A new case study on NHS England’s atlas of shared learning explores how a Deputy Chief Nurse responsible for safeguarding and harm-free care at Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT) identified an opportunity to use new digital technology to introduce electronic Child Protection-Information Sharing (CP–IS) to the Trust. The CP-IS is now being used to help identify children with particular safeguarding needs whenever they are registered as a patient.
Implementation of the CP-IS has facilitated better information sharing, better outcomes for patient safety and better use of resources, as its introduction has reduced cost and time in supporting children and young people’s administrative process (Source: NHS England).
Royal College of Surgeons of Edinburgh (RCSEd), 2017
The Royal College of Surgeons of Edinburgh (RCSEd) has published a number of critical recommendations to government to greatly improve safety in the delivery of surgical treatment and patient care, with seven recommendations for best practice.
The RCSEd surveyed opinions from a cross-section of the UK surgical workforce – from trainees to consultants – which highlighted broad inefficiencies on the frontline which impact the working environment and the delivery of a safe service.
The report notes factors adversely affecting morale, including a lack of team structure, poor communication, high stress levels, and limited training opportunities. The report also records how staff, at times, feel diverted away from the patient-centred care they strive to deliver because of administrative and IT issues, and believe that being more innovative and efficient with existing resources could make a positive difference.
And while there is no doubt the NHS needs more funding, the report indicates improvements can be made by changing how funding is allocated.
Keeping medical practitioners healthy is an important consideration for workforce satisfaction and retention, as well as public safety | Journal of Patient Safety
However, there is limited evidence demonstrating how to best care for this group. The absence of data is related to the lack of available funding in this area of research. Supporting investigations that examine physician health often “fall through the cracks” of traditional funding opportunities, landing somewhere between patient safety and workforce development priorities. To address this, funders must extend the scope of current grant opportunities by broadening the scope of patient safety and its relationship to physician health. Other considerations are allocating a portion of doctors’ licensing fees to support physician health research and encourage researchers to collaborate with interested stakeholders who can underwrite the costs of studies. Ultimately, funding studies of physician health benefits not only the community of doctors but also the millions of patients receiving care each year.
A patient safety intervention was tested in a 33-ward randomised controlled trial | BMJ Open
Objectives: No statistically significant difference between intervention and control wards was found. We conducted a process evaluation of the trial and our aim in this paper is to understand staff engagement across the 17 intervention wards.
Findings: First, there were palpable differences in the ways that the 17 ward teams engaged with the key components of the intervention. Five main engagement typologies were evident across the life course of the study: consistent, partial, increasing, decreasing and disengaged. Second, the intensity of support for the intervention at the level of the organisation does not predict the strength of engagement at the level of the individual ward team. Third, the standardisation of facilitative processes provided by the research team does not ensure that implementation standardisation of the intervention occurs by ward staff.
Conclusions: A dilution of the intervention occurred during the trial because wards engaged with Patient Reporting and Action for a Safe Environment (PRASE) in divergent ways, despite the standardisation of key components. Facilitative processes were not sufficiently adequate to enable intervention wards to successfully engage with PRASE components.
This resource outlines case studies on improving incident reporting culture, providing feedback to staff involved in incidents, sharing learning across the organisation and changing practice to prevent recurrence.
Graling, P.R. (2017) AORN Journal. 105(3) pp. 317–321
In 1980, McLain identified the top five risk management issues in the OR as wrong patient; wrong procedure performed; improper consent; unreconciled sponge, needle, or instrument count; and burns from equipment.
Approximately 20 years later, the Institute of Medicine report To Err Is Human: Building a Safer Health System described the complexity of health care systems in the United States and the epidemic occurrence of medical errors. Despite widespread awareness of medical errors, there has been little progress in this area to improve patient safety, and sentinel or never events continue to occur in the United States.
It is estimated that 1:10 patients in health care sustain harm that is potentially avoidable and which often highlight system errors that were not appreciated | Faculty of Intensive Care Medicine
Investigation results in the identification of these system errors and the generation of solutions to prevent future incidents. Sharing and implementing these lessons improves patient safety.
National Patient Safety Alerts relevant to intensive care
National alerts are produced in response to analysis of centrally reported patient safety incidents. Details of all alerts may be found on the Central Alerting System website (https://www.cas.dh.gov.uk/Home.aspx).
Lessons from adverse incidents
Lessons from local incidents may not be shared widely and to improve wider patient safety, the Joint Standards Committee of the Faculty and the Intensive Care Society has created this forum to allow lessons from local investigations into adverse incidents to be disseminated to the intensive care community.
We welcome you to share important safety lessons that have occurred in your own departments that may have general relevance. Please use the form below (or your local form if you would prefer) to submit an anonymised summary of the incident, the learning arising and any changes that have been implemented to prevent future a reoccurrence.