Digital Clinical Safety Strategy

Digital Clinical Safety Strategy
NHSX , NHS Digital and NHS England and NHS Improvement 17 September 2021

• The strategy is an addendum to the NHS Patient Safety Strategy, outlining the case for improved digital clinical safety across health and social care. The aims of the strategy are to improve the safety of digital technologies in health and care, now and in the future and to identify, and promote the use of, digital technologies as solutions to patient safety challenges.

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement

Learning from patient safety incidents involving acutely sick adults in hospital assessment units in England and Wales: a mixed methods analysis for quality improvement
Journal of the Royal Society of Medicine 4 August 20201
https://doi.org/10.1177%2F01410768211032589 

• Analysis of patient safety incident reports (10 years, 2005–2015) collected from the National Reporting and Learning System which described severe harm/death in acute medical unit (n=377) found that the most common incident types were diagnostic errors (n = 79), medication-related errors (n = 61), and failures monitoring patients (n = 57). To improve patient safety the authors recommend introduction of electronic prescribing and monitoring systems; forcing checklists to reduce diagnostic errors; and increased senior presence overnight and at weekends.

The Safety of Maternity Services in England

The safety of maternity services in England
Health and Social Care Committee 6 July 2021

• This report finds that improvements in the safety of maternity services have been too slow. It recommends urgent action to address staffing shortfalls in maternity services, with staffing numbers identified as the first and foremost essential building block in providing safe care. 
• An accompanying report the Committee commissioned from an expert panel to evaluate government progress on delivering four commitments on maternity services concludes that the government’s overall progress to achieve key commitments in maternity services ‘requires improvement’.

Framework for involving patients in patient safety

Framework for involving patients in patient safety
NHS England 29 June 2021

• This framework provides guidance on how the NHS can involve people in their own safety as well as improving patient safety in partnership with staff: maximising the things that go right and minimising the things that go wrong for people receiving healthcare.

National response to the First Ockenden Report

National Response to the First Ockenden Report
NHS England / NHS Improvement board paper 25 March 2021

• A description of the work in place since publication of the Ockenden report (11 December 2020) and the 7 “Immediate and Essential Actions” (IEAs) to improve care and safety in all maternity services.
• Progress is described in Annex A
• Line of sight from trust level response to the Ockenden Report is described in Annex B

Engaging Patients and Families in Safety: Recommendations, Resources, and Case Examples

Engaging Patients and Families in Safety: Recommendations, Resources, and Case Examples
IHI Team 24 February 2021

• Evidence-based practices, widely known and effective interventions, exemplar case examples, and newer innovations to support the US “Safer Together: A National Action Plan to Advance Patient Safety.”

Introducing our new system for patient safety learning [Blog]

Introducing our new system for patient safety learning [Blog]
NHS England 25 January 2021

• In Spring 2021, a new national Patient Safety Incident Management System (PSIMS) will enter its public beta stage. The new system will be phased in to replace the current National Reporting and Learning System (NRLS). Its aim is to maximise the NHS’s ability to learn from when things go wrong. This blog is an introduction to PSIMS and some of the key features it will bring to support the NHS to make care safer.

Impact of providing patients access to electronic health records on quality and safety of care

Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis
BMJ Quality & Safety 19 November 2020;29:1019-1032.

• A systematic review identified 20 studies (17 387 participants) which evaluate the impact of sharing electronic health records (EHRs) with patients and map it across six domains of quality of care. Analysis supports that sharing EHRs with patients is effective in reducing HbA1c levels, a major predictor of mortality in type 2 diabetes and could improve patient safety.

Investigation into delays to intrapartum intervention once fetal compromise is suspected

Investigation into delays to intrapartum intervention once fetal compromise is suspected
Healthcare Safety Investigation Board 12 November 2020

• This review aimed to identify improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell. It was compiled after a review of 289 maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9 per cent of cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays.

The effects of interoperable information technology networks on patient safety: a realist synthesis.

The effects of interoperable information technology networks on patient safety: a realist synthesis.
Health Serv Deliv Res 2020;8(40)

• Literature searches for three problems that the networks might help to solve: (1) co-ordinating services for older people living at home, (2) ensuring that older people who are prescribed medicines by more than one organisation take the right ones and (3) preventing children who are considered as being at risk coming to harm. 
• There was good evidence in all three searches that there are problems with the co-ordination of services. Similarly, there was evidence in all three searches that professionals find networks difficult to use. But very little evidence about the effects of interoperable networks on patient safety.

Safer care during COVID-19 (PSCs)

Safer care during COVID-19
AHSN Network 8 October 2020

• A rapid-learning report on the role of Patient Safety Collaboratives (PSCs) during the pandemic.

Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation

Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation
BMJ Quality & Safety 25 September 2020. doi: 10.1136/bmjqs-2020-010988

• Following a multisite ethnography with staff across six maternity units and stakeholders [Cambridge, UK] the researchers identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety).

Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy

Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy
BMJ Quality & Safety 2020;29:1-2. 18 September 2020

• While there are many anecdotal accounts of successful hospital based patient safety huddle programmes, analysis of the published evidence around identified 24 articles, of which there were only 2 controlled studies. The authors propose a taxonomy and standardised reporting measures for future huddle-related studies to enhance comparability and evidence quality. 

Abstract 

A Guide to Patient Safety Improvement: Integrating Knowledge Translation & Quality Improvement Approaches

A Guide to Patient Safety Improvement: Integrating Knowledge Translation & Quality Improvement Approaches
Canadian Patient Safety Institute 2020

• This Guide is intended to accompany current best available evidence change ideas, and tools and resources for your specific project. It includes ideal practice changes “the what” and strategies “the how” that creates the evidence-based intervention.

Identifying Patient Safety Specialists

Identifying Patient Safety Specialists
NHS England 25 August 2020

• Patient Safety Specialists will play a key part in the new NHS Patient Safety Strategy. This document outlines key requirements of the role, and how they will work in their own organisation, as well as with local, regional and national partners. NHS organisations in England have been asked to identify one or more person as their designated Patient Safety Specialist(s).
• Patient safety specialists are expected to be in place from April 2021.

Better than cure: Injury prevention policy

Better than cure: Injury prevention policy
IPPR 13 August 2020

• In the United Kingdom, injuries are the leading cause of preventable death in children and young people, and of preventable years of life lost up to age 65. This report address the disconnect between the importance of injury prevention and its neglect in terms of funding, enforcement and strategy. In particular it examines workplace injuries, medical injuries (including patient safety), and travel injuries.
• The report discusses barriers to learning from, about, and for patient safety in particular from the patients themselves and suggests that "uptake of best practice could be disseminated more widely and more quickly through the launch of a patient safety network, which would see those performing best on patient safety designated as ‘anchor institutions’, partnered with a range of providers within their footprint, and given a lead role in raising performance. The focus within the networks should be tackling clearly defined problems through shared learning, training, and peer support."

Exploring the feasibility of patient safety huddles in general practice

Exploring the feasibility of patient safety huddles in general practice
Primary Health Care Research and Development 27 July 2020 https://doi.org/10.1017/S1463423620000298

• Responses by GP practices in West Yorkshire highlight the challenges to introducing patient safety huddles within the current context of UK general practice.

Abstract

Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety

Demonstrating the value of postgraduate fellowships for physicians in quality improvement and patient safety
BMJ Quality & Safety 2020;29:645-654.

• Graduates and mentors of two postgraduate quality improvement (QI) and patient safety (PS) (QIPS) fellowship programmes for physicians embedded within two US academic medical centres were interviewed using newly developed interview instruments.The conceptual framework developed may be useful to other academic medical centres seeking to develop fellowships for postgraduate physician training programmes in QIPS.

Abstract

Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis

Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis
BMJ Quality & Safety 20 May 2020. doi: 10.1136/bmjqs-2020-010927

• A systematic review of the evidence around impact of medication-related interventions on hospital readmissions, medication-related problems, medication adherence and mortality identified 14 original studies n=8182 patients). Interventions consisted mainly of patient education and medication reconciliation in the hospital, and patient education following discharge. Meta analysis indicates that the interventions reduce all-cause hospital readmissions within 30 days and that treatment effects appear to increase with higher intervention intensities.

Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy

Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy
BMJ Quality & Safety 07 April 2020. doi: 10.1136/bmjqs-2019-009911

• A systematic review of peer-reviewed literature related to scheduled, multidisciplinary, hospital-based safety huddles (n=24) found anecdotal accounts of successful huddle programmes and while the evidence appears favourable overall there is little high quality evidence. The reviewers propose a taxonomy and standardised reporting measures for future huddle-related studies.