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Andrew Rochford: Reflections on patient safety

Andrew Rochford

Over 20 million incidents or near misses have been recorded on Datix, Serious Incidents and ‘Never Events’ still occur despite numerous reports, enquiries and patient safety alerts.

This patient safety resource has been supported by a grant from Becton Dickinson (BD). They have had no influence over the production or content of these materials.

Patient safety is one of the four key improvement themes on Medical Care - driving change and I encourage you to view the previous content which is all freely available. It is also clearly an area of clinical interest as our patient safety webinars are the best attended and receive the most positive feedback of all our webinars. Earlier this month, I had the privilege of chairing a webinar on managing sepsis in patients with learning difficulties and autism. The webinar features Paula McGowan, the mother of Oliver McGowan who has championed the importance of education and training for all health and social care professionals in supporting patients with learning difficulties and autism. This training is now mandatory across the NHS and if you have not already done so, I encourage you to complete the highly informative and extremely well-constructed training module that is available on line through your organisation or eLearning for Health. I also encourage you to read the HSSIB report published at the end of last year on caring for adults with a learning disability in acute hospitals, as well as a review and recommendations from the Nuffield Trust.

It seems very timely that our focus this month is patient safety; it is fair to say that it is a very ‘hot topic’ at present. At the first meeting of the Patient Safety Committee two weeks ago we discussed the implementation of Martha’s Rule and considered the redress options recommended by Henrietta Hughes, the Patient Safety Commissioner in her recent Hughes Report. There are at least 46 members of the Patient Safety Committee including representatives from the Medical Specialist Societies, the four nations, RCP Global members, the Patient Carer Network and arm’s length bodies such as HSSIB, NCEPOD and the MHRA. The committee is convened by the RCP and receives reports from the Medicines Safety Joint Working Group and NEWS2 Improvement Advisory Group. The committee contributes to consultations (e.g. NCEPOD, NICE and HSSIB), conferences such as Medicine, Medicine+ and the Bristol Patient Safety Conference, and wider initiatives such as the Acute Kidney Summit held last autumn. Members of the committee have led on patient safety webinars on Medical Care - driving change and this year we aim to highlight more of the committee’s work through the website. We recognise that digital working has its own patient safety implications (which are acknowledged by NHS England) and will be establishing a new Digital Safety Group this year led by Dr Anne Kinderlerer, the RCP’s digital health clinical lead.

Andrew Rochford

I believe that there is much to be said about the importance of kindness and compassion in improving patient safety.

Dr Andrew Gibson, Consultant Neurologist and RCP Representative at NCEPOD, is leading a discussion on why ‘closing the loop’ is such a challenge. Over 20 million incidents or near misses have been recorded on Datix, Serious Incidents and ‘Never Events’ still occur despite numerous reports, enquiries and patient safety alerts (for example, see the HSSIB report on retained surgical swabs from December 2023). Pauline Heslop and colleagues published an excellent article on the impact of the national clinical outcome review programmes in England in Clinical Medicine in 2020 which offers plenty to reflect on. Over the course of this year, the Patient Safety Committee will be looking at this in more detail and will discuss our findings and recommendations on Medical Care - driving change.

Finally, many of you will be aware of the recent Extraordinary General Meeting that took place at the RCP. As this goes to press, we await the results of the vote by Fellows on 5 motions relating to the upcoming regulation of Physicians Associates (PAs). The RCP hosts the Faculty of Physician Associates and whilst many Members and Fellows will have encountered PAs in secondary care, there are a growing number of PAs now working in primary care. In 2019, the GMC was appointed to be the regulatory body for PAs (as well as Anaesthetics Associates, AAs) and regulation is expected to commence later this year. Details of this process can be found at the GMC.

PAs are part of the Medical Associate Professions (MAPs) that are supported in the Long Term Workforce Plan for the NHS. NHS England has written to all providers last week about how to safely and effectively integrate PAs into the multi-disciplinary team. However, there is significant concern about PAs' clinical supervision, scope of practice, and patient safety; the latter of which was highlighted in a recent BMA survey.

Many of you will work with PAs clinically and I am sure that many PAs are great advocates for Patient Safety. At our last Patient Safety Committee meeting, I was asked whether there was any evidence that the PA role compromised patient safety. I am not aware of any clinical studies that have looked into this although there is a helpful review of the literature Physician associates advance patient safety published in the Future Healthcare Journal in 2021. I am concerned about the growing level of animosity towards PAs that is being portrayed in the press and social media which comes at a time of high levels of discontent in the medical workforce. It is important that people feel able to speak out and voice concern (I can thoroughly recommend the work of Prof Amy Edmonson). From a personal perspective, rather than focusing solely on PAs my concern reflects a growing lack of civility towards members of the multi-professional team and I draw your attention back to the work of Dr Chris Turner and the Civility Saves Lives team.

I was at an event at the weekend celebrating the life of a colleague who sadly passed away too young and whilst still working. Her email ‘out of office’ read ‘Be kind and remember your humanity. Surround yourself with love. Call out bad behaviour.’ Dr Ruw Abeyratne has written on Medical Care driving change about the importance of compassion to yourself and others. I believe that there is much to be said about the importance of kindness and compassion in improving patient safety.


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