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.
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.
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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.
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.
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.
Free access. Incident reporting has been a mainstay of patient safety initiatives throughout the world, but its purpose and potential for stimulating safety improvements are still much debated. Record review studies of adverse events revealed the nature and scale of harm to patients, and it was initially hoped that incident reporting systems would capture these adverse events on an ongoing basis.1 2 This epidemiological dream was never realised; studies showed that incident reporting was actually very poor at identifying adverse events.3 Furthermore, incident reporting, record review and other systems such as pharmacy reports capture very different types of problems, which means that combining information sources can provide a more complete picture of safety issues.4 5
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.
The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project included a cluster-randomised, stepped wedge, controlled study to evaluate multiple strategies to prevent catheter-related bloodstream infection. We report an in-depth investigation of the main barriers, facilitators and contextual factors relevant to successfully implementing these strategies in European acute care hospitals.
. To read the full article, log in using your NHS OpenAthens details.
Open access. Editorial. An enduring challenge for the improvement of healthcare quality is variation in the success of quality improvement (QI) interventions when implemented across settings.1 This is particularly true in the field of healthcare-associated infection (HAI) prevention. Some of the brightest success stories in QI have emerged from large-scale efforts to reduce HAIs such as central venous catheter-related bloodstream infections (CRBSIs)2 or catheter-associated urinary tract infections.3 The light dims, however, when efforts to export these interventions to other settings fail to meaningfully improve outcomes.4 5
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Open access. Healthcare organisations often fail to harvest and make use of the ‘soft intelligence’ about safety and quality concerns held by their own personnel. We aimed to examine the role of formal channels in encouraging or inhibiting employee voice about concerns.
Patient safety measurement remains a global challenge. Patients are an important but neglected source of learning; however, little is known about what patients can add to our understanding of safety. We sought to understand the incidence and nature of patient-reported safety concerns in hospital.. To read the full article, log in using your NHS OpenAthens details.
We're expanding our Be Aware updates and want to know what physical health topics you'd like to keep updated on. Let us know your ideas by replying to this email with 'physical health topics' followed by your suggestions
Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care.. To read the full article, log in using your NHS OpenAthens details.
The NHS is today publishing guidance to help trusts work with bereaved families and carers.
Over 70 families and carers worked with NHS England on the guidance which will provide advice to hospitals, mental health and community trusts on how to involve families following the death of a loved one.
Developed to share common critical issues initially identified from CQC’s criminal prosecution work against nine health and care providers that have failed to provide care and treatment in a safe way; each of the resources describe the issue – what happened, what CQC and the provider did about it and the steps that can be taken to prevent similar serious incidents from happening again in the future.
Deputy Chief Inspector of Hospitals, lead for mental health, Dr Paul Lelliott has written to specialist mental health NHS trusts in England to inform them of an upcoming workshop to explore what can be done to improve sexual safety on mental health wards and thank trusts for engaging with CQC on this work.
The CQC has published a focused report on the safety of one ward at South West Yorkshire Partnership NHS Foundation Trust following an inspection in December 2017.
A report published by Picker and The King’s Fund has uncovered striking associations between NHS staff and patients’ experiences in hospitals and NHS trusts’ reliance on agency healthcare workers.
Measurement is a vital part of improvement work. While it is known that the context of improvement work influences its success, less is known about how context affects measurement of underlying harms. We sought to explore the use of a harm measurement tool, the NHS Safety Thermometer (NHS-ST), designed for use across diverse healthcare settings in the particular context of community care. . To read the full article, log in using your NHS OpenAthens details.
Open access. Quality and safety in healthcare, as an academic discipline, has made significant progress over recent decades, and there is now an active and established community of researchers and practitioners. However, work has predominantly focused on physical health, despite broader controversy regarding the attention paid to, and significance attributed to, mental health. Work from both communities is required in order to ensure that quality and safety is actively embedded within mental health research and practice and that the academic discipline of quality and safety accurately represents the scientific knowledge that has been accumulated within the mental health community.
A safety organisation drawing on lessons from the airline industry will have new legal powers to investigate serious patient safety incidents in the NHS in England, under plans laid before parliament today (14 September 2017).
A ‘Trigger Tool’ is used around the world to identify case-notes that warrant further search for adverse events. This paper shows we can get rid of Trigger Tools and just review random notes – we will find just as many adverse events. If we want a ‘canary in the mineshaft’ then we should examine adverse events in case-notes of patients who have died – they have a much higher than random adverse event rate.
Memory, and remembering the past, are fundamental to patient safety. One of the core objectives of safety improvement is to learn from the past in order to improve the future. This commitment to remember and to learn is central to the strategies that have shaped the evolution of patient safety such as ‘An organisation with a memory’,1 and underpins definitive academic research such as Bosk's ‘Forgive and Remember’.2 Remembering the past to improve the future is institutionalised across healthcare in a variety of activities such as safety incident reporting, morbidity and mortality meetings, coroner investigations and public inquiries. Despite this, healthcare systems still suffer striking and acute episodes of forgetfulness3 that are deeply consequential: when harmful events are forgotten, they are likely to be repeated. To read the full article, log in using your NHS OpenAthens details.
Open access. It is now 15 years since Bell and Redelemeier published their landmark study demonstrating higher mortality for people admitted to hospital during weekdays compared with the weekend.1 Examining the records of 3.8 million patients admitted over a 10-year period to emergency departments in Ontario, Canada, this ‘weekend effect’ existed over a range of acute conditions, including 23 out of the 100 leading causes of death.
Since that paper in 2001, over 100 studies have explored the weekend effect, across a range of patient populations and health systems.2 Surprisingly, despite this large number of studies, there remains ongoing debate about whether the weekend effect exists, and if so, what causes it......
The guide, Better Questions, Safer Care, builds on our work for the Measuring and Monitoring of Safety Framework with The Health Foundation, and contains a range of useful resources to help health and care professionals to take a more holistic approach when looking at the safety of care.
We’ve just heard that SSOTP will not be renewing their agreement with SSSFT LKS for library services for this financial year. Because of this we will be reviewing our Be Aware bulletins. Sadly we won’t be accepting any new sign-ups from SSOTP staff and will be withdrawing some of the physical healthcare bulletins that we…
Calling for the rest of the UK to follow the example of Wales and enshrine safe staffing in law, the RCN reports that a dangerous set of pressures is putting patient safety at risk.
Leeds Teaching Hospitals NHS Trust and SFJ Awards have launched a new Level 5 Qualification to ensure staff recognise and develop the knowledge and skills required for intevestigating serious incidents in healthcare care.
The government must do more to coordinate its efforts to establish a culture of open-minded learning and investigation within the NHS in England, says the Public Administration and Constitutional Affairs Committee in its report.
Our review of the way NHS trusts review and investigate deaths has found that opportunities to learn from patient deaths are being missed – and too many families are not being included or listened to when an investigation takes place.
A year after a review commissioned by NHS England uncovered failings at Southern Health Foundation Trust, we look at how acute, community and mental health trusts across the country investigate and learn from deaths of people who have been in their care.
IHealth Education England (HEE) has worked with Public Concern at Work and the National Guardian Office to develop a package of online learning resources that aim to encourage and support NHS staff to raise and respond to concerns.
Available on HEE’s e-Learning for Healthcare (e-LfH) website, two e-learning sessions promote relevant policies, procedures, best practice and available support in relation to raising and responding to concerns.
The consultation outlines a proposal to legally make sure information provided by staff as part of a health service investigation is kept confidential except in limited circumstances, i.e. where there is an immediate risk to patient safety, or where the High Court makes an order permitting disclosure. The proposal aims to reassure staff that the information they provide will not be passed on, while assuring patients and families that they will be given full facts about their care.
Health Education England's e-Learning for Healthcare team (HEE e-LfH) has developed a new online resource for healthcare staff to equip them with the necessary knowledge and confidence to raise public interest concerns.
Safe staffing decisions should be made locally and not be governed by ratios [brief news item]. To read the full article, log in using your NHS OpenAthens details
The average person remembers less than half of the information provided by healthcare professionals during a medical visit.1 The situation is arguably most challenging for patients leaving the hospital, where acute illness, sleep deprivation and delirium add to the challenge of learning and memory.2 ,3 Indeed, research has shown that after hospital discharge, only 59.6% of patients are able to accurately describe their discharge diagnoses, and 43.9% can accurately recall follow-up appointments.4 Approximately one-third of patients have difficulty understanding their discharge medication regimen.5 To read the full article, log in using your NHS OpenAthens details
Come and visit our first pop-up library at Severn Fields, Shrewsbury 19th July 11.00am-3.00pm. Join the library, borrow and return books, get help finding information and evidence, set up an Athens account, find out what the library can do for you and your team.
We're looking at how NHS acute, community healthcare and mental health trusts investigate deaths and learn from their investigations. We also want to assess whether opportunities to prevent deaths have been missed.
A fully independent ‘Guardian Service’ is being launched for the North Essex Partnership University NHS Foundation Trust (NEP) where staff can discuss any matters relating to service users care and safety, whistleblowing, bullying and harassment, and work grievances in complete confidence.
The report makes recommendations about establishing the Healthcare Safety Investigation Branch (HSIB) as well as how to improve investigation, and learning from investigation, across the health system.
Clinical summaries are electronic health record (EHR)-generated documents given to hospitalised patients during the discharge process to review their hospital stays and inform postdischarge care. Presently, it is unclear whether clinical summaries include relevant content or whether healthcare organisations configure their EHRs to generate content in a way that promotes patient self-management after hospital discharge. We assessed clinical summaries in three relevant domains: (1) content; (2) organisation; and (3) readability, understandability and actionability. To read the full article, log in using your NHS OpenAthens details
Safe staffing levels across the NHS have worsened significantly in the last year, according to UNISON’s UK-wide annual survey of nursing professionals published today (Monday), at the start of its annual health conference in Brighton.
Quality and patient safety are the highest priorities of provider boards. NHS providers will have noticed a renewed national focus on building cultures of safety and improvement across NHS organisations, and greater proficiency at learning from mistakes and spreading good practice.
Despite a strong reporting culture in trusts, evidenced by over 1.8 million entries into the National Reporting and Learning System (NRLS) last year, widespread translation of reporting into routine learning and demonstrable improvement has yet to happen.
CQC is carrying out a review of how NHS trusts identify, report, investigate and learn from deaths of people using their services.
This follows a request from the Secretary of State for Health, which was part of the Government’s response to a report into the deaths of people with a learning disability or mental health problem in contact with Southern Health Foundation NHS foundation Trust.
CQC’s review will consider the quality of practice in relation to identifying, reporting and investigating the death of any person in contact with a health service managed by an NHS trust; whether the person is in hospital, receiving care in a community setting or living in their own home. The review will pay particular attention to how NHS trusts investigate and learn from deaths of people with a learning disability or mental health problem.
The first national, integrated whistleblowing policy has been published by NHS Improvement and NHS England, with the aims of standardising the way that staff are supported to raise concerns within NHS organisations.
Its release follows a public consultation on the draft policy, held throughout November 2015.
Health information technology (health IT) has potential to improve patient safety but its implementation and use has led to unintended consequences and new safety concerns. A key challenge to improving safety in health IT-enabled healthcare systems is to develop valid, feasible strategies to measure safety concerns at the intersection of health IT and patient safety. In response to the fundamental conceptual and methodological gaps related to both defining and measuring health IT-related patient safety, we propose a new framework, the Health IT Safety (HITS) measurement framework, to provide a conceptual foundation for health IT-related patient safety measurement, monitoring, and improvement.....To read the full article, log in using your NHS OpenAthens details
Two nurses from Burton Hospitals NHS Foundation Trust have led an innovative project that is putting information on ‘hot topics’ relating to quality and safety literally at the fingertips of nurses, midwives and nursing assistants.
In hospitals, breakdowns in communication has been found to be a major source of errors.1 Communication between clinicians can occur at scheduled times or rounds, through face-to-face meetings or may be facilitated through the use of communication tools such as pagers. For the latter, often urgent communication between clinicians about a patient is required. Problems in communication can result in a failure to rescue or result in poor coordination of care. To read the full article, log in using your NHS Athens
Two £25 vouchers are up for grabs in the library’s ‘Making the Most of Information’ survey.
To take part, just visit http://goo.gl/AdN4ok by Friday 19th February.
Four evidence reviews written to support work NICE carried out on staffing levels in the NHS have been released. Under the Freedom of Information (FOI) Act, the documents had been withheld to give NHS Improvement time to study them in their new remit to consider service improvement. The release of the documents follows an internal review of the FOI decision.
In 2013 the Francis and Berwick reports, published in the wake of care failings at the Mid Staffordshire NHS Trust, identified NICE as a key player to help advise the NHS on staffing levels. The Department of Health and NHS England asked NICE to begin work developing evidence based guidelines focusing on nursing care, one of the main drivers of patient safety.
‘Responding to Concerns’, is a new educational film developed by Health Education England that aims to improve patient safety. Developed with input from patient safety experts, including our raising concerns network, the film aims to equip staff with the knowledge, skills and confidence to adequately and safely respond to patient safety concerns.
Four evidence reviews written to support work NICE carried out on staffing levels in the NHS have been released. Under the Freedom of Information (FOI) Act, the documents had been withheld to give NHS Improvement time to study them in their new remit to consider service improvement. The release of the documents follows an internal review of the FOI decision.
We have announced today the appointment of Dame Eileen Sills, the Chief Nurse at Guy's and St Thomas' NHS Foundation Trust, as the first National Guardian for speaking up safely in the NHS.
A patient safety alert has been issued by NHS England to raise awareness of the importance of taking, recording and responding to vital signs where restraint has been used to manage a person’s behaviour if they are at risk to themselves or others.
We're currently making some changes in the background of our email updates to solve some problems we've been having recently. During our testing phase this may automatically generate some alerts, which will show below, but you can ignore these! If all goes according to plan we will be resuming normal service in the next week…