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Patient Safety & Risk
Recently published guidance, policies, articles and reports
December 2015 - February 2016
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To access full text you may have to log in to your NHS Athens account (click here to register for free). If full text is not available then please email us to request a copy.
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February 2016
Department of Health - Consultation outcome: Pharmacy legislation on dispensing errors and standards
Seeks views on proposals for changes to the legislation on dispensing errors and registered pharmacy standards and other related matters.
General Medical Council - Confidentiality guidance consultation
The General Medical Council has restructured its guidance to make it easier to use, and has expanded advice in a range of areas, including on sharing information about adults at risk of harm, and doctors’ data protection responsibilities.
Health Quality Improvement Partnership - Hip fracture: 30-day mortality rate
The Health Quality Improvement Partnership has published National Hip Fracture Database (NHFD): an analysis of 30-day mortality in 2014. This document is a supplement to the 2015 audit annual report which presented results from over 64,000 patients who were admitted for hip fracture during 2014. The supplement analyses data from the Office for National Statistics which indicates the overall mortality rate within 30 days of hip fracture in 2014 was 7.5%. This continues a pattern of progressive improvement from 8.5% in 2011.
NHS England- National maternity review
NHS England has published Better Births Improving outcomes of maternity services in England: a five Year forward view for maternity care. This report details recommendations for how services should change over the next five years. It finds that despite the increases in the number of births and the increasing complexity of cases, the quality and outcomes of maternity services have improved significantly over the last decade. The framework describes seven key priorities to drive improvement and ensure women and babies receive excellent care wherever they live, and to make care more personal and family friendly.
Additional link: BBC News report Royal College of Midwives RCOP press release
JAMA - Sepsis resources
http://jamasepsis.com/
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January 2016
Royal College of Radiologists - Patients at risk from a lack of systems for communicating abnormal imaging test results
The Royal College of Radiologists (RCR) has carried out an audit of UK hospitals to find out how many have fail-safe procedures in place to ensure that reports containing critical, urgent or unexpected significant findings get through and are acted on. The RCR found that 12% of hospitals have no agreed policy for alerting GPs and consultants when X-rays or scans show such findings.
Health Education England - Patient Safety concerns
Health Education England has released a film aimed at improving patient safety. Responding to concerns aims to equip staff with the knowledge, skills and confidence to adequately and safely respond to patient safety concerns. It covers three scenarios; an experienced community nurse not washing her hands, a near miss in an operating theatre and poor communication between services.
Parliamentary Ombudsman Service - Older people more reluctant to complain about NHS services
The Parliamentary Ombudsman Service has published Breaking down barriers. This report highlights that older people are often more reluctant to speak up, or simply don’t know how to complain when they receive poor care. The report makes a number of recommendations to improve older people’s experience of the complaints system these include: wanting all NHS providers to make older people aware of how to complain, pointing them to the support that is available to them, and make it clear that their future care will not be compromised if they complain.
Additional link: BBC news report
Academy of Medical Royal Colleges - Managing invited reviews within healthcare
The Academy of Medical Royal Colleges, the Royal College of Midwives and Royal College of Nursing have published A framework of operating principles for managing invited reviews within healthcare. The purpose of the framework is to ensure that there are similar principles, standards and working practices across non-statutory external reviews of NHS clinical services carried out by Colleges, professional bodies or other organisations.
Health Education England - New film helps NHS managers respond to safety concerns
‘Responding to Concerns’, a new educational film that aims to improve patient safety has been launched by Health Education England (HEE). Developed with input from patient safety experts, the film aims to equip staff with the knowledge, skills and confidence to adequately and safely respond to patient safety concerns.
NHS Safety Thermometer Report - December 2014 - December 2015
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December 2015
National Patient Safety Foundation - Free from Harm: Accelerating Patient Safety Improvement Fifteen Years after To Err Is Human
Fifteen years after the Institute of Medicine brought public attention to the issue of medical errors and adverse events, patient safety concerns remain a serious public health issue that must be tackled with a more pervasive response. The resulting report calls for the establishment of a total systems approach and a culture of safety, and calls for action by government, regulators, health professionals, and others to place higher priority on patient safety science and implementation.
NHS England - Sepsis action plan
NHS England has published Improving outcomes for patients with sepsis: a cross-system action plan. This document contains a summary of the key actions that health and care organisations across the country will take to improve identification and treatment of sepsis. It is intended for those working across the health and social care landscape including provider organisations, commissioners, and healthcare professionals.
The Health Foundation - Leading in a crisis
The Health Foundation has published a thought paper Leading in a crisis: the power of transparency. The authors review the management of serious clinical crises in the United States, lessons learned from other industries, and the experience of the Mid-Staffordshire crisis in the NHS. They look at legal and media barriers to effective action, review lessons learned from the ‘second victim’ literature and provide recommendations for action for both organisations and leaders.
Local Government Association - Independent health complaints advocacy services
The Local Government Association has published Practice guidelines for independent health complaints advocacy services. This guidance provides a practical tool for local providers and commissioners to use in order to agree local independent health complaints advocacy service specifications, which are based on desired outcomes for the people who use the service.
Parliamentary and Health Ombudsman Service - Quarterly reports on complaints about acute trusts
The Parliamentary and Health Ombudsman Service has published Q2 2015-16 Complaints about acute trusts. The data cover complaints about acute trusts made between July and September 2015 and include the total number of initial complaints the ombudsman has received; the number of these complaints accepted for investigation; and the outcome of investigations.
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Selected articles
The role of emotion in patient safety: are we brave enough to scratch beneath the surface?
Source: Journal of the Royal Society of Medicine
Date of publication: February 2016
Abstract: Healthcare professionals work in emotionally charged settings; yet, little is known about the role of emotion in ensuring safe patient care. This article presents current knowledge in this field, drawing upon psychological approaches and evidence from clinical settings.
Link to abstract: http://jrs.sagepub.com/content/109/2/52 Contact the Clinical Librarian Service for the full text.
Safety climate strength: a promising construct for safety research and practice
Source: BMJ Quality and Safety
Date of publication: January 2016
Abstract: Despite some notable advances in patient safety…. substantially reducing or eliminating harm remains elusive for nearly every healthcare organisation. One consistent recommendation for becoming harm-free is developing a strong safety climate or shared employee perceptions that safety is organisationally rewarded, supported, valued and prioritised relative to other organisational goals.
Link to full text: http://qualitysafety.bmj.com/content/early/2016/01/25/bmjqs-2015-004847.full
Video transparency: a powerful tool for patient safety and quality improvement
Source: BMJ Quality and Safety
Date of publication: January 2016
Abstract: Video recording is taking centre stage in healthcare as technology increasingly allows it to be feasible and streamlined. Despite some fears that video will be used for the wrong purposes, we anticipate that a growing physician and public demand for accountability will reward hospitals and surgical centres that lead the way in advancing this highly effective tool. Leading academic centres will likely be the first to pioneer video transparency, and many have already started to do so. As the medical community continues to seek high-impact ways of advancing patient safety and quality, implementing videos with feedback represents the next great leap forward.
Link to full text: http://qualitysafety.bmj.com/content/early/2016/01/28/bmjqs-2015-005058.full
Personal hand gel for improved hand hygiene compliance on the regional anesthesia team
Source: Journal of Anesthesia
Date of publication: December 2015
Abstract: Hand hygiene reduces healthcare-associated infections, and several recent publications have examined hand hygiene in the perioperative period. Our institution’s policy is to perform hand hygiene before and after patient contact. However, observation suggests poor compliance. This is a retrospective review of a quality improvement database showing the effect of personal gel dispensers on perioperative hand hygiene compliance on a regional anesthesia team.
Methods: Healthcare providers assigned to the Acute Pain Service were observed for compliance with hand hygiene policy during a quality improvement initiative. Provider type and compliance were prospectively recorded in a database. Team members were then given a personal gel dispensing device and again observed for compliance. We have retrospectively reviewed this database to determine the effects of this intervention.
Results: Of the 307 encounters observed, 146 were prior to implementing personal gel dispensers. Compliance was 34 %. Pre- and post-patient contact compliances were 23 and 43 %, respectively. For 161 encounters after individual gel dispensers were provided, compliance was 63 %. Pre- and post-patient contact compliances were 53 and 72 %, respectively. Improvement in overall compliance from 34 to 63 % was significant.
Conclusion: On the Acute Pain Service, compliance with hand hygiene policy improves when individual sanitation gel dispensing devices are worn on the person.
Link to full text article: http://link.springer.com/article/10.1007/s00540-015-2058-0
Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data
Source: PLOS One
Date of publication: December 2015
Abstract:The National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.
Link to full text: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0144107
Simulation in the Executive Suite: Lessons Learned for Building Patient Safety Leadership
Source: Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare
Date of publication: December 2015
Abstract: Introduction: Simulation is a powerful learning tool for building individual and team competencies of frontline health care providers with demonstrable impact on performance. This article examines the impact of simulation in building strategic leadership competencies for patient safety and quality among executive leaders in health care organizations.
Methods: We designed, implemented, and evaluated a simulation as part of a larger safety leadership network meeting for executive leaders. This simulation targeted knowledge competencies of governance priority, culture of continuous improvement, and internal transparency and feedback. Eight teams of leaders in health care organizations—a total of 55 participants—participated in a 4-hour session. Each team performed collectively as a new chief executive officer (CEO) tasked with a goal of rescuing a hospital with a failing safety record. Teams worked on a modifiable simulation board reflecting the current dysfunctional organizational structure of the simulated hospital. They assessed and redesigned accountability structures based on information acquired in encounter sessions with confederates playing the role of internal staff and external consultants.
Results: Data were analyzed, and results are presented as qualitative themes arising from the simulation exercise, participant reaction data, and performance during the simulation. Key findings include high degrees of variability in solutions developed for the dysfunctional hospital system and generally positive learner reactions to the simulation experience.
Conclusions: This study illustrates the potential value of simulation as a mechanism for learning and strategy development for executive leaders grappling with patient safety issues. Future research should explore the cognitive or functional fidelity of organizational simulations and the use of custom scenarios for strategic planning.
Link to abstract:
http://journals.lww.com/simulationinhealthcare/Abstract/2015/12000/Simulation_in_the_Executive_Suite__Lessons_Learned.7.aspx Contact the Clinical Librarian Service for the full text.
Human factors in healthcare: welcome progress, but still scratching the surface
Source: BMJ Quality and Safety
Date of publication: December 2015
Abstract: Calls to integrate human factors and ergonomics (HFE) within healthcare and patient safety have become increasingly frequent in the last few years.1 Judging by the number of recent articles in BMJ Quality and Safety that focus on HFE,2–4 we seem to be a step closer to achieving this goal. Within the USA and UK, groups such as the Human Factors and Ergonomics Society (HFES), the Chartered Institute of Human Factors and Ergonomics (CIEHF) and the Clinical Human Factors Group (CHFG) are also making significant progress in working with clinicians, healthcare managers and patients. Developments such as the UK NHS Concordat on Human Factors and Healthcare5 and increasing interest from the US Food and Drug Administration (FDA) attest to this progress. These are welcome developments; however, there is still some way to go. This editorial aims not to undo these nascent HFE integration efforts within patient safety, but to build on previous articles describing some of the misconceptions and misunderstandings that sometimes surround HFE.6 ,7 Many of these are not unique to patient safety, and some have acted as a barrier impeding efforts to integrate the discipline within other industries.7 There is a risk of repeating history and, in the worst case, revisiting past debates and discussions within HFE. By considering the history, evolution and spread of HFE, we hope to enhance translation into healthcare lessons from industries such as aviation, oil and gas, the nuclear sector, defence and rail transport, which make up the rich heritage of research and practice in HFE over the course of the last 50 or so years.
Link to abstract: http://qualitysafety.bmj.com/content/early/2015/12/18/bmjqs-2015-005074.extract Contact the Clinical Librarian Service for the full text.
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Resources used:
Academy of Medical Royal Colleges
BMJ Quality and Safety
Daily Health Bulletin
Department of Health
General Medical Council
Health and Social Care Information Centre
Health Education England
The Health Foundation
Health Quality Improvement Partnership
JAMA
Journal of Anesthesia
Journal of the Royal Society of Medicine
Local Government Association
NHS England
National Patient Safety Foundation
Parliamentary and Health Ombudsman
Parliamentary Ombudsman Service
PLOS One
Royal College of Radiologists
Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare
Links checked: 02/03/2016
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