New report focuses on recommendations to make ambulance transfers safer

Healthcare Safety Investigation Branch | January 2019 | New report focuses on recommendations to make ambulance transfers safer

A new report from the Healthcare Safety Investigation Branch, Transfer of Critically Ill Adults shows that a lack of national guidance and standard practice for ambulance transfers could be putting patients at risk. 

The report puts forward key recommendations aimed at making transfers safer for adults that are critically ill.

hsib
Image source: hsib.org.uk

This investigation was launched after the Healthcare Safety Investigation Branch were notified of the case of Richard, a 54-year old man, who died during an emergency transfer to a specialist care centre. He had been diagnosed with an acute aortic dissection after experiencing chest pain during exercise earlier that day. Aortic dissection occurs when the innermost layer of the wall of the aorta tears, allowing blood at high pressure to flow in between the layers forcing them apart.

Safety recommendations

The report sets out two safety recommendations:

Patient Safety Collaboratives

NHS Improvement| January 2019 | Patient Safety Collaboratives: A retrospective review 

Almost five years since the establishment of  Patient Safety  Collaboratives (PSCs), NHS Improvement  commissioned a review (in 2018) to better understand the mechanics of the delivery of PSCs, the impact of the programme, and to make recommendations for the recommissioning of the PSCs.

he operational delivery and impact of the Patient Safety Collaborative programme. This report gives its findings and recommendations to strengthen the programme, i.

This review makes 13 recommendations to strengthen the programme, including greater collective focus on priority workstreams and alignment to the forthcoming patient safety strategy, building on momentum achieved to date, and informs the future operating model and commission for the PSCs (Source: NHS England).

NHS Improvement Patient Safety Collaboratives A retrospective review

NHS Safety Culture: Opening the door to change

Care Quality Commission | December 2018 | NHS Safety Culture: Opening the door to change

The CQC collaborated with NHS Improvement to look at issues in NHS trusts that contribute to Never Events taking place. These are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed.

 

opening the door
Image source: cqc.org.uk

Their review sought to answer 4 questions:

  • How do trusts regard existing guidance to prevent Never Events?
  • How effectively do trusts use safety guidance?
  • How do other system partners support the implementation of safety guidance?
  • What can we learn from other industries?

To this end the CQC visited 18 NHS trusts (both acute and mental health) during April and June 2018. They conducted one-to-one interviews, visited different services and reviewed policies and procedures.

CQC also consulted aviation, nuclear and fire and rescue industries to understand other safety-critical industries’ approach to safety.

Although patient safety alerts are generally seen as an effective way to share safety guidance, the context in which they are landing creates challenges for trusts. The report identifies challenges faced by trusts, by the health system as a whole, and in educating and training staff (Source: CQC).

Full news release from CQC 

Opening the door to change 

Opening the door to change Summary

Related:

NHS Improvement Never events data 

Consultation on a national patient safety strategy for the NHS

NHS Improvement| December 2018 | Consultation on a national patient safety strategy for the NHS

NHS Improvement are developing proposals for a new national patient safety strategy to support the NHS to be the safest healthcare system in the world. The strategy is being developed alongside the NHS Long Term Plan and will be relevant to all parts of the NHS, be that physical or mental health care, in or out of hospital and primary care. To make sure the strategy works for patients, NHS staff and providers, they are currently consulting on their proposals. 

megaphone-2374502_640.png

Consultation document and further details are available from the Consultation web page

NHS safety culture and the need for transformation

Opening the door to change: NHS safety culture and the need for transformation | The Care Quality Commission  

This report examines the underlying issues in NHS trusts that contribute to the occurrence of Never Events and the learning that can be applied to wider safety issues. Never Events are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed.

door to change
Image source: http://www.cqc.org.uk

The review sought to answer 4 questions:

  • How do trusts regard existing guidance to prevent Never Events?
  • How effectively do trusts use safety guidance?
  • How do other system partners support the implementation of safety guidance?
  • What can we learn from other industries?

The report finds that too many people are 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.

Full report: Opening the door to change: NHS safety culture and the need for transformation

Procuring for effective wound management [Shared Atlas of Learning Case Study]

NHS England | November 2018 |Procuring for effective wound management

A case study on the NHS England’s Shared Atlas features an innovation from a nursing team who introduced a centralised procurement system,  generating savings of £45,000 which has been reinvested in services.

The nursing team for the Wound and Lymphedema service at the East London Wound Healing Centre identified significant unwarranted variation in the supply and use of wound care products across their service, with variation in a standardised approach to dressing choice and in some instances the most optimal dressing was not being utilised.

hand-357889_640.jpg

This innovation led to:

Better outcomes – Enabling clinicians to directly order on a patient needs-based approach has improved care and outcomes, helping to identify patients with complex needs and triggering specialist interventions. Standardising wound care based upon best practice will also improve outcomes for patients.

Better experience – The supply system has reduced delays in treatment for patients and keeping track of ordering trends has highlighted training needs and targeted support to some teams and providers. The new system has resulted in effective and efficient access to dressings for patients and improved patient care.

Better use of resources – The scheme has operated within the original budget despite an 18% increase in population. Savings of £45,000 have also been reinvested in services. Total wound care spend per patient in Tower Hamlets is significantly below the national average without compromise on quality of service provision. The procurement system has done this by reducing over-ordering and the associated risk of dressings going unused. The scheme has generated cash savings of £82k that has been reinvested back into services such a wound care projects or interventions.

Read the full case study at NHS England 

 

In safe hands? The need to know more about safety in health care

Nuffield Trust | December 2018 | In safe hands? The need to know more about safety in health care

In the latest blog on the Nuffield Trust blog, Sarah Scobie considers whether safety is being measured and monitored appropriately and what steps could improve it in the long run; long run? Scobie argues for a shift in our understanding.

characters-696949_640.png

 

Scobie reflects on:

  • Measuring safety, rather than harm
  • What data tells us
  • Safety gaps

Read the full blog post from the Nuffield Trust