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Content ArticleTrust boards’ regular oversight of the quality and safety of maternity and neonatal services has been the subject of successive inquiries and reviews. In this report, the Sands and Tommy’s Joint Policy Unit review publicly available board papers and minutes for seven NHS Trusts in England. They analyse whether the information presented to boards, the process for review, and actions taken enabled boards to deliver effective oversight over the safety and quality of maternity and neonatal services.
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Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. LFPSE introduces improved capabilities for the analysis of patient safety events occurring across healthcare, and enables better use of the latest technology, such as machine learning, to create outputs that offer a greater depth of insight and learning that are more relevant to the current NHS environment. LFPSE fields can now integrated into Datix incident form, and the information is uploaded to the national database upon the completion of an incident report. After the reviewing manager’s and Patient Safety Team review, any changes are automatically re-uploaded and the information updated in the national database. CSH Surrey share their presentation slides on LFPSE and Datix.
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Content ArticleA BMJ investigation has raised concerns that the Vaccine Adverse Event Reporting System (VAERS) isn’t operating as intended and that signals are being missed. VAERS is supposed to be user friendly, responsive, and transparent. However, investigations by The BMJ have uncovered that it’s not meeting its own standards. Not only have staffing levels failed to keep pace with the unprecedented number of reports since the rollout of covid vaccines but there are signs that the system is overwhelmed, reports aren’t being followed up, and signals are being missed. The BMJ has spoken to more than a dozen people, including physicians and a state medical examiner, who have filed VAERS reports of a serious nature on behalf of themselves or patients and were never contacted by clinical reviewers or were contacted months later.
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Content Article
Thirlwall Inquiry
Mark Hughes posted an article in Other reports and inquiries
The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This website provides information about inquiry team, terms of reference and publications relating to this. -
Content ArticleIn her latest blog, Patient Safety Commissioner Henrietta Hughes discusses MHRA's Yellow Card reporting system and why, until we have mandatory reporting, including for devices that are working as designed, we will continue to see avoidable harm occurring to patients. She stresses that it is vital that the voices and views of patients, clinicians, manufacturer, and health providers participate in the design and delivery of devices.
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Content ArticleThe 'Learning Response Review and Improvement Tool' is intended to be used by: Those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report. Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. Development of this tool and set of standards was informed by a research study from Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), identified ‘traps to avoid’ in safety investigations and report writing. The tool was originally developed by NHS Scotland. It has been further refined in collaboration with HSIB and NHS England after being piloted in approximately 20 NHS trusts and healthcare organisations in England. The content validity of the tool is currently being assessed.
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Content ArticleThis report is aimed at people who are working with those who have a learning disability, in the role of commissioners or providers of services. It was produced on behalf of the Hampshire Safeguarding Adults Board by a multi-agency group and seeks to understand why people with a learning disability are at greater risk of choking, looking at what can be done locally in Hampshire to improve outcomes for people who are at risk of choking, in any care setting. The report makes a number of recommendations based on common sense and good practice.
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Content ArticleThe Learning Disabilities Mortality Review (LeDeR) Programme is a world-first. It is the first national programme of its kind aimed at making improvements to the lives of people with learning disabilities. The University of Bristol is one of the partners in the programme, which is funded and run by NHS England. Reviews of deaths are being carried out with a view to improve the standard and quality of care for people with learning disabilities. People with learning disabilities, their families and carers have been central to developing and delivering the programme. Further information and useful resources can be found on the University of Bristol's website.
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Content ArticleAdverse events are among the most heavily scrutinised parts of the covid-19 vaccine process. But India’s system was woefully unprepared for this, leaving families confused, sowing vaccine hesitancy in communities, while robbing the system of valuable data, reports Priyanka Pulla in this BMJ feature.
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Content ArticleMedicines and Healthcare products Regulatory Agency (MHRA) presentation on their patient involvement strategy and how they are using Patient Reported Outcomes (PROs).
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Content ArticleThis cross-sectional study in BMJ Quality & Safety aimed to assess patient comfort in speaking up about problems during hospitalisation, and to identify patients at increased risk of having a problem and not feeling comfortable speaking up. The authors assessed the responses of 10,212 patients at eight hospitals in Maryland and Washington to the question, "How often did you feel comfortable speaking up if you had any problems in your care?" The study found that 48.6% of respondents indicated that they had experienced a problem during hospitalisation. Of these, 1,514 (30.5%) did not always feel comfortable speaking up. The authors concluded that creating conditions for patients to be comfortable speaking up may result in service recovery opportunities and improved patient experience.
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Content ArticleIn this blog, Dr Amy Proffitt, Royal College of Physicians (RCP) patient involvement officer, explores how the patient voice is represented in patient safety. She highlights the importance of engaging patients from a diverse range of backgrounds and responding to research that highlights particular populations who are experiencing worse outcomes. Eddie Kinsella, chair of the RCP’s Patient and Carer Network, then goes on to share his thoughts on patient safety, highlighting the role of patient partners in bringing about culture change in the NHS, and as advocates for the wider community, especially those who are most disadvantaged.
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Content ArticleSafety communication refers to the sharing of safety information within organisations in order to mitigate hazards and improve risk management. External stakeholders, such as patients and carers, also communicate safety information to healthcare organisations. This article in the Journal of Risk Research examines the nature of safety communication behaviours seen in patients and their families by identifying and examining 410 narrative accounts. The author found that the success of patient and family safety communication in reducing risk was variable. Problems in hospital safety culture such as high workloads and downplaying safety problems, meant that information provided was often not acted upon.
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Content ArticleThrough a data sharing agreement, the Faculty of Intensive Care Medicine can access a record of incidents reported to the National Reporting and Learning System (NRLS). Available information is limited and from a single source; all that is know about these incidents is presented in this report. The safety bulletin aims to highlight incidents that are rare or important, and those where the risk is perhaps something we just accept in our usual practice. It is hoped that the reader will approach these incidents by asking whether they could occur in their own practice or on their unit. If so, is there anything that can be done to reduce the risk?
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Content ArticleThe Regulation and Quality Improvement Authority (RQIA) is the independent body responsible for regulating and inspecting the quality and availability of Health and Social Care services in Northern Ireland. The (RQIA) was commissioned to examine the application and effectiveness of the Procedure for the Reporting and Follow-up of Serious Adverse Incidents in Northern Ireland. The review was conducted by an Expert Review Team established by the RQIA and made five recommendations for implementation.
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Content ArticleThis is the 15th annual clinical radiology census report by The Royal College of Radiologists. The census received a 100% response rate, meaning this report presents a comprehensive picture of the clinical radiology workforce in the UK as it stood in October 2022. Key findings The workforce is not keeping pace with demand for services. In 2022, the clinical radiology workforce grew by just 3%. In comparison, demand for diagnostic activity is rising by over 5% annually, and by around 4% for interventional radiology services. The UK now has a 29% shortfall of clinical radiologists, which will rise to 40% in five years without action. By 2027, an additional 3,365 clinical radiologists will be needed to keep up with demand for services. This will have an inevitable impact on the quality-of-care consultants are able to provide. Only 24% of clinical directors believe they had sufficient radiologists to deliver safe and effective patient care. Interventional radiologists are still limited with the care they can provide. Nearly half (48%) of trusts and health boards have inadequate IR services, and only 1/3 (34%) of clinical directors felt they had enough interventional radiologists to deliver safe and effective patient care. Stress and burnout are increasingly common among healthcare professionals, risking an exodus of experienced staff. 100% of clinical directors (CDs) are concerned about staff morale and burnout in their department. 76% of consultants (WTE) who left in 2022 were under 60. We are seeing increasing trends that the workforce is simply not able to manage the increase in demand for services. 99% of departments were unable to manage their reporting demand without incurring additional costs. Across the UK, health systems spent £223 million on managing excess reporting demand in 2022, equivalent to 2,309 full-time consultant positions. Access the full census report here Related content: The benefits of a nursing led Vascular Access Service Team: A White Paper to outline a standardised structure and approach for the NHS to deliver vascular access services in every hospital (27 June 2022)
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Content Article
UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video, founder of UKCVFamily Charlet Crichton talks to us about the side effects she experienced after having the AstraZeneca Covid vaccine. She outlines why she established the group and describes the support it offers to patients. She outlines some of the issues people face when trying to access diagnosis and treatment, and discusses the limitations of the MHRA's Yellow Card scheme in collecting data about adverse reactions. She also describes how healthcare professionals can support people with adverse reactions by taking their concerns seriously and investigating symptoms thoroughly. -
Content ArticleThe ISMP Targeted Medication Safety Best Practices for Hospitals (TMSBP) were developed to identify, inspire, and mobilise widespread, national adoption in the US of consensus-based best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications. The best practice recommendations presented in this guidance document are based on error reports received through the ISMP National Medication Errors Reporting Program (ISMP MERP) and have been reviewed by an external expert advisory panel and approved by the ISMP Board of Trustees. This initiative was first launched in 2014 and is updated with additional best practices, as needed, every two years. While targeted for the hospital-based setting, some best practices are applicable to other healthcare settings. Facilities can focus their medication safety efforts on these Best Practices, which are realistic and have been successfully adopted by numerous organisations.
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Content ArticleThis blog by the Institute for Safe Medication Practices identifies ten medication safety concerns in the US from 2021 that still need to be addressed. These concerns are: Mix-ups between the paediatric and adult formulations of the Pfizer-BioNTech COVID-19 vaccines Mix-ups between the COVID-19 vaccines or boosters and the 2021-2022 influenza (flu) vaccines EPINEPHrine administered instead of the COVID-19 vaccine Preparation errors with the Pfizer-BioNTech purple cap or grey cap COVID-19 vaccines Errors and delays with hypertonic sodium chloride Errors with discontinued or paused infusions Infection transmission with shared glucometers, fingerstick devices, and insulin pens Adverse glycaemic event errors Every organisation needs a medication safety officer Increasing error reporting
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Content ArticleThis dashboard presents the results of a patient safety survey conducted by the European Alliance for Access to Safe Medicines (EAASM) and European Collaborative Action on Medication Errors and Traceability (ECAMET). The dashboard shows variations in different hospital-reported measures of patient safety across thirteen European countries. The questions in the survey focus on accreditation, training, electronic health records and recording, tracking and publishing of medication error data.
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Content ArticleThis case study is featured on the National Institute for Health and Care Excellence (NICE) shared learning database. The associated project aims to optimise the safe use of medicines and reduce avoidable harm to patients. Objectives: To ensure prescribers in GP practices identify and report medication related incidents and near misses via the National Reporting and Learning System (NRLS) (Each practice was required to share at least 4 records with the CCG between April 2017 and March 2018) To enable CCG-wide learning opportunities and prevent further incidents in order to improve patient safety across the CCG (Themes and trends will be disseminated at least quarterly through the Prescribing newsletter). To ensure practices responded to patient safety alerts from the MHRA in a timely manner.
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Content ArticleThis study in JAMA Network Open aimed to investigate how often patients who read open ambulatory visit notes perceive mistakes, and what types of mistakes they report. The results of the study showed that: 1 in 5 patients who read a note reported finding a mistake 40% perceived the mistake as serious the most common mistakes reported were mistakes in diagnoses, medical history, medications, physical examination, test results, notes on the wrong patient and sidedness. The authors suggest that patients may perceive important errors in their visit notes, and inviting them to report mistakes may be associated with improved record accuracy and patient engagement in safety.
