that having a nursing-led vascular access team in every hospital in the UK will improve patient safety, reduce workload pressures for other staff, and save the NHS money. Vascular access involves the use of devices such as catheters to deliver or remove fluids, blood or medication from a patient’s bloodstream. The paper examines the arguments advocating for Vascular Access Services Team (VAST) across the NHS, acknowledging the current pressures of restarting the NHS following the pandemic and the roadmap to reduce the elective waiting lists. It also outlines how integrating a standardised model of VAST into the healthcare systems of the NHS will benefit patients, the new Integrated Care Systems (ICS) and the wider objectives of the NHS.

The Covid-19 pandemic presented the need for fast decision-making in a rapidly shifting global context. This article in BMJ Evidence Based Medicine looks at the limitations of traditional evidence-based medicine (EBM) approaches when investigating questions in the context of complex, shifting environments. The authors argue that it is time to take a more varied approach to defining what counts as ‘high-quality’ evidence. They introduce some conceptual tools and quality frameworks from various fields involving what is known as mechanistic research, including complexity science, engineering and the social sciences. The article proposes that the tools and frameworks of mechanistic evidence, sometimes known as ‘EBM+’ when combined with traditional EBM, may help develop the interdisciplinary evidence base needed to take us out of this protracted pandemic.

People with a learning disability and autistic people should have the right support in place to live an ordinary life and fulfil their aspirations, in their own home. This action plan from the Department of Health and Social Care (DHSC) aims to strengthen community support for people with a learning disability and autistic people, and reduce reliance on mental health inpatient care. This action plan outlines the government's policy to achieve this by: strengthening community support. reducing the overall reliance on specialist inpatient care in mental health hospitals. improving the experiences of people with a learning disability and autistic people across public services such as health, social care, education, employment, housing and justice. It brings together the commitments that have been made by different organisations to realise these aims, and aims to drive long-term change for people with a learning disability and autistic people.

This open letter from the Pharmacists' Defence Association (PDA) raises concerns about unnecessary full or part-day closures of community pharmacies throughout the UK by some large multiple pharmacy operators. The letter states that these operators are telling patients and the government that they have been unable to find pharmacists, citing an alleged national pharmacist shortage. However, the PDA's members report that this is not the case, and the letter draws attention to closures being planned four weeks in advance, and to locum pharmacists having agreed rates of pay reduced at the last minute. The PDA highlights the risk to patient safety caused by these closures, and calls for more regulatory action to be taken by the government and other regulators. The letter is addressed to: Government Health Secretaries of England, Northern Ireland, Scotland and Wales Chief Executives of the National Health Service in England, Northern Ireland, Scotland and Wales NHS Chief Pharmaceutical Officers for England, Northern Ireland, Scotland and Wales Chief Executive of General Pharmaceutical Council and Pharmaceutical Society of Northern Ireland.

In this McKinsey & Co blog, the authors examine how organisations can achieve cohesion among decentralised business units and transform their culture. Drawing on McKinsey's experience supporting organisations through change, they look at how setting a common cultural goal and minimum standards for how each business unit will achieve this goal, can result in lasting performance improvements. They examine the following facets of cultural change: How you’re changing: Organizational oversight What you’re changing: Mindsets and behaviours Who is responsible at the business unit level?

This report by the Tony Blair Institute for Global Change looks at how the NHS needs to adapt to meet the demands of the current population. It asks the questions, should we and could we go much further in fundamentally changing the design of how the NHS is run, highlighting two key societal changes that make change necessary: increases in our knowledge of how to stay healthy, and huge technological advances such as artificial intelligence.

In July 2021, the UK Government lifted all Covid protections, meaning people were no longer legally obliged to take infection control measures such as wearing face masks in designated places. Twelve months on, the UK is facing high levels of infection and hospitalisations from Covid-19. In this opinion piece for The BMJ, members of Independent SAGE—a group of scientists working together to provide independent scientific advice about Covid-19 to the UK government and public—propose a series of measures to help people make informed decisions that will reduce the risk of illness and disruption to them, their families and their communities. The authors accuse the government of ignoring published scientific advice from their own advisory group, SPI-B, and call for action to give people the information they need to make responsible personal choices as part of the plan to 'live with Covid'.

Nursing workforce shortages are an issue of international concern, with the gap between demand for services and the limited numbers of nurses widening. Recruiting nurses internationally is one solution that is helping to bridge this gap in some health systems. This systematic review in the International Journal of Nursing Studies Advances aimed to explore the lived experiences of international nurses working and living in different countries globally. The authors identified factors that can help nurses from other countries to adapt culturally to the UK health system, and that may support retention of international staff. The authors found that in order to improve the long term retention of international nurses, cultural integration and language barriers should be sensitively managed to enable effective acculturation. Culturally sensitive leadership should also be promoted to ensure zero tolerance of inappropriate racist and discriminatory behaviours.

On his last day in office as Chief Investigator at the Healthcare Safety Investigation Branch (HSIB), Keith Conradi sent this letter to the Secretary of State for Health and Social Care, outlining his concerns about the approach of the Department of Health and Social Care (DHSC) and NHS England to patient safety work carried out by HSIB. In his letter, Keith highlights a lack of interest in HSIB investigations and activity from leaders in both NHS England and DHSC, and describes how this attitude permeates both organisations. He also draws attention to a lack of priority and support for patient safety at a structural level, and calls on government and healthcare leaders to take a new approach and introduce a regulated safety management system with appropriate accountability. Patient Safety Learning has written a blog reflecting on Keith Conradi's letter, highlighting the ways in which his concerns align with those consistently raised by Patient Safety Learning.

The National Audit of Care at the End of Life (NACEL) is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes Programme (NCAPOP). It was carried out by the NHS Benchmarking Network in collaboration with The Patients Association and aims to assess the quality of care that patients receiving end of life care and their families experience, as well as staff perceptions of their confidence and ability to deliver end of life care. The audit included: an Organisational Level Audit covering Trust/Health Board and hospital/submission level questions for 2020/21. a Case Note Review which reviewed 20 consecutive deaths between 12th April 2021 and 25th April 2021 and 20 consecutive deaths between 1st May 2021 and 14th May 2021 for acute providers and up to 40 consecutive deaths in April and May 2021 for community providers. a Quality Survey completed online, or by telephone, by the bereaved person. a Staff Reported Measure, completed online. Key findings Recognising the possibility of imminent death The possibility that the patient may die within the next few hours/days was recognised in 87% of cases audited, compared to 88% in 2019. The median time from recognition of dying to death was recorded as 44 hours (41 hours in 2019). Communication with the dying person Results on all key metrics regarding the recording of conversations with the dying person remain similar to 2019, pre-pandemic levels However, from the Quality Survey, the proportion strongly disagreeing or disagreeing with the statement ‘staff communicated sensitively with the dying person’ increased from 7% (2019) to 11% (2021). Communication with families and others There was little change in 2021 when compared to 2019, with continued high compliance on recording of conversations about the possibility that the person might die and on the individualised plan of care. As in 2019, discussions on hydration and nutrition with families and others were documented, or a reason why not recorded, in only around half of cases. Involvement in decision making Findings from the Case Note Review in 2021 suggest continued strong compliance on involvement in decision making, with similar results to those reported when this theme was last tested in 2018. However, from the Quality Survey, in 2021, 23% of people felt they would like to be more involved in the person’s care compared to 19% in 2019. Individualised plan of care Third round findings from the Case Note Review showed similar results for the existence of an individualised plan of care, 73% of cases compared to 71% in 2019, suggesting this is an ongoing area for improvement. Documented evidence of an assessment of wider needs such as emotional/psychological, spiritual/religious/cultural and social/practical shows a reduction since 2019, which may be a result of continuing pressures of the Covid-19 pandemic on services during 2021. Needs of families and others The needs of the family were identified as an improvement area in both round one and round two of the audit. Comparison with 2019 findings suggests performance has deteriorated, which may reflect the impact of the pandemic on the ability of visitors to access wards and the capacity of staff to assess and address the needs of families and others. Families’ and others’ experience of care The overall rating of care and support to the person who died, and the overall rating of care and support provided to families and others, are lower than in 2019. Governance Governance was last measured in 2018 and Trusts/Health Boards (HB) continue to show high compliance with the existence of key policies related to care at the end of life in 2021. Workforce/specialist palliative care The results show an improvement in access to specialist palliative care, in particular, face-to-face access 8 hours a day, 7 days a week was available in 60% of hospitals/sites compared to 36% in 2019. The increased provision may reflect a response to the pandemic and it is not yet clear whether the change will be permanent. Staff confidence Staff completing the survey expressed confidence in recognition of dying, communication, responding to the needs of the dying person and those important to them, involving people in decision making, accessing specialist palliative care and managing pain and physical symptoms, with less than 6% stating they strongly disagreed or disagreed with positive statements of confidence in these areas. Staff support Training was identified as a potential area for improvement with only 49% of respondents stating they had completed training specific to end of life care within the last three years. Although staff felt support was available from the specialist palliative care team, only 66% felt managerial support was available to help provide care at the end of life. Care and culture Although 83% felt able to raise a concern about end of life care, this should be closer to 100%. Only 80% answered positively that they felt they work in a culture the prioritises care, compassion, respect and dignity, which is also a concern.

Some patients are unable to tolerate imaging procedures such as MRIs due to pain or anxiety. In these cases, a variety of medications are routinely used prior to imaging to allow the procedure to be carried out successfully. Varying levels of sedation before imaging can be appropriate given the need for patients to remain still during the imaging process, but the minimal amount of sedation should be used to mitigate unwanted side effects and reduce the risk of adverse events. This article examines two cases that highlight the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required and when monitoring is limited or inadequate.

In this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.