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Patient Safety Resources

 

 

 

 

Patient Safety Webinar Series  

The RCSEd Patient Safety Webinar programme was launched in September 2019 to mark the first World International Patient Safety Day. This very popular series featured contributions from renowned world experts in the patient safety field drawn from a wide range of disciplines including surgery, clinical psychology, and law.


The ten one-hour webinars ran monthly from November 2019 to August 2020 and were open to all. All sessions were recorded and remain available to the College membership. Please see below for the full programme:

Date Speaker Job Title Topic

 

21/11/2019

 

Professor Thomas Weiser MD MPH FACS

Associate Professor, Department of Surgery, Section of Trauma & Critical Care, Stanford University Medical Centre

Visiting Professor of Surgery, Royal Infirmary Edinburgh 

 

 

Successes and Failures Implementing the WHO Surgical Safety Checklist

 

12/12/2019

 

Mr. Manoj Kumar

 

Consultant General Surgeon, Aberdeen Royal Infirmary

National Clinical Lead Scottish Morbidity & Mortality Programme

Designing Safety: Redefining Safety and Quality Reviews

 

30/01/2020

 

Professor Steven Yule
PhD, FRCSEd

 

Professor of Behavioural Sciences, University of Edinburgh

Associate Professor of Surgery, Harvard Medical School

 

Non-Technical Skills for Surgeons: global approaches to improving patient safety

 

04/02/2020

 

Mr. Martin Bromiley OBE

 

Founder and past Chair, Clinical Human Factors Group

 

What about you? Reflections on how you can make small changes that make a real difference in your day to day working

 

27/02/2020

 

Professor Paul Bowie

PhD, MSc, C.ErgHF, MIEHF, FRCPEd, FRCGP(Hon)

Programme Director (Safety & Improvement) NHS Education for Scotland

Lead Safety, Skills and Improvement Research Collaborative (SKIRC).

 

The Problem with Medical Error

 

13/05/2020

 

Professor Rhona Flin

Professor of Industrial Psychology, Aberdeen Business School, Robert Gordon University and Emeritus

Professor of Applied Psychology, University of Aberdeen

 

Psychological Insights on Intra-operative Decision Making

 

25/06/2020

 

Professor Janet A. Wilson

Professor of Otolaryngology Head and Neck Surgery, Newcastle University

Convenor RCSEd ICONS Workshop

 

Informed Consent - why sharing the decision is safer for everyone

 

08/07/2020

 

Professor Frank Smith

 

Professor of Vascular Surgery, Bristol

CORESS Lead

 

Confidential Reporting and Surgical Safety (CORESS)

 

06/08/2020

 

Mr. Kevin James Turner

MA, DM, FRCS Urol

Consultant Urological Surgeon, Royal Bournemouth Hospital

Visiting Professor Bournemouth University

 

Helping Surgeons When Things Go Wrong

 

13/08/2020

 

Miss Annie Sorbie

 

Lecturer in Medical Law & Ethics, University of Edinburgh, School of Law

 

Embedding the Professional Duty of Candour

 

Patient Safety Surgeons' News Articles  

Over the past 18 months, the Patient Safety Group has endeavoured to educate the membership on several topics across Patient Safety. You can find excerpts of these below: 

 

Non-Technical Skills for Surgeons (NOTSS) 

The aim of the NOTSS project was to develop and test an educational system for assessment and training of non-technical skills in the intra-operative phase of surgery. NOTSS is a behaviour rating system based on a skills taxonomy that allows valid and reliable observation and assessment of four categories of surgeons' non-technical skill: situation awareness, decision making, communication & teamwork, and leadership.  

These are the essential non-technical skills surgeons need to perform safely in the operating room and NOTSS allows measurement of several ACGME (Accreditation Council for Graduate Medical Education) competencies, including professionalism, interpersonal and communication skills, and systems-based practice. The skills taxonomy can be used to structure training and assessment in this important area of surgical competence.

The Royal College of Surgeons of Edinburgh has been successfully running a NOTSS Masterclass in observing and rating behaviour for both consultant/attending and trainee surgeons since 2006. Faculty development has also occurred for groups in North America, East Africa, Japan, Australasia, and Malaysia, all of whom now run their own NOTSS courses. NOTSS has been adopted by the Royal Australasian College of Surgeons as part of their competence assessment and recommended by the ACGME (Accreditation Council for General Medical Education) for workplace assessment in the UK. In order to support trainee assessment, two online training resources have been developed: NOTSS in a Box (for senior trainees and consultants) and NOTSS for Trainees (for early-stage trainees). Many regions in the UK now offer NOTSS courses to all their trainees and this is likely to increase in the next few years. 

 

PINTS Course (Peri-operative Care Practitioners Intra-operative Non-Technical Skills)    

The non-technical skills of perioperative care practitioners play a significant role in patient safety. This one-day course enables perioperative care practitioners (PCPs) and surgical first assistants (SFAs) to improve their intra-operative performance and help them observe and rate intra-operative non-technical skills.

 

Shine Surgical Ward Round Toolkit  

The project to develop the Surgical Ward Round Toolkit was sponsored by a grant from SHINE (Health Foundation) and was carried out jointly between the Patient Safety Board of The Royal College of Surgeons of Edinburgh and the Royal Infirmary of Edinburgh. Using an adapted NOTSS (Non-Technical Skills for Surgeons) system and a ward round based structured checklist, the aim of the Toolkit is to reduce errors and improve safety on surgical wards. 

 

Informed Consent: Sharing the Decision (ICONS) Course 

This innovative educational initiative was developed as a direct and constructive response to the communication inadequacies exposed by the Montgomery case and subsequent legislation. While it is not difficult to give ‘more information’ it is harder for surgeons and patients to achieve a decision partnership.  

The ICONS workshop content has been informed by internationally recognised experts in Shared Decision Making, by consensus among senior practising surgeons, by patients, and by professional experts in risk management and risk communication

Delegates on the ICONS workshops will acquire skills and knowledge to implement best practice in sharing the complex decisions surrounding informed consent. By participating in a workshop, they will also contribute to the development of resources for future training in the important area of informed consent.

 

RCSEd Anti-Bullying and Undermining work  

The Royal College of Surgeons of Edinburgh is committed to eradicating bullying and undermining from the surgical and dental professions.

It is reported that almost a quarter of all NHS staff have experienced harassment, bullying, or abuse from colleagues. Not only does this have a devastating impact on individuals and the teams within which they work, but it can have dire consequences for patient care and impact negatively on patient safety. Bullying also drains limited NHS resources, resulting in increased sickness absence, employee turnover, productivity, and employment relations.  

The RCSEd have a zero-tolerance approach to bullying and have produced a series of Professional Standards we expect RCSEd Fellows and Members to uphold. We have also developed a series of comprehensive resources to help staff and organisations to develop good practice in this area. We work with partners from across healthcare professions to host events, offer advice, and other initiatives, such as the Anti-Bullying Alliance, aimed at developing practical solutions to address bullying in the medical workplace.

 

Whistleblowing: Raising Concerns, Whistleblowing and Speaking Up

All healthcare professionals have a duty to promote a culture that allows staff to raise concerns openly and to take prompt action where patient safety may be compromised. The RCSEd is committed to greater transparency in healthcare and encourages staff to speak up if they have concerns regarding practice that may be detrimental to patient safety. This guide provides advice and support for healthcare workers when speaking up, raising concerns and whistleblowing.

 

Workplace Report: Improving the working environment for safe, surgical care  

The RCSEd have published a number of critical recommendations to government to improve the working environment in surgical units in order to improve the safety of surgical care. 

 

University of Edinburgh MSc Patient Safety and Clinical Human Factors

This three-year part-time online MSc programme in Patient Safety and Clinical Human Factors is part of the Edinburgh Surgery On-Line suite of courses. It aims to support any graduate healthcare professional (ranging from nurses to surgeons and anesthetists) in using evidence-based tools and techniques to improve the reliability and safety of everyday health care systems and processes.  

EXTERNAL RESOURCES

 

Chartered Institute for Ergonomics and Human Factors (CIEHF)

CIEHF, the professional body for Human Factors specialists in the UK, recently produced a white paper on ‘Human Factors for Health & Social Care’ (White Paper). This set out three broad principles for delivering a patient safety strategy: it should be systems focused, design-led, and emphasize improving the wellbeing of patients & staff. Developing systems which can support people to have happy working lives can help to deliver a motivated and well-trained workforce. Having these same people working within robust systems; delivering consistently and striving to improve, is the best way to improve performance.

 

Clinical Human Factors Group 

The Clinical Human Factors Group is a charitable foundation founded by Captain Martin Bromiley after a personal tragedy in 2005. The group raises awareness of human factors at the highest levels in healthcare – promoting education, training, and investigation and has made a significant contribution to current thinking in this area.

 

Supporting Surgeons When Things Go Wrong: Surgical Adverse Events First Aid Response (SAEFAR)

This important work is being undertaken by the Bournemouth Adverse Events Research Team. This research group was co-founded in 2015 by Mr. Kevin Turner, a Consultant Urologist in Bournemouth and visiting Professor at Bournemouth University, with colleagues in the university's Psychology department. The group studies the impact of adverse events on surgeons and is developing interventions to lessen that impact.

 

Confidential Reporting System in Surgery (CORESS)

CORESS is an independent confidential educational service established in 2005 to promote safety in surgical practice, both within the NHS and in the independent sector. Any surgeon or surgical trainee from any specialty can voluntarily submit reports in confidence via the CORESS website. The case is then reviewed by experts in the appropriate specialty and if useful lessons can be learned an unidentifiable version is published in the surgical literature together with comments from the Expert Advisory Committee. 

 

World Health Organization (WHO)

The World Health Organization (WHO), through the World Alliance for Patient Safety and subsequently the Global Patient Safety Collaborative, has ensured that the drive for safer health care is a worldwide endeavor, securing commitment at the highest level from global health leaders. It has provided standards, evidence-based guidance, and practical tools to support those involved in the design of national patient safety programmes.

The WHO has undertaken a number of key international initiatives in this area. These include Global Patient Safety Challenges, Global Patient Safety Summit series, World Patient Safety Day, Global Initiative for Emergency & Essential Surgical Care, and Guidelines for Essential Trauma Care.

Patient Safety: Safe Surgery

WHO Second Global Patient Safety Challenge: Safe Surgery Saves Lives 2008

The goal of this initiative was to improve the safety of surgical care around the world by defining a core set of minimum surgical safety standards that could be universally applied across countries, regardless of circumstance or environment.

Four areas were identified in which dramatic improvements could be made in the safety of surgical care:

  1. Prevention of surgical site infection, through antisepsis and control of contamination;
  2. Safe anaesthesia, by appropriate patient monitoring and advance preparation;
  3. Safe surgical teams, by promoting communication and teamwork;
  4. Measurement of surgical services, by creating public health metrics to measure basic outcomes of surgical care.

Ten essential objectives for safe delivery of surgical care were identified which formed the basis of a one-page Surgical Safety Checklist to be carried out during surgery, to make care safer worldwide. In addition, a set of five standardized surgical ‘vital statistics’ were developed to facilitate the comparison of surgical results across countries. The checklist and surveillance tools were tested at pilot sites in all WHO regions and then disseminated to hospitals worldwide.

WHO Surgical Safety Checklist

The Surgical Safety Checklist was introduced by the WHO in 2008 as part of its Safe Surgery Saves Lives Campaign. It contains 19 items to be read aloud to the whole operating team at three key defined time points during an operation: sign in - when the patient arrives in the theatre complex, time out or surgical pause - immediately before the planned procedure starts and sign out - at the end of the procedure before the patient leaves the operating theatre.

The items are aimed at preventing uncommon but serious errors by reminding the team to confirm patient identity, surgical site, and other important characteristics such as critical stages of the procedure, co-morbid conditions, or anticipated complications. They act as a final check of everyone’s understanding of what the team is about to do and help to resolve concerns.

It is important to recognize that the checklist should not simply be a tick-box exercise, but should serve to change the culture in the operating theatre, building greater teamwork and communication, both key to reducing harm.

 

Video: Surgical Leadership Lecture - Dr  Atul Gawande 

In this video, Dr. Atul Gawande, The New York Times bestselling author of 'Better', 'Complications' and 'The Checklist Manifesto' reveals the surprising power of the ordinary checklist. First introduced decades ago by the U.S. Air Force, checklists have enabled pilots to safely fly aircraft of mind-boggling sophistication. Now innovative checklists are being adopted in hospitals around the world, helping doctors and nurses respond to everything from flu epidemics to avalanches. Even in the immensely complex world of surgery, a simple ninety-second variant has cut the rate of fatalities by more than a third. Gawande is a surgeon at Brigham and Womens Hospital in Boston and a staff writer for The New Yorker.

Video: Surgical Checklist Lecture - Dr Atul Gawande 

In this video,  Atul Gawande, MD, surgeon, author, and worldwide leader in patient safety joined with the S.C. Hospital Association to formally kick off 'Safe Surgery 2015', an initiative developed to bring the Surgical Safety Checklist to every operating room in the United States, starting with South Carolina hospitals.

WHO World Patient Safety Day 

World Patient Safety Day, celebrated on 17 September each year, was established in 2018 at the third World Patient Safety Summit in Tokyo. This global campaign acts as a focus to increase awareness of patient safety, bringing together all key stakeholders to show their commitment to this area.

 

Institute for Healthcare Improvement (IHI)

Founded in the USA in 1991 and experts in the field of improvement science, IHI works closely with local partners to advance a total systems approach to safety across entire organizations. The initial focus was on the identification and spread of best practices in healthcare, reducing defects and errors in hospital microsystems. Their highly successful 100,000 Lives Campaign (an 18-month national initiative to drive adoption of six patient safety practices in US hospitals) and 5 Million Lives Campaign (a two-year endeavor that engaged more than 4,000 US hospitals to prevent five million incidents of medical harm), spread best practice changes nationally and helped create an engaged global improvement community. More recently, through their Triple Aim framework, they are working to optimize whole health system performance in the US.

The Model for Improvement used in all IHI’s improvement efforts asks three questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Plan-Do-Study-Act (PDSA) cycles are employed for small, rapid tests of change to assess whether a change leads to improvement. As these small tests are refined and successfully implemented in a particular context, testing is spread and changes scaled up to produce sustainable improvement. Run Charts and Control Charts monitor performance over time. Change bundles - small, straightforward sets of 3-5 evidence-based practices - are developed which, when performed reliably together, improve patient outcomes.

Patient Safety Champions at every level of healthcare can access an online educational curriculum, community, and range of courses through their Open School Programme.

 

Scottish Patient Safety Programme

The Scottish Patient Safety Programme, established in 2008, was the first national approach to patient safety improvement in the world. It aimed to fundamentally change healthcare culture to put patient safety at its forefront. The programme was coordinated by Healthcare Improvement Scotland with support from the Institute for Healthcare Improvement and offered a national co-ordinated approach to improve patient safety across all Scottish hospitals, regardless of location, clinician experience, or underlying knowledge.

Engagement from all staff was actively encouraged, with principles of quality improvement being embedded in everyday working to create a culture where patient safety was the responsibility of all frontline staff and not just those with a particular interest. Staff education and training was provided and sharing of knowledge facilitated using biannual nationwide meetings. Resources were provided to all frontline teams in quality improvement methodology. Senior leadership support was ensured by having executive sponsors in each health board to raise the profile of patient safety in organisational culture.

At the time of launch, improving patient safety during surgery was one of the four key workstreams of the programme The five peri-operative drivers for change included: surgical site infection, VTE prophylaxis, antibiotic administration, maintenance of normothermia, blood glucose control, and implementation of the WHO surgical brief, checklist and debrief. The programme has many other key workstreams including leadership walkrounds, ICU daily goals, general ward safety brief, national early warning score, acute kidney injury, and healthcare-associated infections.

This ground-breaking national initiative has delivered clear improvements in healthcare quality across many settings. There has been a change in culture to a patient safety focused system of healthcare.

 

Scottish Mortality and Morbidity Programme (SMMP)

The SMMP functions to improve, standardize, and co-ordinate M&M processes throughout NHS Scotland. This programme has developed a Practice Guide and National Training Workshop embedding a basic understanding of clinical human factors to provide skills and support to healthcare staff in the running of effective local M&M reviews. It provides a platform for healthcare teams to share evidence of good practice nationally and advises on IT systems to support the process.

 

NHS England Patient Safety Strategy 

NHS England launched its National Patient Safety Strategy in July 2019, focusing on three key pillars:

  1. Insight into patient safety understanding
  2. Involvement of all key stakeholders
  3. Improvement programmes to enable sustainable change in key areas.

A number of initiatives have been developed. The Patient Safety Incident Management System (PSIMS), the world’s largest and most comprehensive patient safety incident reporting system, provides valuable insight into the patient safety climate nationally. The Patient Safety Incident Response Framework provides central standardized guidance on how NHS organizations should investigate patient safety incidents. A National Patient Safety Alerts System helps to streamline response to emerging risks, coordinating the outputs of all relevant bodies to ensure clear advice is provided regarding action providers need to take on safety-critical issues. A range of Safety Improvement Programmes (SiPs) (e.g. emergency laparotomy collaborative programme) have been developed, delivered by local healthcare providers working within 15 regionally-based Patient Safety Collaboratives and linked to the national team.

A new digital safety learning system has been developed to support learning from what does and does not go well. A new medical examiner system to scrutinize deaths has also been implemented. A process has been created to share insight from litigation and to increase the involvement of patients & carers in patient safety improvement. Patient safety specialists have been introduced into every hospital, and a patient safety syllabus for all staff has been established.

 

National Emergency Laparotomy Audit (NELA)

NELA, commissioned in 2012 by the Healthcare Quality Improvement Partnership, is run by the Royal College of Anaesthetists with input from the Royal College of Surgeons of England. High-quality data from all NHS hospitals in England and Wales that undertake emergency laparotomy is collated and published in order to drive local quality improvement and to provide comparative data at individual hospital level to identify high performing sites and facilitate learning. Information reviewed includes organizational process (e.g. availability of appropriate protocols, resources, personnel, and equipment) and key standards of patient care (e.g. early consultant review, documented assessment of operative risk, presence of consultant surgeon and anaesthetist in theatre, post-operative ICU admission for high-risk patients).

 

National Confidential Enquiry into Patient Outcomes and Death (NCEPOD)

NCEPOD is an independent body whose remit is to assist in maintaining and improving the quality of patient care by undertaking confidential surveys and research. The first major NCEPOD report - Who Operates when published in 1996 - led to major changes in how and when emergency surgery is provided in the UK, including the establishment of now-familiar ‘CEPOD theatres’ to ensure 24-hour theatre availability for emergency care. Examples of other influential surgical NCEPOD audits include Emergency Admissions: A Journey in the Right Direction in 2007 which looked into organizational and clinical aspects of surgical emergency admissions, Knowing the Risk in 2011 which reviewed the peri-operative care of adult patients undergoing in-patient surgery, Treat the Cause in 2016 which looked into acute pancreatitis and, most recently, Delay in Transit in 2020 looking into Acute Bowel Obstruction.

 

Patient Safety in Surgery - Online Journal 

A free online journal for all interested in surgical safety. 

 

Please write to me - Writing outpatient clinic letters to patients - Guidance 

The Academy of Medical Royal Colleges published guidance in 2019 highlighting the benefits of writing outpatient clinical letters directly to patients.

 

Video: Defining Quality - Don Berwick 

In this video, IHIs Former CEO Don Berwick describes a 2001 report by the Institute of Medicine 'Crossing the Quality Chasm', which laid the foundation for health care reform all over the world.

 

  

 

 

 

 

 

  


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