Professor Charles Vincent provides an summary of his recently published second edition on Patient Safety. This 61-page free pdf file, which may be used for non-commercial purposes, is essential reading for anyone starting to undertand the scale and complexity of patient safety.

Charles Vincent Essentials of Patient Safety 2012

When we asked for stories about what our supporters were getting up to, CHFG member Steve Powell sent us information about a patient safety observational study in Nigeria which he conducted with fellow CHFG supporter Chris Ente (and other colleagues).  They worked with their local patient safety and quality Society to determine improvement aims and prioritize solutions.  The first session on Patient Safety Culture was held in March 2011 in Lagos.  Follow this link to read their article on the Patient Safety and Quality Healthcare website.

On Monday 20th February on BBC Radio Four at 8pm, Professor James Reason explores how patient safety can be improved by doctors admitting to mistakes.  He hears from Rick Boothman and Darrell Campbell, creators of a programme in America in which medical practitioners must be open about their errors, and examines the death of ten-year-old Robbie Powell in Britain in 1990, and the ensuing legal battle.

On 26 January 2012, the GMC published Raising and acting on concerns about patient safety (2012) (access the guidance below).  This guidance makes clear that doctors have a duty to act when they believe patient safety is at risk, or when a patient’s care or dignity is being compromised, and explains when doctors need to raise concerns and advises on the help and support available to them, including how to tackle any barriers that they may face.

Raising and acting on concerns about patient safety (2012)

This Seminar, entitled “Human Factors – Moving Forward” is being jointly run with the Institute of Ergonomics and Human Factors, and is generously hosted by City Hospital, Nottingham University Hospitals NHS Trust.

The programme offers stimulating speaker sessions from human factors specialists in both healthcare and non-healthcare related industries, and multiple opportunities to network with fellow CHFG supporters.  An extended ‘Marketplace’, where individuals and organisations will share and showcase their human factors based innovations, experiences and designs will also be a feature of the day.   If you would like to contribute to the Marketplace, please email us as soon as possible outlining your showcase idea.

The response to news of this forthcoming Seminar has been overwhelming, with record registrations, which is of course  excellent news; we are however compiling a waiting list as there are usually cancellations prior to the event so if  you would like to attend this free event simply complete our online registration form, and we will let you know if/when a place becomes available.

We hope you are able to join us at what promises to be a powerful and thought-provoking learning event.

There is no charge to attend this event, due to the generous support of our sponsors the Medical Protection Society, The Health Foundation, Nottingham University Hospitals NHS Trust and the Institute of Ergonomics and Human Factors.

Standardisation has been shown to be an effective mechanism for reducing human error in complex processes or situations. Conversely, the lack of it can increase risk and make human error more likely and in some cases inevitable.

In order to inform the Department of Health’s Human Factors Reference Group, we conducted a rapid on-line survey asking CHFG supporters about the top priority areas which in their view, if standardised, would make a positive contribution to improving patient safety as well as making their work easier and more effective overall.

A textual and content analysis was conducted to produce “categories” of priorities.

Respondents[1]

The majority of respondents:

• describe their primary role as ‘Medical’ (73%) with the next largest group being ‘Patient Safety / Improvement Specialist’ (7%)
• describe themselves as working for / within NHS Acute Providers  (79%)
• are based in England (85%) with an even spread across regions. The next largest groups are from Scotland and Wales both at nearly 6% of respondents.

 Summary of Standardisation priorities

In summary, three main priorities stood out in the analysis:

1. Protocols – this relates to all comments associated with what might otherwise be called “standard operating procedures” for a range of specific clinical circumstances.

Category examples include standardisation of:

• Consent processes
• Protocol-driven management of a wide range of clinical presentations and interventions – specific mentions included sepsis, trauma management, chemotherapy, difficult airways, commencement of surgery
• Screening procedures
• Management of deteriorating patients including vital signs measurement and montioring, escalation protocols etc.

A significant number of comments also related to standardisation of the documentation associated with these protocols.

2.  Medicines handling – this relates to all comments associated with prescription, storage and administration of medicines but excludes drug labelling which has been treated as a separate category. (NB If combined this would elevate “Medicines” to first position)

Category examples include standardisation of:

• Drug / Fluids / Anticoagulation / Insulin chart layouts
• Intravenous drug doses and concentrations including prefilled labelled syringes
• Drug infusions for use in Critical Care / Theatres / Emergency Care
• Drug cupboards, packaging, ampoules
• National prescription chart
• Electronic prescribing – avoiding incorrect prescriptions, drug interactions and incorrect administration.

3.     Equipment – this relates to all comments associated with commonly used monitoring, treatment and other specialist equipment.

Category examples include standardisation of:

• Pumps & Infusion devices
• Monitoring equipment
• Difficult Airway Trolley – NOTE this piece of equipment also had its own category as it had 8 mentions in the respondents’ number 1 priority for standardisation, and 18 in total across all five priority listings
• Equipment packs for CVC insertion
• Operating tables.

 Comments

A number of caveats should be considered when examining the results of this survey.

•  Medically qualified practitioners working in surgical and/or anaesthetics practice were very strongly represented in the sample
• Respondents offered more than fifty additional free text comments. Within these responses there was a wide variation in how the term “standardisation” was being used
• A significant number of respondents suggest “whole NHS” implementation approaches and treat the NHS as a single organisation rather than a federation of semi-independent bodies with their own systems of governance and control.

We are delighted to announce the date for our next CHFG Open Seminar which will be held on 23 March 2012 at the City Hospital Campus in Nottingham.

We will be co-hosting the event with the Institute for Ergonomics and Human Factors (IEHF) and a further email will be sent to announce on-line booking via the CHFG website early in the New Year.

In the meantime “pencil it in” to your diaries.

In the summer of 2011 the CHFG undertook a limited but focused piece of work with the aim of assessing involvement within the CHFG network and exploring perceptions of our impact.

This included a review of our web and e-marketing analytics, the supporter database and a short on–line survey which generated a 35% response rate (against an industry norm of 20%).

Who are we reaching?

We appear to be reaching a wide range of professional groups internationally although the largest single professional group (and respondents to our survey) appear to have medical backgrounds.

Whilst we attract visitors from more than 68 countries worldwide, the majority are UK-based.  The largest group of respondents in our survey work in acute or secondary care settings within the NHS in England and there was a slight London/South bias in the main survey; however, other research work, seminar attendance and our web activity shows a relatively even spread of involvement across UK regions.

On-line activity as well as the response to our face-to-face events shows a very willing and engaged “audience” with useful stories, energy, ideas, practical experience and skills to share.  More than 50% of the survey respondents offered to take part in follow up interviews and provided “additional comments” as part of their survey response.

Our survey demonstrated a good response from people who are quite new to the CHFG network, with 44% of respondents having been connected for less than a year.

The active on-line subscriber base has grown by more than 100% in a year and web traffic shows 22,000 visitors (15,000 absolute unique) to the website in the same period.  68% of these visitors are new and almost 50% come directly to the URL.  The other half are split equally between search engines and referring sites of which there were more than 300.

What the survey tells us about impact

The importance of our on-line channel is clear.  Our regular e-communications and the value of the website were emphasised.  A considerable number of people now make their first connection with CHFG on-line.

The value of the CHFG as an “independent campaigning voice” with a strong “convening” role was also very clear.

Supporters feel that CHFG has had a strong impact on levels of awareness regarding human factors in healthcare and on personal practice, but our impact at policy or organisational level is perceived to be limited.

Martin Bromiley’s personal role and story is still very important in terms of the identity and connection to CHFG identity and message.

Our Manifesto aims are known by many (47% in this survey) but clearly effort needs to be made to continually re-emphasise these as the majority in this survey said they “don’t know” or were “not sure” of the aims.

Summary

For a small charity with very limited infrastructure and resources, the CHFG network appear to create a significant impact.

The combination of an improved and active on-line presence, the success of the “Open Seminar” series and the work to establish the DH Human Factors Reference Group are all important steps forward.

The recently expansion and development of the Board of Trustees and changes in membership of the Standing Group are also important developments in terms of leadership and governance.

The 2011-13 strategy and fund-raising plan provides a platform for future development.

The 2013 Conference Program Committee is accepting submissions of abstracts for paper or poster presentation at the 2013 ORNAC/IFPN International Conference. The theme of the conference is “International Alliance for Perioperative Best Practices”.

Perioperative Nurses are crucial to patient safety and this is an excellent opportunity to celebrate and showcase the perioperative nurses’ contribution, on an international platform.

More details can be found in the pdf below.

ORNAC IFPN Call for Abstracts and Posters Nov 2011

The CHFG has built a solid relationship with Cranfield University over the last few years.  They continue to work with us on a proposal for trialling independent investigation into “never events” for healthcare.  This year, the University has trained a leading clinical investigator in techniques learnt from other industries and is supporting one of our own Trustees studying for a Masters in Human Factors.  It was with great delight that I share with you the news that Cranfield University has been awarded a Queen’s Anniversary Prize for Higher and Further Education for their “World-leading work in aviation safety through research and training in air accident investigation.”

The Queen’s Anniversary Prize is part of the British Honours system and was created to mark the 40th year of The Queen’s reign. It is awarded biennially and Cranfield has won twice before in 2005 and 2007.  Professor Graham Braitwaite from Cranfield wrote to me that “I am really looking forward…to our new developments in the rail, marine and hopefully medical sectors.”  I sincerely hope 2012 we’ll be able to use Cranfield’s talents in healthcare.