News
New standards to boost NHS leadership and patient safety
The NHS has published a framework and supporting resources to help senior board members strengthen board governance, boost leadership and improve patient safety. Resources to support current and aspiring
board members within the NHS to further develop their skills and careers have been sent to leaders, including information on development programmes and peer support networks to develop and share good practice. A Fit and Proper Person Test (FPPT) framework for board members has also been published, which will help prevent directors who have been involved in or enabled serious misconduct or mismanagement from joining a new NHS organisation. NHS England was commissioned to update the
framework as part of five recommendations from Tom Kark’s KC review of the ‘Fit and Proper Person Test’. In response, NHS England will introduce the following: l A new standard reference for people leaving NHS board roles for any reason which will be held on file until the person turns 75, including details on any ongoing or discontinued complaints and disciplinary issues.
l Data fields in the Electronic Staff Record to record board members’ Fit and Proper Person Tests.
l An extension of the scope of the FPPT framework to all commissioners including Arms-Length Bodies, Care Quality Commission and NHS England.
Leading experts at IP2023 to tackle critical IP&C issues
Top experts will be gathering at the Infection Prevention Society’s annual conference (17-19 October), at the ACC in Liverpool, to discuss the pressing challenges and emerging threats in infection prevention and control. Building on last year’s successful conference,
Em Wilkinson-Brice, National Director for People at NHS England, said: “It is right that NHS board members are supported to develop in what are incredibly challenging roles, which is why we are publishing resources to aid existing and aspiring leaders in the health service including through development programmes, peer support networks, and mentoring. “As part of this, a revised Fit and Proper
Person Test has been published, building on the recommendations of the Kark review, to help ensure that robust governance and assurance processes are in place at NHS England, NHS Trusts, ICB boards and CQC.” Visit:
www.england.nhs.uk/leaders/
IPS is offering an extensive programme of world-class speakers, alongside an exhibition of the latest innovations and solutions, aimed at reducing the risk of healthcare-associated infections and the transmission of pathogens that pose a threat to public health. The themes, this year, are critical to the IP&C agenda and include: Antimicrobial Resistance, Preparedness and Environment. Among the many informative presentations, by leading experts, include sessions by: Dr. Emma Burnett on ‘Challenging the status quo in IPC’; Prof. Martin Kiernan, on ‘The effect of climate on healthcare infection’; and Dr Lena Ciric on ‘What can sampling tell us about the role surfaces might play in transmission of pathogens?’. Prof Didier Pittet and Ms Alexandra Peters will host the ‘Clean Hospitals Workshop’, on developing a self assessment tool. To view the full programme, visit:
https://ip2023conference.net
Report recommends packaging and labelling change to prevent implant ‘never event’
HSIB’s latest report recommends changes to the packaging and labelling of implants used in patients undergoing haemodialysis, to reduce the risk of the incorrect one being inserted. In this investigation, the implant is a vascular
graft and is one option for haemodialysis treatment – it is designed to connect an artery to a vein and create a larger and stronger opening for blood to travel. There are different types of vascular grafts (different diameters, lengths and may be tapered or non-tapered). Some grafts are for delayed use (needing two weeks between insertion and first use) and others for rapid use (used approximately 72 hours after insertion.) The investigation explored the factors that influence the selection and insertion of vascular grafts and highlighted the risk that a graft could be mis-selected and lead to another surgical procedure for the patient. This increases risk of infection and can be distressing for the patient as
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well as placing extra demand on surgical teams. These issues were illustrated in the case of Teri, a patient with chronic kidney disease, who needed regular haemodialysis. She was referred to her local hospital for a rapid access type of graft. However, she was fitted with a delayed use graft. As the wrong type of graft was fitted, Teri needed to have another surgical procedure. The report findings included:
l The packaging of rapid access and delayed use vascular grafts may be very similar, resulting in an increased risk of staff selecting and inserting the wrong type of graft.
l The wording used on packaging and labels to describe vascular grafts does not reflect the terminology used by clinicians in the operating theatre.
l There is Medicines and Healthcare products Regulatory Agency (MHRA) guidance for the labelling and packaging of medicines, but not for
medical devices such as vascular grafts.
l There was a lack of standardisation and therefore variation in how checklists and ‘team briefs’ (procedures that aim to ensure patient safety) were completed/conducted and recorded in different operating theatres.
l The incorporation of national safety standards alone may not be successful without an embedded safety culture being in place.
HSIB has made four recommendations focused on reviewing system requirements for barcode scanning technology; updating the applicable standard/s to state that medical device labelling and packaging should detail the specific use of an item; amending the assurance processes for designated approved bodies to consider context of use and usability guidelines; and the publication of guidance on the labelling and packaging of medical devices. Download the report at:
www.hsib.org.uk
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