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NHS England » Patient safety learning response toolkit

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NHS England » Patient safety learning response toolkit

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Patient safety incident investigation report template

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Quick Reference guide to getting started with PSIRF

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Quick Reference guide to getting started with PSIRF

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Kindly shared by Ciara O'Regan

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Patient Safety Collaborative Maternity event

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Patient Safety Collaborative Maternity event

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PSRIF Implementation Event 110123 - Final Slidedeck

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The Patient Safety Incident Response Framework.pptx  -  Final

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NSHE safety culture, learning from best practice

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NSHE safety culture, learning from best practice

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Systems Frameworks_ Introduction to SEIPS _ Level 2 award in Safety Investigation - September 2022

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Shared by SE PSIRF Steering Group

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20221025 PSIRF prep guide - plan on a page and action plan

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Human Factors: Using the SEIPS Framework for Patient Safety and Investigations (healthcareconferencesuk.co.uk)

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SEIPS 2.0 is the most widely used model in human factors in healthcare. This one day masterclass will look at the model itself and how it can be applied to healthcare departments.

We will look at real world examples as well as the literature.

SEIPS 2.0 is the next-generation healthcare human factors model , which embraces 3 principles of Systems orientation, Person-centeredness and Design-driven improvement.
Key Learning Objectives

What is SEIPS 2.0?

How does SEIPS link to Patient Safety?

How to use SEIPS 2.0 clinically?

How to improve technology?

Engaging patients and families

Facilitator
The course is facilitated by Perbinder Grewal, a General & Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner; leads on medical education both locally and nationally; Member of the Faculty of Surgical Trainers at the Royal College of Surgeons of Edinburgh; formerly lead for e-learning for healthcare for the Royal College of Surgeons of England; experienced trainer and coach who uses new insights to develop patient safety, staff engagement and psychological safety; has Postgraduate Certificates in Leadership and Coaching.

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Human Factors: Using the SEIPS Framework for Patient Safety and Investigations

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SEIPS 2.0 is the most widely used model in human factors in healthcare. This one day masterclass will look at the model itself and how it can be applied to healthcare departments. We will look at real world examples as well as the literature.

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PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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Presentation shared by KSSAHSN and Unity Insights

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Presentation shared by KSSAHSN and Unity Insights

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TEMPLATE Incidents Complaints and Claims report - NHS Patient Safety - FutureNHS Collaboration Platform

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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Shared by Jen Wadsworth from Being Human in Healthcare Ltd who have been working with NHSE

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Stakeholder Map Template - NHS Patient Safety - FutureNHS Collaboration Platform

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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Shared by Southern Health
AAR are round table discussions

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Shared by Sothern Heath for incidents related to falls

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Discussion points for after action report

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Shared by Southern Health
Ideally the hot brief should take place on the day/shift that the incident occurs by all staff on shift.

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- PSIRF training requires level 1 and 2 only from the patient safety syllabus. These are available online and should be easy to access as you mentioned. Levels 3-5 of the patient safety syllabus are not PSIRF training requirements.

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Quality improvement: bitesize learning resources - Eastern AHSN

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Quality improvement: bitesize learning resources - Eastern AHSN

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This quality improvement (QI) in practice series of bitesize sessions is aimed at health and care professionals.

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Framework for involving Patients in patient safety

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Framework for involving Patients in patient safety

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Framework for Involving Patients in Patient Safety - NHS Patient Safety - FutureNHS Collaboration Platform

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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PSIRF: a fundamental shift in how the NHS responds to patient safety incidents (hsib.org.uk)

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PSIRF: a fundamental shift in how the NHS responds to patient safety incidents

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As part of our investigation education seminar series for HSIB staff, NHS England joined us for our September session. In this blog, Melanie Ottewill shares some of their key messages.

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All materials available via the website and QR code

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https://www.hsib.org.uk/investigations-and-reports/never-events-analysis-of-hsibs-national-investigations/

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Centre for Perioperative Care

The Centre for Perioperative Care has already instituted a NatSSIPs working group with wide membership and clear terms of reference. An initial meeting in January 2021 has occurred. We have started on the plan to review and revise the National Safety Standards for Invasive Procedures (NatSSIPs).

We will seek views on the practicalities of what might work in any clinical setting where invasive procedures are undertaken.

We will review the current NatSSIPs, literature and reports indicating where revision may be required.

We will involve our Board members and advisory group members to identify different perspectives. We aim to produce a revised version of NatSSIPs, in particular with increased standardisation of safety critical steps that are common across organisations.

We will keep HSIB informed of our progress with the work throughout the project. We will consider different audiences and staff groups and whether specific education is required.

We will seek assistance, including from HSIB, with ensuring that our revised NatSSIPs are disseminated widely and used as part of a monitoring framework to assist uptake.
Actions:

CPOC to institute a NatSSIPs working group. TIMELINE: Dec 2020 - done.

First meeting of NatSSIPs working group. TIMELINE: Jan 2021 - done.

Further meetings and electronic consultation on key issues identified in the review of current NatSSIPS. TIMELINE: Jan - Sept 2021.

Drafting a revision of NatSSIPs. TIMELINE: 2021.

Dissemination plan. TIMELINE: 2021.

Response received 9 March 2021

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Never events: analysis of HSIB's national investigations

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Centre for Perioperative Care The Centre for Perioperative Care has already instituted a NatSSIPs working group with wide membership and clear terms of reference. An initial meeting in January 2021 has occurred. We have started on the plan to review and revise the National Safety Standards for Invasive Procedures (NatSSIPs).

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https://beta.jobs.nhs.uk/candidate/jobadvert/C9277-23-8155

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Oxleas NHS Foundation Trust

Job summary

The post holder will work with the Patient Safety Team and the Patient Safety Specialists to drive the new National Patient Safety Strategy and deliver the Patient Safety Incident Response Plan ensuring it is embedded within the Trust.

The post holder will work with clinicians and managers across all Clinical Groups, Corporate Teams and external stakeholders to deliver the requirements for the framework, tracking and reporting progress following robust project management methodology.

The Patient Safety Specialist Project Lead will lead and support the local implementation of the NHS patient safety strategy and response framework which supports the three strategic aims of improving understanding of safety (insight), equipping patients, staff and partners with the skills and opportunities to improve patient safety (involvement) and designing and supporting programmes that deliver effective and sustainable change (improvement).

The postholder will ensure the strategy is aligned with the national programme and liaise with trusts first adopters of the Patient Safety Incident Response Framework to learn from their experience and adapt our plan where required.

Main duties of the job

The PSIRF Project Lead manages all aspects of implementation of the Patient Safety Incident Response Framework, by building, managing and maintaining strong and collaborative working relationships with all the key stakeholders. The Project Lead works closely with the Patient Safety Specialists, the Incident Team Lead and colleagues in the PSIRF Implementation Group.

The Project Lead is responsible for delivering the existing workstreams, directing and advancing their progress. The Project Lead will also identify new areas, establishing the relevant project governance to drive the successful implementation of the PSIRF within the Trust.

At Oxleas our mission is to "Improve Lives"

Our values express what the Trust sees as the heart of Oxleas. They are the lens we look through that informs how we act, the decisions we make, and how we work with our service users, patients, families, carers, and colleagues.

The postholder will sit within the Patient Safety Team, which is a friendly, supportive team.

About us

Oxleas offers a wide range of NHS healthcare services to people in community and secure environment settings. Our services include community health care such as district nursing and speech and language therapy, care for people with learning disabilities and mental health care such as psychiatry, nursing and therapies. Our multidisciplinary teams look after people of all ages and we work in close partnership with other parts of the NHS, local councils and the voluntary sector and through our new provider collaboratives. Our 4,300 members of staff work in many different settings including hospitals, clinics, prisons, secure hospitals, children's centres, schools and people's homes.

We have over 125 sites in a variety of locations in the South of England. In London we operate within the Boroughs of Bexley, Bromley Greenwich and into Kent. We manage hospital sites including Queen Mary's Hospital, Sidcup and Memorial Hospital, Woolwich, as well as the Bracton Centre, our medium secure unit for people with mental health needs. We are the largest NHS provider of prison health services providing healthcare to prisons within Devon, Dorset, Bristol, Wiltshire and Gloucestershire, Kent and South London. We are proud of the care we provide and our people.

Our purpose is to improve lives by providing the best possible care to our patients and their families. This is strengthened by our new values:

Agenda for change

Band 8a

Fixed term

1 years

Full-time

277-5029013-CORP

Pinewood House

Pinewood Place

Dartford

DA2 7WQ

Job description

Job responsibilities

Ensure the organisation has a robust and effective patient safety strategy in place which aligns with the NHS patient safety

Project management of the implementation of the NHS patient safety strategy within the organisation.

Provide patient safety expertise within the organisation; demonstrating compassionate leadership, visibility and engagement for development of the requirements for the trust to meet the national patient safety strategy.

Ensure mechanisms/policies are in place so that insights lead to actionable recommendations/improvements that can be evidenced, measured and monitored across the organisation from all internal and external organisational reviews, high level enquiries and reports relating to patient safety.

Ensure patient safety improvement programmes are aligned to the NHS patient safety strategy.

Work with and influence the Clinical Groups to complete safety culture assessment at start of process for each Clinical Group and review national staff survey data.

Ensure information and intelligence from data sources is used as the basis for prioritising local patient safety development and ensuring proposed improvement approaches are based on an understanding of underlying causes.

Work collaboratively with Head of Patient Experience & Patient Safety to establish a system and approach of continuous improvement of quality and impact of incident investigations, currently through the new Patient Safety Incident Response Framework (PSIRF).

Make informed decisions based on highly complex and sensitive information available from multiple sources, including patient safety incident data to deliver the Patient Safety Incident Response Plan aligned to national and Trust strategy.

Work in partnership with the Patient Safety Lead to manage, develop and support the patient safety partners in accordance with the Patient Safety Partner Framework.

Work with Patient Safety Lead and the Datix Manager to align Trust incident policy to new framework.

Job description

Job responsibilities

Ensure the organisation has a robust and effective patient safety strategy in place which aligns with the NHS patient safety

Project management of the implementation of the NHS patient safety strategy within the organisation.

Provide patient safety expertise within the organisation; demonstrating compassionate leadership, visibility and engagement for development of the requirements for the trust to meet the national patient safety strategy.

Ensure mechanisms/policies are in place so that insights lead to actionable recommendations/improvements that can be evidenced, measured and monitored across the organisation from all internal and external organisational reviews, high level enquiries and reports relating to patient safety.

Ensure patient safety improvement programmes are aligned to the NHS patient safety strategy.

Work with and influence the Clinical Groups to complete safety culture assessment at start of process for each Clinical Group and review national staff survey data.

Ensure information and intelligence from data sources is used as the basis for prioritising local patient safety development and ensuring proposed improvement approaches are based on an understanding of underlying causes.

Work collaboratively with Head of Patient Experience & Patient Safety to establish a system and approach of continuous improvement of quality and impact of incident investigations, currently through the new Patient Safety Incident Response Framework (PSIRF).

Make informed decisions based on highly complex and sensitive information available from multiple sources, including patient safety incident data to deliver the Patient Safety Incident Response Plan aligned to national and Trust strategy.

Work in partnership with the Patient Safety Lead to manage, develop and support the patient safety partners in accordance with the Patient Safety Partner Framework.

Work with Patient Safety Lead and the Datix Manager to align Trust incident policy to new framework.

Person Specification

Experience

Essential

Significant knowledge of patient safety gained within a complex organisation

Project Management within a complex organisation

Evidence of managing a successful project

Desirable

Project Management qualification

Person Specification

Experience

Essential

Significant knowledge of patient safety gained within a complex organisation

Project Management within a complex organisation

Evidence of managing a successful project

Desirable

Project Management qualification

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

Additional information

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

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Oxleas NHS Foundation Trust The post holder will work with the Patient Safety Team and the Patient Safety Specialists to drive the new National Patient Safety Strategy and deliver the Patient Safety Incident Response Plan ensuring it is embedded within the Trust.

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"Phase 2 Diagnostic & Discovery Analysis"

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"Phase 2 Diagnostic & Discovery Analysis"

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Shared by Martin Kinley on Futures

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Copy of Incident Response Standards Gap Analysis

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NHS Elect

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NHS Elect is a national membership organisation staffed by NHS colleagues with extensive experience across a diverse range of subjects.

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Hot' Debriefing: Rapid post-incident team briefing following medical emergencies

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Hot' Debriefing: Rapid post-incident team briefing following medical emergencies

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Northumbria Healthcare finalist at Bright Ideas Health Awards.

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Shared by Warrington and Halton Hospitals Feedback welcome to Deborah Carter

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Human Factors and Civility Education to Engender Safety Culture

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Human Factors and Civility Education to Engender Safety Culture

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South Tees Hospitals are amongst finalists for Innovation in Clinical Education

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Yorkshire Contributory Factors Framework - Improvement Academy

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Response to harm - for patients and their families Archives - NHS Resolution

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How you support patients and their families when an incident occurs is essential part of resolution.

On average, every year we are notified of around 10,500 new clinical negligence claims. As an organisation we are committed to supporting clinicians and healthcare providers when things go wrong and steer them to improving systems, processes and principles. We do this in order to help foster a learning culture, prevent animosity between service users and providers and reduce the risk of recurrent patient safety incidents.

This module is a collection of resources that highlight the benefits of response to harm and early resolution for patients and their families and/or carers, following incidents that cause harm.

Video

Faculty of Learning resource

Presentation

Faculty of Learning resource

Leaflet

Faculty of Learning resource

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Response to harm - for patients and their families Archives - NHS Resolution

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How you support patients and their families when an incident occurs is essential part of resolution. On average, every year we are notified of around 10,500 new clinical negligence claims. As an organisation we are committed to supporting clinicians and healthcare providers when things go wrong and steer them to improving systems, processes and principles.

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Inquests Archives - NHS Resolution

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Attending a Coroner's Court to give evidence can be nerve-racking if this is something you have never done before, or if you have previously had a challenging experience. This module shares educational content to help prepare staff called to give evidence at an inquest.

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Response to harm - for staff Archives - NHS Resolution

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Report

Being fair sets out the rationale and discussions for organisations adopting a more reflective approach to learning from incidents and supporting staff.

Faculty of Learning resource

Leaflet

A just and learning culture is the balance of fairness, justice, learning - and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong. This leaflet contains advice on supporting a just and learning culture for staff and patients following incidents in the NHS.

Faculty of Learning resource

Video

Suzette Woodward, co-author of 'Being Fair, talks about supporting a just and learning culture for patients and staff following incidents in the NHS.

Faculty of Learning resource

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Response to harm - for staff Archives - NHS Resolution

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Treating staff fairly when things go wrong allows staff be open about their mistakes, feel confident to speak up, without fear of being blamed. A just and learning culture in healthcare is the balance of fairness, justice, learning - and taking responsibility for actions.

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Shared by Joanne Kinborough Mata

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Kindly shared by Ciara O'Regan

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162-3867-AV-A_Job Description & Person Specification (1)

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shared by Joe Allen on futures

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20230215-02 SOP - Smaller independent providers 0.5

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NHS England » Policy guidance on recording patient safety events and levels of harm

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Introduction

This policy guide sets out expectations for the recording of patient safety events and their associated levels of harm when using the 'Learn from patient safety events' service. It provides the definitions of the patient safety event types that have been included in the new LFPSE service. This publication supersedes any previous guidance for the NRLS and is the official policy guidance for recording patient safety events to the LFPSE service.

Further contextual information on who should use this service, how to implement it, and other frequently asked questions (FAQs) is available online.

Recording the appropriate level of harm associated with a patient safety incident is important so that:

we have an accurate description of the event and its impact on the patient, based on the best information at the time

there is consistency and comparability within the organisation's own data

the national patient safety team can use the recorded information to analyse, triage and learn from consistent and high-quality data

other policies such of Duty of Candour can be enacted appropriately.

Incident recording is mandatory in certain circumstances (see the LFPSE FAQs for further details) and very much encouraged in all others. If in doubt, it is always better to record a patient safety incident using the available information and best judgement, and LFPSE is designed to support record updates as and when new information becomes available. There are certain mandatory reporting requirements set out in CQC regulations, but ultimately determining when an incident has occurred, the extent to which that incident has caused harm, and the level of harm caused, are all judgements.

To support these judgements, this policy guide sets out the definitions of Incident and Good Care event types, level of harm, and answers some frequently asked questions relating to the recording of incidents.

Definitions - event types

The full definitions of the patient safety event types in this guide are:

Patient Safety Incident - Something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm.

What does this mean? - This event type encompasses all patient safety incidents, including "near misses". Select this option if you know that something did not go as intended or expected - whether an act or an omission - and as a direct result the incident could have or did harm one or more patients.

Good Care - An example of good care that can be learned from

What does this mean? - Positive learning opportunities. Select this option if you want to share experiences or learning from things that have gone well whilst delivering care.

Definitions - harm grading

In the NHS, degree of harm recording relates to the actual impact on a patient from the particular incident being reported. Just as in NRLS, LFPSE maintains this principle. Patient safety incident harm definitions should always be applied based on the best information about the actual impact of the incident at the time of recording. The harm grading can be reviewed and updated as more information becomes available, but should not be used to speculate about, for example more severe "potential harm" if that does not appear to have been caused.

The descriptions of the different levels of physical harm in this document are not intended to alter the thresholds of different levels of harm that were described in previous NRLS guidance. They have been developed to provide more clarity and to support more consistent harm grading, but are based on the thresholds that have been used in the NRLS for some time.

A new addition in this policy guide and in relation to patient safety incident data in the LFPSE service relates to specific capture of information on psychological harm. Previously in the NHS, harm grading included psychological harm as well as physical harm within one measure. Following feedback from staff, patients and families, physical and psychological harm have been separated out and each can now be recorded in the LFPSE service.
Where practical, it is good practice to discuss the level of harm with the patient affected and to consider the patient's perspective on the harm definitions stated below.
The full definitions of the harm gradings are as follows:

Physical harm
No physical harm
No physical harm
Low physical harm
Low physical harm is when all of the following apply:

minimal harm occurred - patient(s) required extra observation or minor treatment

did not or is unlikely to need further healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit

did not or is unlikely to need further treatment beyond dressing changes or short courses of oral medication

did not or is unlikely to affect that patient's independence

did not or is unlikely to affect the success of treatment for existing health conditions.

Moderate physical harm
Moderate harm is when at least one of the following apply:

has needed or is likely to need healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit, and beyond dressing changes or short courses of medication, but less than 2 weeks additional inpatient care and/or less than 6 months of further treatment, and did not need immediate life-saving intervention

has limited or is likely to limit the patient's independence, but for less than 6 months

has affected or is likely to affect the success of treatment, but without meeting the criteria for reduced life expectancy or accelerated disability described under severe harm.

Severe physical harm
Severe harm is when at least one of the following apply:

permanent harm/permanent alteration of the physiology

needed immediate life-saving clinical intervention

is likely to have reduced the patient's life expectancy

needed or is likely to need additional inpatient care of more than 2 weeks and/or more than 6 months of further treatment

has, or is likely to have, exacerbated or hastened permanent or long term (greater than 6 months) disability, of their existing health conditions

has limited or is likely to limit the patient's independence for 6 months or more.

Fatal (previously documented as 'Death' in NRLS)
You should select this option if, at the time of reporting, the patient has died and the incident that you are recording may have contributed to the death, including stillbirth or pregnancy loss. You will have the option later to estimate to what extent it is considered a patient safety incident contributed to the death.

Psychological harm

Please note that when recording psychological harm, you are not required to make a formal diagnosis; your answer should be an assessment based on the information you have at the point of recording and can be changed if further information becomes available.
No psychological harm
Being involved in any patient safety incident is not pleasant, but please select 'no harm' if you are not aware of any specific psychological harm that meets the description of 'low psychological harm' or worse. Pain should be recorded under physical harm rather than psychological harm.
Low psychological harm
Low psychological harm is when at least one of the following apply:

distress that did not or is unlikely to need extra treatment beyond a single GP, community healthcare professional, emergency department or clinic visit

distress that did not or is unlikely to affect the patient's normal activities for more than a few days

distress that did not or is unlikely to result in a new mental health diagnosis or a significant deterioration in an existing mental health condition

Moderate psychological harm
Moderate psychological harm is when at least one of the following apply:

distress that did or is likely to need a course of treatment that extends for less than six months

distress that did or is likely to affect the patient's normal activities for more than a few days but is unlikely to affect the patient's ability to live independently for more than six months

distress that did or is likely to result in a new mental health diagnosis, or a significant deterioration in an existing mental health condition, but where recovery is expected within six months

Severe psychological harm
Severe psychological harm is when at least one of the following apply:

distress that did or is likely to need a course of treatment that continues for more than six months

distress that did or is likely to affect the patient's normal activities or ability to live independently for more than six months

distress that did or is likely to result in a new mental health diagnosis, or a significant deterioration in an existing mental health condition, and recovery is not expected within six months

When are harm grading fields mandatory?

If an incident has happened where a person(s) is directly involved (regardless of impact/harm) then recording levels of physical and psychological harm is mandatory in the LFPSE system.

Below are detailed examples of patient safety incident events and where the recording of harm is required or not:

Incident where a patient was harmed: for example, patient given a medication to which they have a known allergy

Harm grading required: yes

Details for LFPSE recording: Select the appropriate level of actual physical and/or psychological harm, within the categorical fields and provide further details in the "Describe what happened" free text section, including how the issue was identified.

Incident where the patient sustained no harm: for example, patient given incorrect medication, but to no ill-effect, physically or psychologically

Harm grading required: yes

Details for LFPSE recording: These should be recorded with no physical/no psychological harm within the categorical fields and provide further details in the "Describe what happened" free text section, including how the issue was identified.

Incident where a patient was involved, but harm to the patient was prevented: for example, medication stored at the incorrect temperature was selected, but not administered to the patient because temperature control issues were identified in time; or, patient invited for the wrong procedure, but the invited patient queried the procedure prior to attending

Harm grading required: yes

Details for LFPSE recording: LFPSE also records "near miss" or 'prevented incidents' in which specific patients are identifiable, but the incident resulted in no harm due to a timely intervention. These should be recorded with no physical/no psychological harm, within the categorical fields, and further details provided in the "Describe what happened" free text section, including how the issue was identified, and how the intervention protected the patient(s).

Incident where no patients were involved: for example, medicine storage issues identified before medicines are selected to be administered to any patients; or, oxygen supply disruption in patient areas but patients were not present at the time; or, temporary power issues in a computer which holds a ward's falls assessment templates, though no patients were admitted during the time the system was off-line

Harm grading required: no

Details for LFPSE recording: This should be recorded with 0 patients within LFPSE as no specific patient can be identified as having been involved, and so no patient information need be recorded. You will however be asked if the incident creates an imminent risk (within 2 weeks) of severe harm or death, and if so, if there are any specific patient populations who might be at most risk. This information is used to triage such risks for review at the national level. Answers are understood to be subjective and speculative.

Incident where multiple patients were involved: for example, an overrunning outpatient clinic requiring multiple patients to be rebooked for their follow up appointments; or, infection control - outbreak in ward area; or, faulty CT scanner preventing multiple patients from having their scans

Harm grading required: yes

Details for LFPSE recording: LFPSE allows you to record the details for up to 10 individual patients affected by one incident; the harm fields must be completed for each of these. This field can be updated as more information becomes available. If a patient safety incident affects more than 10 patients, you need only record one patient's details with the most serious single harm, physical or psychological, in the categorical fields and can outline the other impacts within the "describe what happened" free text field including the number of patients involved.

Recording guidance questions and answers

The questions and answers presented below represent questions or issues that frequently arise in relation to patient safety event recording. If you have a question that is not covered below please send it to england.patientsafetyhelpdesk@nhs.net.

1. Do we only record patient safety incidents that we know have occurred in our organisation?

No. You should record patient safety incidents whether they occurred during an episode of care at your organisation or occurred during care provided by another healthcare provider if you are the first provider to become aware of them.

For example, if a pressure ulcer was present on hand over to your organisation from a previous provider, it should still be recorded as a patient safety incident, stating 'No' to the question "Did the incident occur whilst the patient was under your organisation's care?" and documenting the organisation where the care was provided previously.

NB: this record will then become visible to, and "owned by" that provider. Depending on the provider type and location, your organisation may or may not maintain visibility of that record.

If a patient presents to your organisation with a pressure ulcer and has not been under the care of a health care provider (see FAQs for details on which services this includes) prior to presentation, then this does not align with the definition of a patient safety incident and does not need to be recorded to LFPSE. However, if the pressure ulcer were then to deteriorate further during the healthcare episode, an incident should be recorded.

This documentation supersedes previous NRLS documentation ( Implementing the pressure ulcer framework in local reporting systems and reporting to NRLS 2019) specifically in relation to:

Recommendation 11 - 'The definition of a new pressure ulcer within a setting is that it is first observed within the current episode of care.'

Recommendation 15 - 'Reporting of all pressure ulcers grade 2 and above on admission (POA) (which is observed in the skin assessment on admission to that service) should be incorporated into local monitoring systems.

2. Can category of pressure ulcer be matched to a LFPSE degree of harm?

No, the degree of harm depends on the actual impact for this patient as a result of the patient safety incident and does not corelate with the category of pressure ulcer. For example, a patient with a category 3 pressure ulcer could fall into moderate harm because they needed additional healthcare for 3 months.

However, if the same ulcer was on the heel and expected to affect mobility even after healing, then that would be graded as severe harm. Each pressure ulcer must be assessed for degree of harm, using category of pressure ulcer only as a guide and the reason for the level of harm selected should be demonstrated in the free text description of the incident.

If a patient has multiple pressure ulcers that developed by the same mechanism, then only one incident need be recorded. The harm associated with this incident would be the actual level of harm to the patient (i.e., the highest level of harm the patient has incurred from any or all of the pressure ulcers).

If a patient has multiple pressure ulcers which developed due to different mechanisms (i.e, one develops due to a monitoring device, and the other is related to profiling bed equipment), two distinct incidents have occurred and should be recorded as such.

3. How are suicides, self-harm and deaths from drugs and alcohol recorded as patient safety incidents?

The following summarises the guidance for organisations providing specialist mental health services. Further detailed guidance for mental health service providers (including self-harm and restrictive practice) will be published shortly:

NOTE: 'Former patient' is defined as any patient who has been discharged from the Trust's services or who does not have a current open episode for inpatient or community care.

As a general guide, if a patient dies from actual or apparent suicide within 6 months of discharge, or during a further referral to Mental Health (MH) services, a judgement needs to be made as to whether a patient safety incident may have occurred. That incident could be something such as inappropriate discharge or failure in communication. If it is determined that an incident has occurred, the incident should be recorded locally and to the LFPSE service.

It is less likely that death of a former patient more than 6 months after discharge will indicate a patient safety incident has occurred. However, judgment can still be applied to determine if a patient safety incident should be recorded.

The free text incident description should demonstrate how the incident meets the reporting criteria i.e. whether patient is former or current, details of the act or omission that indicates it is or might be a patient safety incident, clearly indicating the actual injuries, or stating that death occurred.

Whilst MH services rightly are mindful that determining if a death is suicide is the role of the coroner, all contextual information that would suggest the likelihood of fatal self-harm needs to be included in the initial incident record.

It is accepted that sometimes toxicology or wider information-gathering is needed to determine if a death is from self-harm, accidental or natural causes. MH services may have to initially record the event on the basis that they suspect rather than can confirm self-harm, but they should not routinely report all unexpected deaths solely because the possibility of self-harm cannot yet be excluded. The CQC accepts recording at a later date in circumstances where self-harm did not initially appear a likely cause of death.

4. Can I change the level of harm of an incident recorded to the LFPSE service after initial record submission?

Yes. As new information becomes available, the incident harm grades (and any other relevant information) can be amended to reflect the update. Please complete the free text description to explain any changes made to the harm grades.

5. How do we select the degree of harm when the ultimate clinical impact of a patient safety incident is not known?

A best assessment at the time of the incident should be carried out and if, at a later date, more information is received, the incident degree of harm and other details about the incident can be amended.

6. Can I still record an incident's level of psychological harm if I am not a trained mental health professional?

Yes, all staff users should be able to make an initial selection of levels of harm on both the physical and psychological scales as it is understood to be a snapshot of limited information at this stage. A formal diagnosis is not required - only the recorder's clinical judgement. To support this, we have:

Worked with users to provide clarified definitions and examples for each, to help guide decision-making.

Mirrored the language used in the physical and psychological scales, to make it simpler for recorders.

Provided the ability to amend all fields including these, should further information become available at any point. This can be done by the original recorder, or by designated users with enhanced permissions at the review stage.

It is important that all records for incidents are submitted with this data, even if it is an initial best-guess, to enable local and national prioritisation and response.

7. What if a death is considered to be due to the natural disease process but a patient safety incident occurred during the provision of care that did not lead to the death?

Based on what is known at the time of recording, a judgement would be needed by the reporter as to the actual impact on the patient from the incident they are reporting. Where it is considered that the incident could have resulted in the death of the patient, rather than the progression of their natural disease, this should be recorded as an incident with a degree of harm selected as fatal. Where the impact is not considered to have resulted in the fatality, a lower level of harm can be recorded.

The supplementary question "how much did the incident contribute to the outcome for the patient?" allows the reporter to indicate their best assessment of the extent of association between incident and outcome.

8. Can we re-classify incidents recorded as fatal if it is later found the death was due to natural causes and not the incident that occurred?

Yes. If it is considered, after review of the circumstances, it is unlikely the incident was associated with the death, the harm level can be downgraded to reflect more accurately the actual harm the incident likely led to, and a rationale in the free text field for why this has been done should be included.

9. Additional observations are taken after an inpatient fall, so does this make all falls low harm?

Levels of harm should be selected based on the information available about the presentation of the patient at the time: observations may help to establish this, but taking them to ascertain the presence or absence of neurological harm does not in and of itself equate to harm level. Should any initial observations be abnormal and necessitate an extended observation period, and/or treatment, this may indicate a higher degree of harm has been caused.

Each incident should be judged individually, based on the LFPSE definitions and examples, and please note that all of the statements in the definition of low harm must apply for the level of physical harm selected to be "low".

10. Are falls resulting in fractured hips classed as severe harm?

A patient who has fractured a hip from an inpatient fall is unlikely to regain the levels of mobility and independence they had prior to the fall, in which case the degree of harm is severe. However, in a few cases the patient could recover after an extended hospital stay (moderate) or die (fatal). Each incident should be judged individually, based on the LFPSE definitions and examples.

11. What if no problems in care preceded the incident? How is harm graded? For example, a patient falls in hospital and fractures their neck of femur, but the ensuing information-gathering or review highlights no lapses in care or treatment.

If a patient falls and suffers a fractured hip, that would more often than not result in severe harm. Review of the circumstances might be unable to identify problems in care, but something unexpected or unintended still happened that resulted in harm to the patient and so the definition of a patient safety incident is met. As noted earlier, it may not always be clear if an incident has occurred or the extent to which an incident was associated with harm, but it is always preferable to err on the side of caution and report, not least as the circumstances of the fall could still represent important intelligence locally or nationally.

12. Are falls resulting in sub-dural haematoma classed as severe harm?

A patient who has a sub-dural haematoma from an inpatient fall is unlikely to regain the levels of mobility and independence they had prior to the fall; but in a few cases the patient could recover after an extended hospital stay (moderate) or die (fatal). Each incident should be judged individually, based on the LFPSE definitions and examples.

13. Does discharge from hospital indicate full recovery after a patient safety incident during hospital admission?

No, discharge from hospital does not in itself indicate full recovery. A patient may be discharged after a patient safety incident with any level of non-fatal harm: after a full recovery, or with a permanent disability. Levels of harm should be judged individually, based on the LFPSE definitions and examples, and updated accordingly if further information emerges.

14. Do the NHSE Clinical Reviewers amend the harm grading if they appear incorrect?

No, The National Patient Safety Team Clinical Reviewers do not alter any data submitted. They may identify data quality concerns and flag these to the Patient Safety Reporting Leads (RLs), who may contact the reporting organisation to offer support, advice and guidance.

15. If recording incidents that have occurred in another organisation, what should the degree of harm be?

You should record the harm level of an incident in another organisation as you would for an incident that occurred in your organisation. The harm should not be downgraded because it occurred elsewhere. The nature of typical patient pathways that cross primary, secondary and tertiary care means that effective recording and learning frequently relies on one organisation identifying and recording incidents that occurred earlier in the care pathway.

16. Does Duty of Candour apply to both the LFPSE physical and psychological scales?

Yes, any incident which is graded as having resulted in moderate or higher harm on either or both scale triggers the Duty of Candour. A severe psychological harm with low physical harm, for example, would qualify.

17. What can be recorded as a Good Care event?

A Good Care event is a positive learning opportunity from care events that have gone well whilst delivering care to and for patients.

A trust provided a recent example: " pioneering the adoption of elastomeric devices to facilitate early discharge of patients on antibiotics. Since their introduction at the beginning of the year, these devices have saved 1750 bed days for a total of 120 patients, with no increase to the number of readmissions in comparison to the baseline. Further evaluation on satisfaction and outcomes is being carried out and the evidence will be shared with the ICB ".

18. How does recording patient safety events to LFPSE relate to the new Patient Safety Incident Response Framework (PSIRF)?

Events recorded to LFPSE can form one source of data for deciding on your local priorities to be included in your Patient safety incident response plan (PSIRP). These should be considered alongside other potential issues, such as complaints, claims, Section 28 letters, and other data sources. The PSIRF module will allow users to annotate existing records with details of whether a safety response was taken forward for that issue, and any relevant findings or safety actions agreed as a result.

It may not always be the case that issues being explored under PSIRF (or according to a provider's PSIRP more specifically) are recorded as individual incidents on LFPSE. This is because providers may choose to explore broader issues including those spanning care pathways for example. These therefore do not need to be entered into LFPSE if they do not meet the definition of a patient safety incident.

Developed by the NHS England National Patient Safety Team. For any enquiries, please contact england.patientsafetyhelpdesk@nhs.net

Publication reference: PRN00444

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NHS England » Policy guidance on recording patient safety events and levels of harm

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This guidance is for users of the new Learn from Patient Safety Events (LFPSE) service, to provide context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate o…

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Episode 10 Bringing together patient safety, QI and organisation development for system transformation.

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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Using your claims scorecard (vimeo.com)

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Maternity insights, closing the loop elfh

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Maternity insights, closing the loop elfh

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Catalogue (learninghub.nhs.uk)

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Being fair 2 - improving organisational culture in the NHS - NHS Resolution

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Being fair 2 aims to promote the value of a person-centred workplace that is compassionate, safe and fair.

A just and learning culture is the balance of fairness, justice, learning - and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong, nor the absence of responsibility and accountability.

Since the publication of in July 2019, and with ongoing work across the NHS, it is apparent that organisations still require support to improve the culture for those working within the health system to tackle issues of incivility, bullying and harassment.

Our second Being fair report sets out the benefits to an organisation of adopting a more reflective approach to learning from incidents and supporting staff.

The key messages from the report are:

There is a clear link between culture, workforce and patient safety.

A poor culture is costly: The cost of non-clinical, work-related stress claims closed over a ten-year period (2010-2020) was in excess of £14 million.

Minority groups are disproportionately impacted by formal disciplinary processes: Our Practitioner Performance Advice service found that ethnic minority groups had 1.7 times the rate of cases per 1000 and were significantly more likely to have a case with the service compared with white practitioners. Redressing disproportionate rates of disciplinary action between ethnic minority and white staff across the healthcare system is essential to foster a just system that supports staff to learn from incidents. This is in line with other recent findings.

A diverse and inclusive working environment is beneficial for productivity and staff retention: When staff feel valued, able to speak up and psychologically safe this can have a positive impact on teamwork, staff wellbeing, efficiency and lead to higher standards of patient care.

There is already a wealth of resources and guidance available across the system to support organisations to drive improvements in culture. This report makes reference to key guidance and best practice throughout. It also provides a 'Just and learning culture charter' that we invite organisations to consider adopting.

Organisational culture is everyone's business. Everyone within healthcare has an important role to play, across all professional groups and at all levels. We hope this report acts as a toolkit for organisations looking to adopt a just culture when managing incidents and supporting staff.

We are grateful to a wide range of organisations who have contributed to this report including the Care Quality Commission, British Medical Association, Royal College of Nursing, Health and Care Professions Council, The National Guardian's Office, NHS England, the General Medical Council and others.

At NHS Resolution, we provide expertise to the NHS to resolve concerns and disputes fairly, share learning for improvement and to help preserve resources for patient care. Our work and the work of others across the system has identified that issues of incivility, bullying and harassment are prevalent across the NHS. This has a negative impact on staff recruitment, retention and overall wellbeing. We hope this document highlights not only the importance of this issue but encourages organisations to take an evidence-based approach to improving organisational culture. We will continue to work with key partners to ensure the best practice referenced throughout the report is implemented.
Dr Denise Chaffer, Director of Safety and Learning, NHS Resolution

Being Fair 2 uses Practitioner Performance Advice's experience and expertise to strengthen its recommendations. Our findings show that practitioners from ethnic minority groups and those who qualify outside the UK are statistically more likely to have a case with us compared to white practitioners who qualify in the UK. This is an important contribution to the discussion and highlights the need to redress disproportionate rates of disciplinary action through agreed frameworks that support a consistent approach for everyone.

The report also highlights the significant link between organisational culture and individual behaviours, emphasising how fairness and open cultures of continuous quality improvement can improve staff wellbeing and patient safety. This link is explored as part of the advice that we provide and is also a key driver for our Compassionate Conversations programme, which aims to support honest conversations on practitioner performance.
Vicky Voller, Director of Advice and Appeals, NHS Resolution

Recent years have seen a growing evidence base linking organisational culture, and the behaviours it enables or incentivises, and patient care. One aspect of this is whether organisations and individual managers respond when things don't go as planned. Initiatives such as the 'Just culture' movement seek to emphasise learning not blame when things go wrong. The use of accountability nudges at the point of incident have helped to reduce biased decisions to disproportionately investigate ethnic minority groups when incidents occur.

This revised version of the original Being fair report will build on that work which has already helped to significantly reduce the numbers of disciplinary cases in the NHS and reduce the relative likelihood of ethnic minority staff entering the disciplinary process. The resultant emphasis on learning not blame inevitably benefits patient care.
Roger Kline OBE, Research Fellow at Middlesex University Business School and one of the report authors

I welcome NHS Resolution's Being fair 2 report, promoting a person-centred workplace that is compassionate, safe and fair. This is important given the recent news of the decrease in workers' confidence to speak up in this year's NHS Staff Survey results. No one should feel they cannot speak up to protect their patients or their colleagues.

As highlighted in the report, ensuring effective speaking up arrangements are truly embedded and at the heart of any healthcare organisation is key to improving workplace culture. While Freedom to Speak Up guardians are an additional route for workers to speak up, they cannot improve the speaking up culture on their own and organisations must take a proactive approach to foster a culture where all workers feel safe to speak up and feel heard.
Dr Jayne Chidgey-Clark, National Guardian for the NHS

In line with Being fair 2, we're clear that a just culture - that balances fairness, learning and accountability - is key to ensuring safe, effective and kind care for people who use services.

Everyone working in healthcare has a responsibility to foster these positive working cultures. That includes being open and candid with the people in your care about all aspects of care and treatment, including when any mistakes or harm have taken place. This means lessons can be learnt quickly to protect people from harm in the future.

Our Code also encourages each nurse, midwife, and nursing associate to speak up if they see something they feel isn't right - all professionals should be able to without fear of being discriminated, excluded, victimised, bullied or undermined.
Anne Trotter, Assistant Director of Professional Practice, Nursing and Midwifery Council

We know that the right organisational culture is crucial to safety and, as demonstrated in recent reports such the Ockenden review, the impact workforce wellbeing has on patient safety is also becoming increasingly evident. How an organisation responds to bullying and harassment can have a massive impact on individuals and the quality of care provided, as well as other important factors like staff recruitment and retention.

CQC's strategy is clear that learning and improvement must be the primary response to all safety concerns and in order to achieve this, staff should be able to report concerns openly and honestly, confident that they won't be blamed and that their voices will be listened to and acted on.

Being fair 2, and the just and learning culture charter that accompanies it, will help organisations promote a workplace that is compassionate, safe and fair - benefitting both their staff and the patients they care for.
Dr Sean O'Kelly, Chief Inspector of Healthcare, Care Quality Commission

We welcome NHS Resolution's Being fair 2 report which highlights the need to focus on the wellbeing and retention of healthcare staff; reduce stress and incidents of bullying, harassment or assaults; and to work together to instil fair, learning cultures in the workplace.

The data is clear, we must do more to turn the tide of talented registrants leaving the NHS. Creating compassionate leadership and safe, supportive working environments are absolutely vital, not only to the welfare of doctors, but also to the future of the NHS and to the safety of patients.

We're taking firm steps to achieve long-lasting change and support the wider health system to overcome barriers to change. We have accelerated our commitment to eliminate disproportionate complaints from employers about ethnic minority doctors by 2026, and to eradicate disadvantage and discrimination in medical education and training by 2031. Additionally, we continue to deliver our Welcome to UK practice workshops. And we've developed the Professional Behaviours and Patient Safety training programme which discusses ways of responding to unprofessional behaviours, because everyone is entitled to be treated with courtesy and dignity in the workplace.

Taking practical steps to improve doctors' working environments will not only improve their wellbeing, but will help retain their skills and experience. If doctors are happier in their working environments, and they are allowed to thrive, they will achieve better results, which will support patient safety.
Anna Rowland, Assistant Director of Policy and Business Transformation, General Medical Council

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Being fair 2 - improving organisational culture in the NHS - NHS Resolution

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Being fair 2 aims to promote the value of a person-centred workplace that is compassionate, safe and fair. A just and learning culture is the balance of fairness, justice, learning - and taking responsibility for actions. It is not about seeking to blame the individuals ...

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nhs resolution duty of candour animation - Bing video

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nhs resolution duty of candour animation - Bing

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Intelligent search from Bing makes it easier to quickly find what you're looking for and rewards you.

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To support consent, inquests, and response to harm- for patients, families, and staff.

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To support consent, inquests, and response to harm- for patients, families, and staff.

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Faculty of Learning - NHS Resolution

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The Faculty of Learning is a repository of educational learning products and resources. This section of our website showcases learning material developed by NHS Resolution to support the health service to learn from harm. We work in partnership with other arm's length bodies (ALB's), the Royal Colleges, other stakeholders and charities to promote best practice and support collaboration.

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The evolution of the Early Notification Scheme

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The evolution of the Early Notification Scheme

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The second report: The evolution of the Early Notification Scheme - NHS Resolution

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Report resource

Although the NHS remains one of the safest healthcare systems in the world within which to give birth, avoidable errors within maternity still occur. Maternity costs make up the largest cost to the NHS in value of claims. The Early Notification Scheme provides a faster and more caring response to families whose babies may have suffered severe harm.

The second report: The evolution of the Early Notification Scheme provides an overview of progress made since the report into the first year of the scheme, which was published in 2019. The report updates on the progress of the key recommendations which were made in the first report and reflects on modifications and improvements made to the scheme since its launch five years ago. It provides an analysis of the main clinical themes, based on a small cohort of cases, and makes recommendations to further improve outcomes for affected families.

We've also produced a one page infographic that summarises the key messages at a glance:
The Early Notification Scheme Infographic
On Thursday 6 October, we ran a webinar to introduce the Early Notification Scheme's second report and its key themes and recommendations. We also provided an update on Early Notification Scheme processes. You can watch the full video above and the slide deck used is available here:
The Early Notification Scheme 2nd Report Webinar Download The second report: The evolution of the Early Notification Scheme

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The second report: The evolution of the Early Notification Scheme - NHS Resolution

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Although the NHS remains one of the safest healthcare systems in the world within which to give birth, avoidable errors within maternity still occur. Maternity costs make up the largest cost to the NHS in value of claims. The Early Notification Scheme provides a faster ...

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fact sheet 5

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NHS England » Core competency framework v2: Minimum standards and stretch targets

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Publishing ref: PRN00239_ii (official)

In collaboration with national maternity and neonatal partner organisations, the Maternity Transformation Programme published a Core Competency Framework (CCFv1) in December 2020. This publication, the Core Competency Framework version 2 (CCFv2), updates and replaces that first version.

CCFv2 sets out clear expectations for all trusts, aiming to address known variation in training and competency assessment across England. It ensures that training to address significant areas of harm are included as minimum core requirements and standardised for every maternity and neonatal service.

Module 1: Saving babies' lives care bundle

Requirements for this module have been aligned to the third version of the Saving Babies Lives Care Bundle (SBLCB).

Minimum standard

90% attendance - annually for each element with eLfH module every three years.

Training must include learning from incidents, service user feedback and local learning.

Training must include local guidelines and care pathways.

e-Learning can be appropriate for some elements.

Learning must be responsive to local clinical incidents and service user feedback.

Stretch target - ambition/aspiration

≥95% attendance.

Shared learning from incidents across local maternity systems (LMS) and buddy local maternity and neonatal systems (LMNS) relating to morbidity and mortality.

Benchmarking against other organisations with a similar clinical profile, and national programmes.

Staff evaluation on quality of training in place with evidence of improvement.

Service users share their experiences as part of training day.

Use of positive case examples to learn from.

Training to be tailored to role and place of work for each element.

1.1 Smoking in pregnancy

Minimum standard

Training must include:

all multidisciplinary staff trained to deliver Very Brief Advice to women and their partners NCSCT e-learning

local opt-out pathways/protocols, advice to give to women and actions to be taken.

CO monitoring and discussion of result.

individuals delivering tobacco dependence treatment interventions should be fully trained to NCSCT standards

Stretch target - ambition/aspiration

1.2 Fetal growth restriction

Minimum standard

Training must include:

local referral pathways, identification of risk factors and actions to be taken.

evidence of learning from local Trust detection rates and actions implemented.

symphysis fundal height measuring, plotting, and interpreting results practical training and assessment, and case reviews from examples of missed cases locally.

Stretch target - ambition/aspiration

Use of service user case study.

Review of trust's detection rates, compared to other similar organisations and national data.

Audit of compliance against training action plan developed as a result of incidents related to fetal growth restriction.

1.3 Reduced fetal movements

Minimum standard

Training must include:

local pathways/protocols, and advice to give to women and actions to be taken.

evidence of learning from case histories, service user feedback, complaints, and local audits.

Stretch target - ambition/aspiration

Use of service user case study.

Audit of compliance against training action plan developed as a result of incidents related to fetal movements.

1.4 Fetal monitoring in labour

See Module 2.

1.5 Preterm birth

Minimum standard

Training must include:

identification of risk factors and local referral pathways

all elements in alignment with the BAPM/MatNeoSIP optimisation and stabilisation of the preterm infant pathway of care.

a team-based, shared approach to implementation as per local unit policy.

risk assessment and management in multiple pregnancy.

Stretch target - ambition/aspiration

Evidence of impact using the improvement strategies to optimise preterm birth outcomes.

Use of clinical simulations.

Review of outcomes in relation to multiple births and identified improvement(s).

Use of service user case study.

1.6 Diabetes in pregnancy

Minimum standard

Training must include:

identification of risk factors and actions to be taken.

referral through local multidisciplinary pathways including Maternal Medicine Networks and escalation to endocrinology teams.

Intensified focus on glucose management in line with NHS Long Term Plan and NICE guidance, including continuous glucose monitoring.

Care of the diabetic woman in labour

Stretch target - ambition/aspiration

Learning from local and national case reviews are disseminated.

Use of service user case study with diabetes in pregnancy.

Module 2: Fetal monitoring and surveillance (in the antenatal and intrapartum period)

Minimum standard

90% attendance.

Annual update.

All staff will have to pass an annual competency assessment that has been agreed by the local commissioner (ICB) based on the advice of the clinical network. Trusts should agree a procedure with their ICB for how to manage staff who fail this assessment. (Pass mark of 85%)

One full day's training in addition to the local emergencies training day.

Fetal monitoring lead trainers must attend annual specialist training updates outside of their unit.

Stretch target - ambition/aspiration

≥95% attendance.

≥95% pass mark/evaluation.

Use of positive case examples to learn from.

Shared learning across LMNS and Buddy LMNS.

Benchmarking against other organisations with similar clinical profile and national programmes.

Evidence of multidisciplinary team (MDT) case scenario discussions and shared with wider team to increase accessibility.

Evidence of improvement following staff evaluation on training when ≤95% feedback is evaluated as good or excellent.

Lead specialists are in collaboration with the national network of fetal monitoring specialists to support own learning, practice developments and evidence-based care.

Wider training, i.e., on neonatal hypoxic ischemic encephalopathy (HIE) and nervous system physiology.

Intrapartum midwives attend additional high-level training to support fetal monitoring knowledge on the ABC programme when available.

Independent external evaluation of local training.

Module 3: Maternity emergencies and multiprofessional training

Minimum standard

Annual update.

Training should be face-to-face (unless in exceptional circumstances such as the covid pandemic).

Stretch target - ambition/aspiration

≥95% attendance.

Shared learning across LMNS or network.

Use of positive case examples to learn from.

Programme of clinical simulations at point of care in variety of settings including community and evidence of learning, actions, feedback and debrief.

Staff evaluation on quality of training in place with evidence of improvement if ≤95% feedback is evaluated as good or excellent.

Module 4: Equality, equity, and personalised care

Minimum standard

90% attendance (three yearly programme of all topics).

Training should cover local pathways and key contacts when supporting women and families.

Training must include:

One topic from each of the following lists must be covered as a minimum, identified from unit priorities, audit report findings, and locally identified learning, involving aspects of care which require reinforcing and national guidance:

List A

ongoing antenatal and intrapartum risk assessment and risk communication

maternal mental health

bereavement care.

List B

personalised care and support planning (including plans when in use locally)

informed decision making, enabling choice, consent, and human rights

equality and diversity with cultural competence.

Stretch target - ambition/aspiration

≥95% attendance.

Involving MNVPs/Service Users in coproducing and/or delivering training based on lived experiences.

Service user feedback gained from Personalised Care and Support Plans (PCSP) audits are embedded into training.

Use of positive case examples to learn from.

Benchmarking against other organisations with similar clinical profile and national programmes.

Training on learning disabilities and Autism, that is maternity specific, is embedded in personalised care training.

Equality and diversity training includes unconscious bias, LGBTQ+.

Risk assessment and risk communication includes genetic risk.

Staff evaluation on quality of training in place with evidence of improvement where ≤95% feedback is evaluated as good or excellent.

Yearly training on any subject.

Stakeholder support, i.e., SANDS involved in supporting delivery of training.

Module 5: Care during labour and immediate postnatal period

Minimum standard

90% attendance (three-yearly programme of all topics).

Training must:
include learning from incidents, audit reviews and investigations, service user feedback and local learning

learning from themes identified in national investigations, e.g., HSIB

have a focus on deviation from the norm and escalating concerns

include national training resources within local training, e.g., OASI Care Bundle (obstetric anal sphincter injuries), RoBUST Operative Simulation Birth Course, prevention and optimisation of premature birth.

be tailored for specific staff groups depending on their work location and role, e.g., homebirth or birth centre teams/maternity support worker (MSW).

Stretch target - ambition/aspiration

>95% attendance of relevant staff group.

Shared learning across LMNS.

Use of positive case examples to learn from.

Benchmarking against other organisations with similar clinical profile and national programmes.

Staff evaluation on quality of training in place, with evidence of improvement where ≤95% feedback is evaluated as good or excellent.

Use of service user case studies and service users to share their experiences.

Module 6: Neonatal basic life support

Minimum standard

90% attendance at a neonatal basic life support annual update, either as an in-house neonatal basic life support training or newborn life support (NLS).

Only registered RC-trained instructors should deliver their local NLS courses and the in-house neonatal basic life support annual updates.

Stretch target - ambition/aspiration

≥95% attendance.

Attendance on separate certified NLS training for maternity staff should be locally decided; but this would be the gold standard with updates every four years.

Evidence of MDT point of care simulation programme, attendance records and learning from them with innovative practices to ensure wide attendance from all staff groups/unsocial shifts/community staff.

Learning from national investigations and programmes, e.g., HSIB and ATAIN.

Benchmarking against other organisations with similar clinical profile and national programmes.

Staff evaluation on quality of training in place with evidence of improvement plans where ≤95% feedback is evaluated as good or excellent.

Use of service user case studies and parents sharing their experiences including the use of positive case examples to learn from.

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Core competency framework v2: Minimum standards and stretch targets

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Publishing ref: PRN00239_ii (official) In collaboration with national maternity and neonatal partner organisations, the Maternity Transformation Programme published a Core Competency Framework (CCFv1) in December 2020. This publication, the Core Competency Framework version 2 (CCFv2), updates and replaces that first version.

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Bringing together patient safety, QI and organisation development for system transformation by NHS England

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Key to the success of the Patient Safety Incident Response Framework (PSIRF)  https://www.england.nhs.uk/patient-safety/incident-response-framework/ is working collaboratively across organisations utilising the skills of colleagues from different departments. 
 
We have previously held two webinars discussing creating common ground between PS/QI and OD. Recordings are available on our FutureNHS platform. 
•	Creating Common Ground - NHS Patient Safety - FutureNHS Collaboration Platform https://future.nhs.uk/NHSps/view?objectId=43249296
•	PSIRF and QI conversation cafe - NHS Patient Safety - FutureNHS Collaboration Platform https://future.nhs.uk/NHSps/view?objectId=45241776
 
In this podcast we aim to further progress the conversation with special guests:
•	Liz Maddocks-Brown, formerly NHS Horizons 
•	Claire Cox, Andy Wilmer and Lorraine Catt from Kings College Hospital
•	Stefan Cantore from Sheffield University Management School. 
 
If you would like to get in touch about the content of this podcast, please contact us on patientsafety.enquiries@nhs.net. Find out more about PSIRF on the NHS England website www.england.nhs.uk/patient-safety/…onse-framework/

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This model – restorative practice – encourages people to take responsibility for their actions, and repair any harm that they have caused. Its use has been found to reduce behaviour problems, improve achievement levels, and develop emotional literacy.

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What is Restorative Practice in Schools & Social Work?

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Restorative practice is an approach to consider adopting if you have not already. We outline how it works in schools and social work settings, here.

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Maternity and Neonatal Senior advocate roll.

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Maternity and Neonatal Senior advocate roll.

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Ockenden recommendation.
The Maternity Independent Senior Advocate (MISA) helps parents-to-be, new parents and families to be listened to and heard by their maternity and neonatal care providers. The MISA will provide support to women and their families, navigating the healthcare system and providing advocacy when they have a concern about the care they are receiving.

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Martha's rule: challenging culture will make our hospitals safer

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Martha's rule: challenging culture will make our hospitals safer

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Best of Today - Martha’s Rule: Challenging culture will make our hospitals safer - BBC Sounds

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Merope Mills’ daughter Martha died after failures by doctors to spot her sepsis

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The Swiss Cheese model was created in 2000 by Reason in a British Medical Journal (BMJ) article called “Human error: models and management”. It is often used in risk analysis and management, and describes how different layers of protection can theoretically prevent failure. In the model, Reason uses slices of Swiss cheese to demonstrate layers of defence against what he calls active failures and latent conditions. Each layer has "holes," or weaknesses, and the idea is that it's unlikely for the holes in all layers to align and allow a hazard to pass through.

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rosie.courtney1@nhs.net

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Learning Response Review and Improvement Tool

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Learning Response Review and Improvement Tool

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Engaging and involving patients, families and staff

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Engaging and involving patients, families and staff

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Engaging and involving patients, families and staff following a patient safety incident

Under the Patient Safety Incident Response Framework (PSIRF) there will be greater engagement with those affected by an incident, including patients, families and staff. Ensuring they are treated with compassion and able to be part of any investigation.

Guide to engaging and involving patients, families and staff following a patient safety incident

The 'Guide to engaging and involving patients, families and staff following a patient safety incident', published alongside PSIRF, sets out expectations for how organisations should engage with all those affected by patient safety incidents. Organisations should work hard to answer any questions and to involve those affected in patient safety incident investigations.

This guidance has been published in partnership with the Healthcare Safety Investigation Branch (HSIB) and Learn Together.

RELATED EVENT:
Engaging Patients & Families in Complaints under Patient Safety Incident Response Framework (PSIRF) and the Complaints Standards Framework
Virtual CPD Masterclass

Tuesday 27th June 2023

This virtual masterclass will build confidence in compassionately engaging and involving families and loved ones to work within the requirements of PSIRF and the Complaints Standards Framework.

Find out more:
www.healthcareconferencesuk.co.uk/engaging-patients-families-complaints

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Engaging and involving patients, families and staff following a patient safety incident

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Engaging and involving patients, families and staff following a patient safety incident

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This programme is in partnership with...

NHS Patient Safety Syllabus training programme

When patients are harmed, it has an impact on them, their loved ones, our staff, and others who work in the healthcare system. It is crucial that all staff, whatever our roles, see safety not just as our collective responsibility, but as a key priority. We all need to think differently about what patient safety means and how we can make improvements.

Overall, we can make healthcare even safer by:

Dealing with risks before they can cause harm

Working to create a positive patient safety culture

Building safer systems

Recognising everyone's role in patient safety

For details of how to access the programme please scroll down to the 'How to Access' section.

More information

The NHS Patient Safety Strategy will help us deliver the changes we need. The Strategy includes a patient safety syllabus and training programme for the whole NHS. This is designed to help everyone who works in the NHS take all the necessary steps to ensure our patients are safe while they are in our care.

This training has five levels, which build on each other, please click on the boxes below to find information about each level.

Level one - Essentials for patient safety

Level one - Essentials for patient safety

Level One - Essentials for Patient Safety (estimated completion time 30mins)
Is the starting point for all NHS staff, and includes sections on:

Listening to patients and raising concerns

The systems approach to safety, where instead of focusing on the performance of individual members of staff, we try to improve the way we work

Avoiding inappropriate blame when things don't go well

Creating a just culture that prioritises safety and is open to learning about risk and safety

There is no skills assessments in Levels 1 although a certificate of completion will be received.

Level one - Essentials of patient safety for boards and senior leadership teams

Level one - Essentials of patient safety for boards and senior leadership teams

Level One - Essentials for Patient Safety for Boards and senior leadership teams (estimated completion time 30mins)
Additional session for senior leaders and executive teams, covering:

The human, organisational and financial costs of patient safety

The benefits of a framework for governance in patient safety

Understanding the need for proactive safety management and a focus on risk in addition to past harm

Key factors in leadership for patient safety

The harmful effects of safety incidents on staff at all levels

There is no skills assessments in Levels 1 although a certificate of completion will be received.

Level two - Access to practice

Level two - Access to practice

Level two - Access to Practice (estimated completion time 45mins)
Access to practice is intended for all clinical and non-clinical staff who have an interest in understanding more about patient safety or who want to go on to access the higher levels of training. There are two sessions:

The first introduces systems thinking (how the way we work can be used to reduce error and improve safety) and risk expertise (how we can identify and manage risk to keep patients safe).

The second session looks at human factors (the science of work and of working together in safely designed systems) and safety culture (the significance of a true learning culture, free of inappropriate blame).

Level two Access to Practice includes an assessment, which on completion staff will receive a certificate and will have access to the sector specific sessions covering Mental Health, Primary Care, Maternity Care, Acute Care, and Management and Administration.

Level two - Sector Specific Sessions

Level two - Sector Specific Sessions

Level two - Sector Specific sessions (Accessible following completion of Level two Access to Practice)
On completion of Level 2 Access to Practice all staff will have access to five patient safety sector specific sessions covering good practice, human factors, risk management, systems thinking, and safety culture. Each of these sessions can be completed by individuals or used as part of a group discussion. These sessions aim to highlight the learning from Level 2 - Access to Practice. The sessions cover:

Mental Health

Primary Care

Acute Care

Maternity Care

Management and Administration

A certificate of completion is available following completion of each session.

Levels three to five

Levels three to five
Levels 3-5 are in development and expected to be available from Autumn 2023.

Acknowledgements

Acknowledgements of assistance developing the training modules

We would like to acknowledge those who have helped review these training modules as they were developed. This included members of key stakeholder organisations and over 50 frontline clinical staff.

We would like to acknowledge the support and guidance offered by members of the following organisations represented on our Advisory Group for development of the syllabus.

Allied Health Professions Federation

Academic Health Science Network

Care Quality Commission

Council of Postgraduate Medical Deans

Council of Deans of Health

Department of Health Northern Ireland

General Medical Council

Heath and Care Professions Council

Healthcare Safety Investigation Branch

Health Education England

Health Education and Improvement Wales

Lay representatives

Medical Schools' Council

National Association of Clinical Tutors

NHS Clinical Commissioners

NHS Education for Scotland

NHS Employers

NHS England and Improvement

Nursing and Midwifery Council

Royal College of General Practitioners

Royal College of Midwives

Royal College of Nursing

Royal College of Physicians including its Chief Registrar Programme

Royal Pharmaceutical Society

Society & College of Radiographers

UK Foundation Programme

Patient Safety Development Team

How to Access

In order to access any elfh programme, you will need an elfh account. If you do not have one, then you can register by selecting the Register button below.
Register >
To view the NHS Patient Safety Syllabus training programme, select the View button below. If you already have an account with elfh, you will also be able to login and enrol on the programme from the View button.
View >
If you already have an account with elfh, then you can enrol on to the NHS Patient Safety Syllabus training programme by logging in to the elfh Hub, selecting My Account > Enrolment and selecting the programme. You can then access the programme immediately in the My e-Learning section.

NHS healthcare staff in England - ESR

The NHS Patient Safety Syllabus training programme is also available to NHS healthcare staff via the Electronic Staff Record (ESR). Accessing this e-learning via ESR means that your completions will transfer with you throughout your NHS career.

Further details are available here.

Registering large numbers of users

If you are a HR, IT or Practice Manager and would like to register and enrol large numbers of staff within your organisation for access onto the NHS Patient Safety Syllabus training programme, please contact elfh directly.

Organisations wishing to use their own LMS

For HR departments wanting to know more about gaining access to courses using an existing Learning Management System please contact elfh directly to express interest.

More information

Please select the following link for more information on how to use the elfh Hub.

elfh is a NHS England programme in partnership with the NHS and professional bodies

© elearning for healthcare 2023

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NHS Patient Safety Syllabus training - elearning for healthcare

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Safer culture, safer systems, safer patients

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Audit guidance, documents and files

The following clinical audit documents are provided for you to download and use:

Clinical audit resources

Please note that the hot-debrief has now been renamed post-fall debrief and post fall review has been revised to the post fall SWARM huddle.
Datasets & uploading specifications

Other resources

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The following clinical audit documents are provided for you to download and use: Please note that the hot-debrief has now been renamed post-fall debrief and post fall review has been revised to the post fall SWARM huddle.

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First embedding webinar and use of toolkit

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First embedding webinar and use of toolkit

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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Shared by Being Human in Health Care

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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Shared by gloshospitals.nhs.uk

Resources to be shared with pride and acknowledgment.

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CARe QI Handbook Fill in the form below to be taken to our downloads page where you can download the full CARe QI Handbook for FREE!

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We are a collaboration platform empowering everyone working in health and social care to safely connect, share and learn across boundaries. Be part of a FutureNHS.

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Continuing our series of blogs that look at the range of investigation methods we use, Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator's 'swiss army knife' when planning and undertaking patient safety investigations.

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The Preventable Deaths Tracker is the first and only open database of all published coroner reports in England and Wales. It includes over 4,800 reports and is updated weekly. We use this database to provide real-time analytics and bespoke research investigations.

The mission of the Preventable Deaths Tracker is to make coronial data accessible so that it can be used to learn lessons and improve public safety. Ultimately, we seek to save lives by reducing preventable deaths.

Explore our real-time analytics

Impact of the Tracker

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A platform to learn lessons from coroners' inquests - Preventable Deaths Tracker

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The Preventable Deaths Tracker is the first and only open database of all published coroner reports in England and Wales. It includes over 4,600 reports and is updated weekly. We use this database to provide real-time analytics and bespoke research investigations.

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FMEA model used at UHS to look at SI's where fetal compromise was a contributory factor.

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A systematic, proactive method for evaluating a process or product to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change.
Note: Spanish and Portuguese translations of this tool also available for download.
Failure Modes and Effects Analysis (FMEA) includes review of the following:

Steps in the process

Failure modes (What could go wrong?)

Failure causes (Why would the failure happen?)

Failure effects (What would be the consequences of each failure?)

Teams use FMEA to evaluate processes for possible failures and to prevent them by correcting the processes proactively rather than reacting to adverse events after failures have occurred. This emphasis on prevention may reduce risk of harm to both patients and staff. FMEA is particularly useful in evaluating a new process prior to implementation and in assessing the impact of a proposed change to an existing process.
*NOTE: Before filling out the templates, first save the PDF files to your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved.
FMEA Tool Overview

Related Content

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Failure Modes and Effects Analysis (FMEA) Tool

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A systematic, proactive method for evaluating a process or product to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change.

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Resources for patients and their families

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Resources include leaflets, posters, social media assets and case study guidance