PATIENT SAFETY
associated deconditioning harm that can result following falls and injury.
The value of creating an acute frailty bundle is being considered as well as focusing more on the management of patients presenting to hospital with acute frailty syndromes. The Stop the Pressure Programme (STPP) has already delivered a revised definition and measurement framework, the launch of the national pressure ulcer audit, a new education curriculum, a national pressure ulcer improvement collaborative and nutrition improvement resources. By October bespoke improvement resources for some specialist clinical areas will be available for all provider settings. Since last September, the STPP has been linked to the new national wound care strategy which extends beyond hospitals and into primary care, domiciliary and social care settings. This national strategy concerns the development of relevant pathways of patient care, workforce, education, research and developing an approach to data. In addition to pressure ulcers, the strategy focuses on improving the care of lower limb and surgical wounds. Programmes to improve safety for those with learning disabilities are included in the Patient Safety Strategy.
There is greater understanding of the inequalities and inequities which surround the care of those with learning disabilities, from recent shameful disasters which have led to harm and death. The government has consulted on the introduction of mandatory training on learning disability and autism to give health and care staff the knowledge and skills to accomplish this and will be responding to the consultation in the coming months. The Learning Disabilities Mortality Review programme (LeDeR) provides insight about the care provided to those with a learning disability who die and has already shown they experience more respiratory problems, diagnostic overshadowing84 and under- recognition of early deterioration. LeDeR is being accelerated and will be supported and aligned with the medical examiner system. Continued emphasis on reducing
opportunities for antimicrobial resistance are in line with the new strategy for AMR.8
A
number of different projects are underway relating to patient safety and the AMR situation. Urinary tract infections are being managed by a ‘Right Care Urology Programme’ in primary care to reduce inappropriate antibiotic use. The Getting it Right First Time Project (GIRFT) is engaging front line clinicians to review and reduce variation in surgical wound management to tackle surgical site infections. The promotion of vaccination is undertaken to prevent the development of secondary respiratory infections and thereby reduce antibiotic use.
Research and innovation
Safety improvement relies on innovation, be that incremental or disruptive, and innovation relies on research to generate and
test new ideas.9 Adoption of evidence-based
tools to support safety priorities as well as developing innovative solutions to pre-empt emerging threats is therefore a priority. The National Institute for Health Research (NIHR)-funded Patient Safety Translational Research Centres (PSTRCs) exist to do just this – to pull advances from basic research of potential relevance to patient safety into early pilot/feasibility clinical, applied and health services research of relevance to patient safety. They provide a vital route for innovation in patient safety, involving patients at all stages of commissioning research. The innovation based on evidence is reliant on the NIHR and some other institutions to provide clinically relevant research and for it to drive the creation of appropriate patient safety solutions. Links and funding therefore will continue to be provided to NIHR and the Patient Safety Collaboratives to enable their continued work.
Conclusion
Action on patient safety and a greater understanding of the failures of the care which is currently provided is always welcome – however hard it is for clinicians to accept the mistakes which lead to harm and possible death.
Shining a light into dark corners such as the care of those with learning disabilities or falls by the elderly in hospital must be welcomed across the board. Strategy documents are essential to enable Trust Boards to find their priorities and review the clinical imperatives within their sphere of influence. New roles, such as the medical examiners and patient safety partners, will
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all need to be carefully planned into current schemes. With more people focused entirely on patient safety, the reminders may be heard more frequently – helping all staff involved in any way in clinical care.
References
1 Institute of Medicine. 2000 To err is human: Building a safer Health System
https://www.ncbi.nlm.nih.gov/pubmed/25077248
2 The NHS Patient safety Strategy. July 2019 NHS England and NHS Improvement. Accessed at
https://improvement.nhs.uk/resources/patient- safety-strategy/
3 Reason J. Managing the risks of organisational accidents. 1997
4 Catchpole K, Giddings A et al 2007 Improving patient safety by identifying latent failures in successful operations Accessed at
https://s3.amazonaws.com/
academia.edu. documents/8143014/
5 The National Quality Board. Learning from deaths. Guidance for NHS trusts on working with bereaved families and carers 2018 Accessed at
https://www.england.nhs.uk/wp-content/uploads/ 2018/08/learning-from-deaths-working-with- families-v2.pdf
6 NHS England. Saving Babies Lives Care Bundle Version 2. 2019 Accessed at
https://www.england.nhs.uk/publication/saving- babies-lives-version-two-a-care-bundle-for- reducing-perinatal-mortality/
7 Ibid 8 Department of Health and Social Care. 2019. UK %-year action plan for antimicrobial resistance 2019- 2024 Accessed at
https://www.gov.uk/ government/publications/uk-5-year-action-plan- for-antimicrobial-resistance-2019-to-2024
9 Ibid SEPTEMBER 2019
CSJ
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