To obtain a comprehensive insight of the impact of patient and family engagement on patient safety and identify issues in implementing this approach.. To read the full article, log in using your MPFT NHS OpenAthens details.
Avon & Wiltshire Mental Health Partnership was fined £80,000 in August by Taunton Magistrates’ Court after the trust admitted that it had failed to provide safe care and treatment to people in its care.
The Care Quality Commission brought the prosecution following an incident at Applewood Ward, an inpatient mental health ward unit in Swindon that cares for people who need to be admitted to hospital as a result of severe mental health problems.
In this series of case studies, we highlight what providers have done to take a flexible approach to staffing.
The case studies show different ways of organising services. They focus on the quality of care, patient safety, and efficiency, rather than just numbers and ratios of staff.
They illustrate how providers have redesigned services to make the best use of the available range of skills and disciplines. Or they found new ways to work with others in the local health and care system.
The RCN has published a report outlining the evidence behind its calls for specific legal responsibilities for workforce planning and supply across the health and care system.
The report, titled Standing Up for Patient and Public Safety, follows the release of recent NHS figures showing there are now a record 43,617 vacant nursing posts in the NHS in England.
Free access. Despite consensus that preventing patient safety events is important, measurement of safety events remains challenging. This is, in part, because they occur relatively infrequently and are not always preventable. There is also no consensus on the ‘best way‘ or the ‘best measure’ of patient safety. The purpose of all safety measures is to improve care and prevent safety events; this can be achieved by different means. If the overall goal of measuring patient safety is to capture the universe of safety events that occur, then broader measures encompassing large populations, such as those based on administrative data, may be preferable. Acknowledging the trade-off between comprehensiveness and accuracy, such measures may be better suited for surveillance and quality improvement (QI), rather than public reporting/reimbursement. Conversely, using measures for public reporting and pay-for-performance requires more narrowly focused measures that favour accuracy over comprehensiveness, such as those with restricted denominators or those based on medical record review.
After 9 months of the 18-month Reducing Restrictive Practice programme, staff on Nostell ward reduced their use of ‘restrictive practices’ by 56%. The reductions have been achieved using innovative methods of care, including changing access rules to areas that were previously restricted by time or location, such as the patient’s therapy area. The national programme, which launched in November 2018 and concludes in March 2020, aims to reduce the use of restrictive practices by one third in 41 wards across 25 mental health trusts.
The introduction of standardised patient information boards will improve safety and communication at The Shrewsbury and Telford Hospital NHS Trust (SaTH), which runs the Princess Royal Hospital in Telford and the Royal Shrewsbury Hospital, by providing clear and easy patient information a glance.
The symbols used on the patient information boards are consistent with those already used across the Trust to provide uniformity for staff who move between wards and departments.
Key information on the information boards includes clinical alerts for diabetes, dementia, allergies and if the patient is a risk of falling.
Clinical negligence claims are costly events, both in terms of the harm caused and the expense that results. Helen Vernon, Chief Executive of NHS Resolution, discusses the importance of generating and sharing insight from the harm that can result in clinical negligence claims.
Dr Nikita Kanani, NHS England and NHS Improvement’s Medical Director of Primary Care, describes the changes that will underpin safety improvement in primary care.
The key ingredients for healthcare organisations that want to be safe are: staff who feel psychologically safe; valuing and respecting diversity; a compelling vision; good leadership at all levels; a sense of teamwork; openness and support for learning.
Chief Executive of the West of England Academic Health Science Network and Patient Safety Collaboratives lead Natasha Swinscoe, and Head of Patient Safety Programmes Phil Duncan on how the National Patient Safety Improvement Programme will use continuous quality improvement to deliver safer care.
Giving everyone in the NHS a foundation level understanding of patient safety is critical, but we also need experts to lead on safety in their own organisations. Feedback from the consultation strongly supported the development of a network of patient safety specialists in local systems.
These specialists should be recognised as key leaders within the safety system, visible to their organisations and others, able to support their organisations’ safety work. In some ways the concept is similar to designating someone a Caldicott Guardian, Director of Infection Prevention and Control or Freedom to Speak Up Guardian. But in contrast to these designations we want the introduction of the patient safety specialist concept to develop existing people and roles rather than create new posts.
Prof Wendy Reid, Executive Director of Education and Quality and National Medical Director at Health Education England (HEE), describes the plans for a universal patient safety syllabus and training programme for the whole NHS.
Background: Safe patient handling practices reduce injury risk for healthcare workers (HCW) and patients, but may conflict with goals of rehabilitation and person-centred care by minimizing (a) active participation in transfers and (b) autonomy and dignity while using mechanical lifts. Active assist transfer devices (AATDs) have potential to address both safety and support needs for appropriate clients. You can request a copy of this article by replying to this email. Please ensure you are clear which article you are requesting.
To gain a deeper understanding of the differences in patients and staff perspectives in response to aggression and to explore recommendations on prevention.. To read the full article, log in using your NHS Athens details. To access full-text: click “Log in/Register” (top right hand side). Click ‘Institutional Login’ then select 'OpenAthens Federation', then ‘NHS England’. Enter your Athens details to view the article.
Responding to the Independent Review of Gross Negligence Manslaughter and Culpable Homicide, Danny Mortimer, chief executive of NHS Employers, said: “Employers will welcome this report, which carefully balances an appreciation of the impact of clinical errors and mistakes on patients and their families, and our medical workforce.
Mechanical restraint (MR) is used to prevent patients from harming themselves or others during inpatient treatment. The objective of this study was to investigate whether incident MR occurring in the first three days following admission could be predicted based on analysis of electronic health data available after the first hour of admission.. To read the full article, log in using your NHS Athens details. To access full-text: click “Log in/Register” (top right hand side). Click ‘Institutional Login’ then select 'OpenAthens Federation', then ‘NHS England’. Enter your Athens details to view the article.
Artificial intelligence (AI) has enormous potential to improve the safety of healthcare, from increasing diagnostic accuracy,1 to optimising treatment planning,2 to forecasting outcomes of care.3 However, integrating AI technologies into the delivery of healthcare is likely to introduce a range of new risks and amplify existing ones. For instance, failures in widely used software have the potential to quickly affect large numbers of patients4; hidden assumptions in underlying data and models can lead to AI systems delivering dangerous recommendations that are insensitive to local care processes,5 6 and opaque AI techniques such as deep learning can make explaining and learning from failure extremely difficult.7 8 To maximise the benefits of AI in healthcare and to build trust among patients and practitioners, it will therefore be essential to robustly govern the risks that AI poses to patient safety.. To read the full article, log in using your NHS OpenAthens details.
Active patient participation in safety pathways has demonstrated benefits in reducing preventable errors, especially in relation to hand hygiene and surgical site marking. The authors sought to examine patient participation in a range of safety-related behaviours as well as factors that influence this, such as gender, education, age and language.. To read the full article, log in using your NHS OpenAthens details.
This study aims to explore and understand factors influencing the decisions of mental health professionals releasing service users from seclusion.. To read the full article, log in using your NHS Athens details. To access full-text: click “Log in/Register” (top right hand side). Click ‘Institutional Login’ then select 'OpenAthens Federation', then ‘NHS England’. Enter your Athens details to view the article.
Designed and tested by IHI’s world-renowned safety experts, the Toolkit includes documents on improving teamwork and communication, tools to help you understand the underlying issues that can cause errors, and valuable guidance about how to create and maintain reliable systems. Each of the nine tools includes a short description, instructions, an example, and a blank template.
Krysia Canvin looks at the outcome of a restraint reduction programme (‘REsTRAIN YOURSELF’) to minimise physical restraint in acute mental health services.
This report gives the interim findings from our review of the use of restrictive interventions in places that provide care for people with mental health problems, a learning disability and/or autism.
Safe staffing and coercive practices are of pressing concern for mental health services. These are inter‐dependent and the relationship is under‐researched.. To read the full article, log in using your NHS Athens details. To access full-text: click “Log in/Register” (top right hand side). Click ‘Institutional Login’ then select 'OpenAthens Federation', then ‘NHS England’. Enter your Athens details to view the article.
Open access. The Primary Care Patient Measure of Safety (PC PMOS) is designed to capture patient feedback about the contributing factors to patient safety incidents in primary care. It required further reliability and validity testing to produce a robust tool intended to improve safety in practice.
Open access. Use of physical restraint is a common practice in mental healthcare, but is controversial due to risk of physical and psychological harm to patients and creating ethical dilemmas for care providers. Post-incident review (PIR), that involve patient and care providers after restraints, have been deployed to prevent harm and to reduce restraint use. However, this intervention has an unclear scientific knowledge base. Thus, the aim of this scoping review was to explore the current knowledge of PIR and to assess to what extent PIR can minimize restraint-related use and harm, support care providers in handling professional and ethical dilemmas, and improve the quality of care in mental healthcare.
The University of Southampton report found that hospital wards across the NHS in England are still understaffed and putting patient lives at risk despite new policies coming into force as a result of the 2013 Mid-Staffordshire Inquiry. According to the study, hospitals are facing major challenges in recruiting and retaining registered nurses.
RCN England Director Patricia Marquis said: “It will trouble patients and the public today to hear the experts warn again of the deadly risks being run and that some parts of the NHS have one in five posts vacant, according to this report.”
Professional Psychology: Research and Practice (Apr 11, 2019). DOI:10.1037/pro0000239
Veterans with posttraumatic stress disorder (PTSD) are at elevated risk for engaging in suicidal self-directed violence (S-SDV). Safety Planning has been widely implemented in the Veterans Health Administration to prevent S-SDV; however, limited guidelines exist regarding considerations for Safety Planning with veterans with PTSD. In this article, we discuss clinical considerations to guide health care providers in customizing each step of Safety Planning for veterans with PTSD.. To read the full article, log in using your NHS OpenAthens details.
How do you use information for your work and CPD? What do you think of MPFT library services? Tell us here and you could win £25 vouchers: https://www.surveymonkey.co.uk/r/B2JVNPR
We can all remember individual children in whom a deterioration went unrecognised. Sometimes fatally. Our defences were little more than the pearls offered by senior colleagues of grave warning signs: ‘beware grunting in an infant’ or ‘watch out for a tachycardia after the temperature has fallen’. But this advice was unstructured, and children are so different, and their comorbidities so broad, we failed some of them. Paediatric Early Warning Systems (PEWS) are serious attempts to reduce the unacceptable and dangerous variability in this recognition and response process.. To read the full article, log in using your NHS OpenAthens details.
Our latest blog from University Hospitals Bristol NHS Foundation Trust explains why they are linking healthy, safety and wellbeing in their organisation.
The blog shares examples of their joint working initiatives and talks about how working together has had a positive impact and given a boost to their overall wellbeing offer to their workforce.
One of the five overarching principles of the Mental Health Act: Code of Practice is to provide patients with care and treatment which is least restrictive whilst encouraging recovery and promoting independence. However, there is limited research which explores the application of these principles within a medium secure unit. The aims of the research were to explore what are patient’s experiences of least restrictive practices and to what extent do they perceive that least restrictive practices maximise their independence and recovery.. Please contact the library to request a copy of this article - http://bit.ly/1Xyazai
We've added 10 new Be Aware updates following your suggestions:
Musculoskeletal ; Osteoporosis ; Nutrition and obesity ; Falls ; HR ; Research Methods ; Information Governance ; Bladder, bowel and pelvic healthcare ; Rheumatology ; Medicines and healthcare products regulatory agency (circulated email)
The Secretary of State for Health and Social Care asked us to work with NHS Improvement to look at issues in NHS trusts that contribute to Never Events taking place.
Speaking up is important for patient safety, but healthcare professionals often hesitate to voice their concerns. Direct supervisors have an important role in influencing speaking up. However, good insight into the relationship between managers’ behaviour and employees’ perceptions about whether speaking up is safe and worthwhile is still lacking.. To read the full article, log in using your NHS OpenAthens details.
We'd like to hear your suggestions for new book alert topics. Simply reply to this email with 'Book Alert Topic' and your suggestions. You can also view and sign-up to our current new book alerts here: http://library.sssft.nhs.uk/librarykeepuptodate
In a national report published today, the Care Quality Commission (CQC) found that too many people are being injured or suffering unnecessary harm because NHS staff are not supported by sufficient training, and because the complexity of the current patient safety system makes it difficult for staff to ensure that safety is an integral part of everything they do.
Sheffield Health and Social Care NHS Foundation Trust is reducing harm from tobacco to service users and staff, addressing complex implementation challenges.
The commitment includes a proposal for some of the most important types of avoidable harm to patients to be halved over the next five years in areas such as medication errors and Never Events, alongside developing a ‘just culture’ for the NHS where frontline staff are supported to speak up when errors occur.
An innovative new tool is helping to ensure patient safety at UHNM. PACE (Prevent, Assess, Call-bell, Environment) is a new risk assessment system designed to reduce the likelihood of falls amongst haemodialysis patients. It was developed by Quality Nurse Lisa Ellis and Link Nurse Jo Verdin, who met with staff to talk about why issues may arise and how patient safety can be enhanced.