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Content ArticleA fire at the University Hospital of Leicester in 2023 led to the recommendation of a full evacuation of the tertiary neonatal unit. The incident was ultimately stood down—however, it highlighted the lack of inter-agency understanding regarding the difficulty and complexity of moving critically unwell and premature babies in the event of a major incident. In response, the Leicester Royal Infirmary and other agencies staged a simulation exercise to enable teams to prepare for possible future incidents. This HSJ article describes the simulation exercise and the lessons it revealed about managing neonatal unit evacuations during major incidents. It highlights key learnings around the two themes of communication and estates.
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Content Article
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In this blog, Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, explains how she became involved in Appreciative Inquiry and asks the question: what could Appreciative Governance start to look like in the NHS and what small steps can we all do to achieve that together? -
Content ArticleIn healthcare, 'speaking up' refers to when healthcare workers raise concerns regarding patient safety through questions, sharing information, or expressing their opinion to prevent harmful incidents and ensure patient safety. Conversely, withholding voice is an act of not raising concerns, which could be beneficial in certain situations. Factors associated with speaking up and withholding voices are not fully understood, especially in strong authoritarian societies, such as Malaysia. This study aimed to examine the factors associated with speaking up and withholding the voices of healthcare workers in Malaysia, thus providing suggestions that can be used in other countries facing similar patient safety challenges.
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EventuntilSince the publication of the PSIRF learning response toolkit in Aug 2022 healthcare providers across the NHS in England have been exploring the application of different tools made available for learning and improving following a patient safety event. After Action Review (AAR) is one such tool. In response to feedback from providers, NHS England, HSSIB and AAR experts have produced a draft AAR report template to use to summarise the output of an AAR. This webinar will explain the template design and include some reflections from a provider that has tested the template in practice. The draft template is available on FutureNHS here: AAR Resources - NHS Patient Safety - FutureNHS Collaboration Platform Recordings, slides and Q&As will be made available on Future NHS here: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: PSIRF webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, NHS England Melanie Ottewill, HSSIB Judy Walker, AAR expert Jane Carthey, Human Factors and Patient Safety expert Gabby Walters, Royal London and Mile End Hospitals Register
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Content ArticleThe Canadian Medication Incident Reporting and Prevention System (CMIRPS) is a national voluntary medication incident and ‘near miss’ reporting programme founded for the purpose of sharing the learning experiences from medication errors. Implementation of preventative strategies and system safeguards to decrease the risk for error-induced injury and thereby promote medication safety in healthcare is our collaborative goal. Medication incidents (including near misses) can be reported to ISMP Canada (i) through the website: www.ismpcanada.ca/report/ (ii) by telephone: 416-733-3131 or toll free: 1-866-544-7672.
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Content ArticleTotal parenteral nutrition (TPN, also known as PN) is a method of providing nutrition directly into the bloodstream to those unable to absorb nutrients from the food they eat. TPN is used in all age groups, but in babies its use is often as part of a temporary planned programme of nutrition to supplement milk feeds in those too immature to suckle or too sick to receive milk feeds as a result of intestinal conditions. TPN consists of both aqueous and lipid components, which are infused separately into the baby via specific administration sets and infusion pumps. The rate at which TPN is administered to a baby is crucial: if infused too fast there is a risk of fluid overload, potentially leading to coagulopathy, liver damage and impaired pulmonary function as a result of fat overload syndrome. In a recent three and a half year period 10 incidents were identified where infusion of the aqueous and/or lipid component of TPN at the incorrect rate resulted in severe harm to babies through pulmonary collapse, intraventricular haemorrhage or organ damage, and where intensive intervention and treatment were needed. Most of these incidents involved too rapid a rate of infusion.
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News Article
‘Burdensome’ patient safety inquiries taking up too much time, says NHSE chief
Patient Safety Learning posted a news article in News
NHS England’s head of patient safety has suggested too much time and resource is being spent on “burdensome” inquiries to investigate failings in the system. Aidan Fowler said national chiefs want to see a shift away from “looking back 10 years and asking ‘what did we miss’”, and instead wants teams to be resolving problems in real time. At trusts where safety concerns have been highlighted, he said “people descend, and there are a lot of asks, and the pressure mounts, and they end up with an action list of hundreds of things, and it becomes very burdensome – we have to avoid that”. Speaking at a session at the NHS Confederation Expo event in Manchester this week, he encouraged organisations to report concerns early so NHSE can respond more quickly, supporting them and working through problems to prevent public inquiries from needing to happen in the first place. Mr Fowler added: “We have to get more proactive. We will spend less of our time in the future, is the plan, than we are now – doing what I call driving in the rear view mirror. “We don’t want to be looking back 10 years and asking, ‘what did we miss’, we want to be seeing things in real time… we don’t want to be spending our time in big inquiries into failings in the system.” Read full story (paywalled) Source: HSJ, 14 June 2024 -
Content ArticleCurrent adverse effects of medical treatment (AEMT) incidence estimates rely on limited record reviews and underreporting surveillance systems. This study evaluated global and national longitudinal patterns in AEMT incidence from 1990 to 2019 using the Global Burden of Disease (GBD) framework. It found that although the global population increased 44.6% from 1990 to 2019, AEMT incidents rose faster by 59.3%. The net drift in the global incidence rate was 0.631% per year. The proportion of all cases accounted for by older adults and the incidence rate among older adults increased globally. The high SDI region had much higher and increasing incidence rates versus declining rates in lower SDI regions. The age effects showed that in the high SDI region, the incidence rate is higher among older adults. Globally, the period effect showed a rising incidence of risk after 2002. Lower SDI regions exhibited a significant increase in incidence risk after 2012. Globally, the cohort effect showed a continually increasing incidence risk across sequential birth cohorts from 1900 to 1950. As the global population ageing intensifies alongside the increasing quantity of healthcare services provided, measures need to be taken to address the continuously rising burden of AEMT among the older population.
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Content ArticleThis poster from presents preliminary data from a proof-of-concept examining the use of artificial intelligence technology, which can aid medical staff in locating, automatically reporting and effectively classifying safety incidents
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Content ArticleThe Patient Safety Authority's 2023 Annual Report.
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Content ArticleThis template standardises the reporting of After Action Reviews (AARs). It is not intended to be an AAR facilitation guide. The template has been co-designed with staff leading AARs in a range of healthcare organisations. The structure is purposefully simple so that AARs can focus on reflective conversation and do not become a bureaucratic documentation exercise. This structure will continue to be evaluated and developed by the National Patient Safety Team. It can be downloaded from the attachment below or it's available on FutureNHS within the AAR tool space here: https://future.nhs.uk/NHSps/view?objectId=42826256
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Content ArticleThis study sought to understand the types of clinical processes, such as image and medication ordering, that are disrupted during electronic health record (EHR) downtime periods by analysing the narratives of patient safety event report data. Patient safety report data offer a lens into EHR downtime–related safety hazards. Important areas of risk during EHR downtime periods were patient identification and communication of clinical information; these should be a focus of downtime procedure planning to reduce safety hazards. The study concluded that EHR downtime events pose patient safety hazards, and the authors highlight critical areas for downtime procedure improvement.
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Content ArticleWhen healthcare students witness, engage in, or are involved in an adverse event, it often leads to a second victim experience, impacting their mental well-being and influencing their future professional practice. This study aimed to describe the efforts, methods, and outcomes of interventions to help students in healthcare disciplines cope with the emotional experience of being involved in or witnessing a mistake causing harm to a patient during their clerkships or training.
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EventThis training will support the development of expert understanding and oversight of systems based patient safety incident response throughout the healthcare system - in line with NHS guidance, based upon national and internationally recognised good practice. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: PSIRF and associated documents (PSIRP, PSII standards) oversight framework effective oversight and supporting processes related to incident response maintaining an open, transparent, and improvement focused culture importance of communication and involvement of those affected (preventing further harm) commissioning and planning of patient safety incident investigations complex investigations spanning different organisational, care setting, and stakeholder boundaries. WHO SHOULD ATTEND Executives, commissioning, & service managers supporting service lead investigator roles. The following only after attending the 2-day systems approach to patient safety incident response: All Executive, Commissioner and Service Leads for investigation; All Lead investigators conducting patient safety incident investigations investigators conducting. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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EventTraining to support the development of expertise involving patients, families, carers and staff when things go wrong, in line with NHS guidance, based upon national and internationally recognised good practice. To include the duty of candour and ‘being open’ principles. This course covers the end-to-end systems-based patient safety incident response based upon the new NHS PSIRF and includes: Duty of candour regulations. Being open and apologising when things go wrong. Challenges/complexities associated with cases where there is more than one investigation. Effective communication, including dealing with conflict and difficult conversations. Effective involvement of those affected by a patient safety incident throughout the incident response process to ensure a thorough and richer investigation. Sharing findings. Signposting and support: including loss, trauma and stress. WHO SHOULD ATTEND Lead investigators conducting patient safety incident investigations. Executive and service lead for duty of candour. Executive and service lead for patient safety. Executive and service lead for the supporting response to patient safety incidents. Investigators supporting patient safety incident investigations. Register hub members receive a 20% discount. Email info@pslhub.org for discount code.
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Content ArticleIn this opinion piece for BMJ, David Oliver, consultant in geriatrics and acute general medicine, looks at how the professional duty of candour operates in the NHS. In doing so he considers the effectiveness of actions taken in the last five years by the Care Quality Commissioner, General Medical Council and Nursing and Midwifery Council over failure to exercise the duty of candour.
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Content ArticleThis narrative review aimed to investigate adverse events in trauma resuscitation, evaluate contributing factors and assess methods, such as trauma video review (TVR), to mitigate adverse events. The authors found that, when integrated with standardised tools, TVR shows promise for identifying adverse events. They suggest that future research should prioritise linking trauma team performance to patient outcomes and developing sustainable TVR programs to enhance patient safety.
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Content Article
Appreciative inquiry case study
katy.fisher posted an article in Patient Safety Incident Response Framework (PSIRF)
Appreciative inquiry is one of the Patient Safety Incident Response Framework (PSIRF) tools that can be used to learn from patient safety incidents. Katy Fisher, Senior Nurse Quality & Improvement at NHS Professionals, shares how she designed and introduced an appreciative inquiry tool at her hospital.- Posted
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News Article
GPs and patients invited to share views on legal ‘duty of candour’
Patient Safety Learning posted a news article in News
The Government is inviting views on how well GP practices and other NHS organisations are complying with their legal duty of candour when things go wrong. Patients and health professionals are being asked whether the statutory duty is well understood and adequately regulated by the CQC. Under the statutory duty of candour, introduced for all CQC-registered providers in 2015, GP practices must be open and honest with their patients when something goes wrong and has caused harm. In December, the Department of Health and Social Care (DHSC) announced a review into whether healthcare providers are following the duty of candour rules. This was in response to concerns that the duty is not always being met and that there is variation in how the rules are being applied. The DHSC has published its ‘call for evidence’ to gather views on how well the duty of candour obligation is working for both patients and health professionals. Patients have been asked whether GP practices and other providers ‘demonstrate meaningful and compassionate engagement’ with patients who have been affected by an incident. The call for evidence also asks for views on whether the criteria for triggering the duty are appropriate and well understood by staff. Read full story Source: Pulse, 16 April 2024 -
Content ArticleIncident reports of medication errors are valuable learning resources for improving patient safety. However, key information is often contained within unstructured free text, which prevents automated analysis and limits the usefulness of these data. Natural language processing can be used to structure this free text automatically and retrieve relevant past incidents and learning materials, but this requires a large, fully annotated and validated set of incident reports. This study in Nature used a set of 58,658 machine-annotated incident reports of medication errors to test a natural language processing model. The authors provide access to the validation datasets and machine annotator for labelling future incident reports of medication errors.
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Content ArticleThose who use any type of health or social care service have a right to be informed about all elements of their care and treatment. Health and social care providers have that fundamental responsibility to be open and honest with those who are under their management and care. In particular, when things go wrong during the provision of care and treatment, patients and service users and their families or caregivers expect to be informed honestly about what happened, what can be done to deal with any harm caused, and to know what will be done to prevent a recurrence to someone else. In November 2014, the government introduced a statutory (organisational) duty of candour for NHS trusts and NHS foundation trusts via Regulation 20 of the Health and Social Care Act 2008. In essence, the duty places a direct obligation upon trusts to be open and honest with patients and service users, and their families, when something goes wrong that appears to have caused or could lead to moderate harm or worse in the future (known as a ‘notifiable safety incident’). The Department of Health and Social Care (DHSC) are seeking views on the statutory duty of candour for health and social care providers in England. This call for evidence closes at 11:59 pm on 29 May 2024.
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Content ArticleWe know from several reports, reviews, and inquiries over recent years that the patient and family voice has not been heard. These voices are essential to learning and improvement because of their unique insight into how care is delivered. To improve safety we must understand its reality as experienced by patients. In a blog for the Patient Safety Commissioner website, Rosie Benneyworth, interim chief executive officer of the Health Services Safety Investigations Body (HSSIB), explains how HSSIB involves families in its investigations.
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Content ArticleJudy Walker describes how an After Action Review following a sporting event ensured significant learning took place and led to a worldwide change in first aid training.
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Content ArticleClinical guidelines can contribute to medication errors but there is no overall understanding of how and where these occur. This study aimed to identify guideline-related medication errors reported via a national incident reporting system, and describe types of error, stages of medication use, guidelines, drugs, specialties and clinical locations most commonly associated with such errors.
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Content ArticleAs Rob Behren steps down as the Parliamentary and Health Service Ombudsman (PHSO) he records an episode of Radio Ombudsman, reflecting on his seven years in office. He also tells us about his early life, his career before PHSO and shares his future plans.
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