UKMA Hot Topics of The Week.
Hot Topic of the Week
Monday 24th March 2025
What is a GMC Approved Practice Setting?
If you are a Doctor with an Approved Practice Setting (APS) condition on your GMC Licence to Practise, you must have a connection to a Designated Body, before you start work as a Doctor in the UK.
The APS condition equates to having a Designated Body
Each Designated Body is recognised as an APS. They provide supervision, appraisals, CPD, and revalidation support.
Types of Designated Bodies include: NHS Trusts, Private Clinics, Locum Agencies and certain Independent Organisations, such as the Independent Doctors Federation.
The GOOD NEWS is, that if you are appointed to a non-training post in the NHS, that NHS Trust will provide you with Designated Body status, before you start work with them
Furthermore, if you are appointed to a training programme in the NHS, the Training Deanery will become your Designated Body
Doctors with full registration must work in APS until the end of their 5-year revalidation period, unless also joining the GP or Specialist Register. Swiss applicants and F1 doctors are exempt.
However, special care needs to be taken when considering undertaking NHS Bank locum work, as it is uncommon for Designated Body Status to be granted by an NHS Trust in these circumstances. You must only undertake NHS Bank locum work, if you have a Designated Body, either by negotiating with the Trust to connect you to their Designated Body before you start work, or that you already have a connection to another Designated Body.
Also, special care needs to be exercised when undertaking a Clinical Attachment, as you will not be granted Designated Body Status by the Trust. For this and for Indemnity Insurance reasons, a Clinical Attachment should only be an Observership.
The GMC’s guidance on Clinical Attachments is:
A clinical attachment allows an international medical graduate to gain an overview of medical processes and systems in the UK, specifically in the NHS, by observing a consultant
in a relevant speciality at work. During the attachment, the doctor is not given any responsibility and is not able to make clinical decisions or give clinical advice.
After a set period observing the consultant, the graduate may start to take on some limited clinical duties. This will be following a risk assessment, and at the discretion of and under the
overall supervision of the supervising consultant. Duties are generally limited to:
• Observing consultations
• Participating in patient administration (clerking)
• Taking patient histories
• Physical examinations (under direct supervision)
• Directly observing surgery
Monday 17th March 2025
Epistemology in Medicine – The Pursuit of Truth and Knowledge
At its core, medicine is an epistemic practice—it relies on the acquisition, interpretation, and application of knowledge to diagnose and treat disease. However, medical knowledge is not absolute; it is shaped by uncertainty, probability, bias, and evolving paradigms. This raises profound philosophical questions about how doctors know what they know and whether their knowledge is reliable.
The Nature of Medical Knowledge
Medical knowledge is derived from multiple sources, each with its own strengths and limitations. Empirical evidence comes from clinical trials, epidemiology, and biostatistics, forming the backbone of evidence-based medicine. However, no study is perfect, and data can be incomplete, biased, or misinterpreted. Pathophysiological reasoning helps guide diagnosis and treatment through an understanding of disease mechanisms, but theoretical knowledge does not always translate to effective care.
Many treatments that make sense in theory fail in practice. Clinical experience plays a crucial role in decision-making, relying on pattern recognition, intuition, and heuristics. However, experience is also subject to cognitive biases, anecdotal reasoning, and overconfidence. Patient narratives provide vital insight into holistic care, yet self-reported symptoms and histories are subjective and influenced by personal, cultural, and psychological factors. Each of these sources contributes to medical epistemology, but none are infallible. The challenge for doctors is to navigate this uncertainty and make the best possible decisions with the knowledge available.
Uncertainty and the Limits of Medical Knowledge
Medicine operates in the grey zone of probability, not certainty. Unlike mathematics, where truths are absolute, medical knowledge is probabilistic. A test result may be 95% accurate, but there is still a 5% chance it is wrong. It is also context-dependent, as the same treatment may work for one patient but fail for another due to genetic, environmental, or social factors. Medical knowledge is constantly evolving, and what is considered best practice today may become obsolete tomorrow, as seen in the changing recommendations for hormone replacement therapy. A good doctor must therefore embrace uncertainty, think critically, and continuously update their understanding.
Bias and the Fallibility of Medical Knowledge
Medical decision-making is vulnerable to numerous cognitive and systemic biases. Confirmation bias leads doctors to selectively focus on evidence that supports their pre-existing beliefs while ignoring contradictory data. The availability heuristic causes physicians who recently diagnosed a rare disease to overdiagnose it in subsequent cases. Overconfidence bias makes experienced doctors trust their intuition even when evidence contradicts it. Publication bias skews the body of available evidence, as studies with positive results are more likely to be published. Financial and institutional biases further shape what knowledge is promoted and adopted, influenced by pharmaceutical companies, medical device manufacturers, and healthcare policies. Overcoming bias requires epistemic humility, the willingness to question assumptions, seek opposing viewpoints, and acknowledge the limits of one's knowledge.
The Role of Evidence-Based Medicine (EBM) and Its Critiques
Evidence-Based Medicine (EBM) aims to systematise medical knowledge through rigorous research and clinical guidelines, but it is not without its critics. Algorithmic medicine provides general recommendations, yet it may not always apply to a specific patient with unique comorbidities or preferences. The over-reliance on Randomised Controlled Trials (RCTs) presents another challenge, as RCTs are considered the gold standard but often exclude real-world patients such as the elderly or those with multiple diseases. The crisis of reproducibility has also raised concerns about the reliability of medical research, as many published studies fail to be replicated. A balanced epistemological approach recognises the value of evidence while maintaining the flexibility to adapt to individual patient needs.
The Future of Medical Knowledge – AI, Big Data, and the Changing Role of Doctors
With the rise of Artificial Intelligence (AI) and machine learning, the nature of medical epistemology is shifting. AI can analyse vast datasets beyond human capacity, identifying patterns and predicting disease with increasing accuracy. Big Data personalises medicine, tailoring treatments to an individual’s genetic and lifestyle profile. However, AI has epistemic limitations—it relies on past data, which may include biases, and lacks human judgment, ethical reasoning, and contextual understanding. The challenge for future doctors will be to integrate AI-driven insights while maintaining the uniquely human aspects of medicine, including empathy, ethical judgment, and clinical intuition.
Final Thoughts – The Physician as a Knowledge Seeker
A doctor is fundamentally a seeker of truth in an uncertain world. Practising medicine requires lifelong learning, constantly updating knowledge as science evolves. It demands critical thinking, evaluating evidence and questioning assumptions. It necessitates humility, recognising the limits of one’s knowledge and avoiding overconfidence. It also calls for ethical reasoning, applying knowledge in a way that respects patient autonomy and well-being. In the end, epistemology in medicine is about striking a balance between knowledge, uncertainty, and wisdom—understanding not only what we know but also what we don’t know, and what we need to know next.
Monday 13th January 2025
Monday 13th January 2025
Dr Atul Gawande and the WHO Surgical Safety Checklist: A Revolution in Patient Safety
In the fast-paced, high-stakes world of modern medicine, even the most skilled professionals are not immune to human error. The operating theatre, in particular, is an environment where a small oversight can lead to catastrophic consequences. Dr Atul Gawande, a Harvard-trained surgeon, author, and public health researcher, recognised this vulnerability and sought to create a simple, universally applicable solution. The result was the WHO Surgical Safety Checklist, a tool that has since transformed surgical safety around the globe.
Dr Gawande’s career exemplifies the power of critical thinking and innovation in medicine. Known for his best-selling books like The Checklist Manifesto, Dr Gawande has a knack for identifying systemic problems and creating practical, scalable solutions. In 2007, he collaborated with the World Health Organization (WHO) to address preventable surgical errors. Statistics revealed that nearly half of all hospital complications occurred during or after surgery, with the death rate for major surgeries ranging from 0.4% in developed countries to as high as 10% in resource-limited settings. Many of these complications were entirely avoidable.
Inspired by checklists used in aviation, Dr Gawande proposed a similar approach for surgery. In partnership with WHO, he developed the Surgical Safety Checklist to improve communication, standardise practices, and minimise errors.
The first phase, Sign In, occurs before anaesthesia. During this phase, the team confirms the patient’s identity, surgical site, procedure, and consent. The anaesthesia machine and medication checks are completed to ensure readiness. A pulse oximeter is placed on the patient and tested, and the patient is assessed for allergies, airway risks, and potential blood loss. Additionally, institutions often include a review of DVT prophylaxis, ensuring that appropriate measures, such as anticoagulants or compression devices, are planned for patients at risk of developing deep vein thrombosis.
The Time Out phase takes place immediately before the skin incision. This step ensures all team members introduce themselves by name and role, fostering communication and clarity. The patient’s identity, surgical site, and procedure are reconfirmed. Antibiotic prophylaxis is verified to ensure it has been administered appropriately, and the team discusses anticipated critical events, including potential complications, equipment needs, and the estimated duration of the procedure. This phase ensures that all team members are aligned and prepared for the surgery.
The final phase, Sign Out, occurs before the patient leaves the operating room. The nurse confirms the procedure performed and completes instrument, sponge, and needle counts to account for all materials used. Specimen labelling is verified, ensuring that all samples are correctly identified. The team discusses any equipment issues encountered and outlines key recovery concerns, ensuring that the patient’s postoperative care is well planned and communicated.
The checklist’s impact has been profound. A study in The New England Journal of Medicine demonstrated a 36% reduction in complications and a 47% decrease in surgical deaths following its implementation in eight hospitals worldwide. The checklist’s success lies in its simplicity and ability to foster teamwork and communication. By empowering all team members to speak up if they notice potential issues, it has created a culture of shared responsibility.
Since its introduction, the checklist has been adopted globally, including by the NHS, which made it mandatory in 2010. Beyond surgery, it has inspired similar tools in obstetrics, emergency medicine, and intensive care. Dr Gawande’s work highlights the importance of simplicity, teamwork, and evidence-based interventions in healthcare. The WHO Surgical Safety Checklist serves as a powerful example of how innovative thinking can address systemic challenges and improve patient safety worldwide.
Hot Topic of the Week
Monday 30th December 2024
Have you ever made a Diagnostic Error?
Let’s look at the work of Professor Pat Croskerry on Strategic Debiasing
Professor Pat Croskerry is a Canadian Emergency Room Physician, Researcher, and Thought Leader in patient safety and clinical reasoning.
He is internationally recognised for his pioneering work on cognitive biases and decision-making errors in healthcare, focusing on improving diagnostic accuracy and reducing medical errors.
Key Elements of Prof Croskerry's Work on Strategic Debiasing
and Understanding Cognitive Biases
Cognitive biases are systematic errors in thinking that affect judgements and decisions.
Prof Croskerry identified two main types of biases:
A] Affective Biases (Emotion-Driven):
Overconfidence Bias: Feeling excessively certain about a diagnosis, leading to premature closure.
Emotionally Driven Anchoring: A strong emotional reaction to a patient or situation can cause a clinician to cling to an initial impression. Example: A distressed patient with dramatic complaints might be dismissed as having anxiety, overlooking serious underlying conditions.
Empathy Bias: Over-empathising with a patient might lead to under-investigation, such as avoiding painful but necessary diagnostic tests.
Frustration Bias: Dealing with a difficult patient might provoke frustration, leading to less thorough evaluations or care.
B] Cognitive Biases (Information-Processing Errors):
Anchoring Bias: Fixating on an initial diagnosis and failing to adjust despite new evidence. Example: Persisting with a GERD diagnosis for a patient with chest discomfort despite abnormal cardiac markers indicating an MI.
Confirmation Bias: Focusing on evidence that supports a preconceived notion while ignoring contradictory data. Example: Assuming fatigue is due to depression and not investigating anaemia despite signs like pallor.
Availability Bias: Relying on recent or vivid cases to guide decisions. Example: Misdiagnosing the sixth patient with musculoskeletal chest pain after seeing five consecutive cases of it, even if the sixth has an MI.
Representativeness Bias: Judging the likelihood of a diagnosis based on its similarity to a typical case. Example: Misdiagnosing a young woman with chest pain as having non-cardiac causes because she does not fit the stereotype of a heart attack patient.
Dual Process Theory
Prof Croskerry applies Dual Process Theory to explain decision-making:
System 1 (Intuitive Thinking): Fast, automatic, and prone to bias. Example: Quickly diagnosing anxiety in a patient with palpitations based on prior similar cases.
System 2 (Analytical Thinking): Slow, deliberate, and less error-prone. Example: Carefully considering alternative possibilities and reviewing evidence in detail.
Strategic debiasing often involves shifting from System 1 to System 2 thinking, especially in critical situations.
Techniques for Strategic Debiasing
Metacognition: Thinking about one’s own thinking to recognise and correct biases.
Cognitive Forcing Strategies: Pausing to actively consider alternative diagnoses. Example: Deliberately evaluating rare but high-risk diagnoses when symptoms seem similar to recent cases.
Checklists and Protocols: Using structured tools to standardise decision-making and reduce reliance on intuition.
Simulation and Training: Practising in controlled settings to identify and counteract biases.
Feedback Mechanisms: Providing real-time or retrospective feedback to reinforce accurate decision-making.
Teaching and Implementing Debiasing
Prof Croskerry emphasises embedding debiasing education into medical training and ongoing professional development. He advocates creating a culture of safety where clinicians feel comfortable discussing errors and biases without fear of blame. Reflective practice is encouraged to help clinicians continually refine their decision-making skills.
Outcomes and Importance
Strategic debiasing improves diagnostic accuracy, reduces medical errors, and enhances patient safety. It is a vital component of broader efforts to optimise clinical reasoning and decision-making under pressure.
Hot Topic of the Week
Monday 16th December 2024
What is the Clinical Negligence Scheme for Trusts (CNST)?
The Clinical Negligence Scheme for Trusts (CNST) plays a critical role in ensuring patient safety, financial security, and risk management within the NHS. Established to manage and mitigate the financial implications of clinical negligence claims, the scheme has grown into a cornerstone of the NHS’s approach to quality assurance and patient safety. For healthcare professionals and organisations, understanding CNST is not only essential for compliance but also integral to fostering a culture of accountability and improvement.
In this blog, we’ll explore the history, purpose, and key aspects of CNST, its impact on clinical governance, and why it matters for healthcare professionals across the UK.
What Is the Clinical Negligence Scheme for Trusts?
The Clinical Negligence Scheme for Trusts, operated by NHS Resolution, is a risk-pooling arrangement designed to cover the costs of clinical negligence claims made against NHS trusts and other member organisations. It provides indemnity to NHS bodies for incidents that occur during NHS care.
The scheme was introduced in 1995 as part of broader efforts to centralise and streamline the management of negligence claims. By pooling resources, the scheme reduces the financial burden on individual trusts and provides a consistent framework for handling claims.
The primary objectives of CNST are:
1. Financial Risk Management: By pooling resources, the scheme ensures that NHS trusts are not financially overwhelmed by large or multiple claims.
2. Consistency: Establishing standardised processes for managing claims fosters uniformity and fairness in how negligence cases are handled.
3. Encouraging Safer Practices: CNST incentivises trusts to improve risk management and clinical practices by linking contributions to performance against safety standards.
4. Protecting Patients and Staff: Ensuring patients harmed by negligence receive compensation while safeguarding the reputation and financial stability of NHS bodies.
How Does CNST Work?
Membership and Contributions
NHS trusts and other eligible healthcare organisations voluntarily join the scheme. Members pay an annual contribution based on:
- The size and type of organisation.
- The nature of services provided.
- Historical claims data.
- Risk management performance.
These contributions fund the scheme, creating a collective pool to cover the costs of claims.
Claim Management
When a negligence claim is made, NHS Resolution manages the process, which includes:
1. Investigating the Claim: Assessing the validity of the claim by reviewing clinical records, interviewing staff, and consulting expert witnesses.
2. Settling Valid Claims: Negotiating settlements that fairly compensate patients for harm caused by negligence.
3. Defending Unwarranted Claims: Ensuring that the NHS is not held liable for incidents unrelated to negligence.
Risk Management Standards
CNST also incorporates risk management standards that trusts must meet to minimise contributions. These standards cover areas such as:
- Incident reporting.
- Patient safety initiatives.
- Staff training.
- Clinical governance.
Trusts that demonstrate effective risk management and a commitment to safety may benefit from lower contributions, creating a financial incentive for improvement.
Why Is CNST Important?
Financial Sustainability
Clinical negligence claims can involve significant costs, including legal fees and compensation payouts. For individual trusts, this financial liability can be overwhelming. CNST distributes the risk, ensuring the financial sustainability of NHS organisations.
Promoting Accountability
CNST encourages trusts to adopt best practices in clinical care and governance. By linking contributions to safety performance, the scheme creates accountability and incentivises continuous improvement.
Enhancing Patient Safety
The scheme places a strong emphasis on risk reduction. By focusing on learning from incidents and implementing preventive measures, CNST helps to create a safer healthcare environment for patients.
Supporting Staff
For healthcare professionals, the fear of litigation can be stressful. CNST provides a structured framework that protects staff from personal financial liability while ensuring they learn from mistakes in a constructive manner.
Challenges and Criticisms of CNST
Rising Costs of Claims
The cost of clinical negligence claims has risen significantly in recent years. According to NHS Resolution, the total value of claims liabilities in 2023 exceeded £128 billion. Factors contributing to this include:
- Increasing patient awareness and willingness to pursue claims.
- Higher legal costs.
- Complex and high-value claims, such as those involving birth injuries.
This rising cost has raised concerns about the long-term sustainability of CNST.
Focus on Financial Metrics
Critics argue that the scheme can sometimes prioritise financial metrics over the human aspects of patient safety. While risk management standards are valuable, they must be balanced with a genuine focus on improving patient care and staff well-being.
Impact on Trusts
Trusts with higher claims histories may face disproportionately high contributions, which can strain already limited budgets. This challenge highlights the importance of addressing root causes of negligence at a systemic level.
The Role of Healthcare Professionals in CNST
Healthcare professionals, including doctors, nurses, and allied health workers, play a crucial role in the success of CNST. While the scheme is largely administrative, its effectiveness relies on the commitment of frontline staff to:
1. Adopt Best Practices: Staying informed about and implementing national guidelines such as those from NICE and NSF.
2. Participate in Risk Management: Reporting incidents, engaging in safety audits, and contributing to a culture of transparency.
3. Continuous Professional Development: Regular appraisals and revalidation help maintain high standards of care, reducing the likelihood of negligence.
4. Patient Communication: Clear and compassionate communication can prevent misunderstandings that often lead to complaints or claims.
How CNST Aligns with Clinical Governance
CNST is intrinsically linked to the principles of clinical governance, which encompass accountability, quality improvement, and risk management. By incentivising trusts to prioritise safety and learning, CNST supports the core pillars of clinical governance:
- Accountability: Ensuring clear processes for managing and learning from claims.
- Quality Improvement: Promoting safer practices through financial incentives.
- Risk Management: Encouraging proactive measures to prevent incidents.
For healthcare professionals, understanding this alignment reinforces the importance of their individual contributions to broader organisational goals.
Conclusion: Embracing CNST for a Safer Future
The Clinical Negligence Scheme for Trusts is more than a financial safety net; it is a powerful driver of change within the NHS. By fostering accountability, promoting patient safety, and incentivising best practices, CNST helps to protect both patients and healthcare professionals.
However, the challenges of rising costs and the complexity of claims require continued innovation and collaboration. For healthcare professionals, embracing the principles underpinning CNST—transparency, learning, and improvement—is essential for shaping a safer, more effective healthcare system.
As we navigate the evolving landscape of healthcare, CNST stands as a reminder that excellence in patient care is not just a goal but a collective responsibility.
Hot Topic of the Week
Monday 2nd December 2024
What is The NHS Patient Safety Strategy?
The NHS Patient Safety Strategy, published by NHS England and NHS Improvement in July 2019, outlines a comprehensive framework to improve patient safety across healthcare settings. Built around three core pillars—Insight, Involvement, and Improvement—the strategy focuses on reducing harm, saving lives, and fostering trust in healthcare. Subsequent updates in 2021 and 2023 have built upon this framework, ensuring it evolves to address emerging challenges and priorities effectively.
Insight: Enhancing the Understanding of Safety
The Insight pillar aims to improve how the NHS captures, shares, and uses safety information. This involves several key initiatives:
- Sharing Safety Information: The Learn from Patient Safety Events (LFPSE) service replaced older systems like the National Reporting and Learning System (NRLS), allowing staff to report and learn from incidents more effectively.
- Data Analysis and Learning: Leveraging advanced analytics, including artificial intelligence (AI), to identify patterns, predict risks, and take pre-emptive actions to prevent harm.
- Safety Metrics: Developing indicators to track and benchmark safety performance across NHS organisations.
- Just Culture: Encouraging open reporting and learning from incidents to foster accountability rather than assigning blame.
The 2023 updates highlighted significant progress, with the NHS reporting that it is halfway toward achieving its target of saving 1,000 additional lives and reducing care costs by £100 million annually.
Involvement: Empowering Patients and Staff
The Involvement pillar ensures patients and staff are active participants in improving safety. Key initiatives include:
- Patient Empowerment: The integration of Patient Safety Partners (PSPs) into governance structures ensures that patients’ voices influence safety decisions.
- Staff Training: Delivery of the Patient Safety Syllabus, focusing on essential safety principles such as systems thinking and human factors.
- Psychological Safety: Creating environments where staff feel confident reporting errors and suggesting improvements without fear of reprisal.
- Collaborative Practices: Encouraging multidisciplinary teamwork to address safety challenges collectively.
The 2023 updates reinforced these efforts, placing particular emphasis on addressing health inequalities and ensuring all patient groups benefit equitably from safety improvements.
Improvement: Delivering Sustainable Changes
Improvement focuses on implementing lasting changes in processes and systems that influence patient safety. Key components include:
- Patient Safety Incident Response Framework (PSIRF): A proactive approach replacing the Serious Incident Framework, focusing on systemic learning rather than individual blame.
- National Patient Safety Improvement Programmes: Targeted harm reduction initiatives in critical areas such as maternity care, surgical safety, and medication management.
- Quality Improvement (QI) Tools: Training staff in methodologies like Plan-Do-Study-Act (PDSA) cycles and clinical audits. PDSA cycles allow for iterative testing of interventions, while audits provide systematic reviews to ensure sustained adherence to clinical standards.
- Addressing Inequalities: The 2023 updates reaffirmed the need to tailor safety initiatives to diverse populations, reducing disparities in healthcare delivery.
The 2023 updates also emphasised system resilience, incorporating lessons learned from the COVID-19 pandemic to enhance preparedness for future challenges.
Conclusion
The NHS Patient Safety Strategy, first published in 2019, remains a dynamic framework for addressing patient safety challenges. Through the pillars of Insight, Involvement, and Improvement, the strategy has made measurable progress, with updates in 2021 and 2023 reflecting its adaptability and ongoing relevance.
The 2023 updates added significant momentum to the strategy by:
- Demonstrating progress toward saving 1,000 additional lives and reducing care costs by £100 million annually.
- Enhancing equity in patient safety initiatives to benefit all populations.
- Strengthening system resilience through lessons learned from the COVID-19 pandemic.
- Expanding the use of robust tools like PSIRF, PDSA cycles, and audits to ensure sustainable improvements.
By fostering a culture of collaboration, learning, and innovation, the NHS is embedding safety into every level of care. The strategy’s continued evolution underscores its commitment to reducing harm, enhancing outcomes, and maintaining trust in healthcare systems across the UK.
Hot Topic of the Week
Monday 25th November 2024
Monday 25th November 2024
What are the Adverse Event Reporting Systems in the NHS?
Adverse Event reporting systems in the NHS are critical tools for documenting and learning from incidents where patient safety has been compromised. They help identify patterns, improve safety practices, and prevent recurrence. Here are the key systems currently used:
1. Datix
- Purpose: The most commonly used local system for reporting clinical incidents, near misses, and non-clinical events.
- Features:
- Enables NHS staff to log incidents at a local level.
- Supports tracking and resolution of reported incidents.
- Integrates with national systems like LFPSE for broader analysis.
- Significance: A primary tool for fostering local learning and compliance with national reporting requirements.
2. Learn from Patient Safety Events (LFPSE)
- Purpose: The national system for reporting and learning from patient safety incidents, replacing the National Reporting and Learning System (NRLS) as of June 30, 2024.
- Features:
- Facilitates real-time reporting and improved data analysis.
- Designed for better integration with modern technologies and NHS systems.
- Focuses on fostering a culture of learning and safety improvements across the NHS.
- Integration with Local Systems: Systems like Datix now align with LFPSE to ensure seamless reporting and learning from local to national levels.
3. Serious Incident Framework
- Purpose: Provides a structured approach for managing and investigating serious incidents in NHS organizations.
- Features:
- Ensures thorough root cause analysis.
- Requires development of action plans to address systemic issues.
- Aims to prevent recurrence of significant events like patient deaths or major harm.
4. Yellow Card Scheme
- Purpose: Used for reporting adverse drug reactions (ADRs), defective medical devices, and vaccine side effects.
- Managed by: Medicines and Healthcare products Regulatory Agency (MHRA).
- Features:
- Enables pharmacovigilance and post-market surveillance.
- Open to healthcare professionals and the public.
5. Radiation Incident Reporting
- Purpose: Reporting system for incidents involving ionizing radiation under the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R).
- Managed by: Care Quality Commission (CQC).
- Features:
- Focused on ensuring patient safety during medical exposure to radiation.
- Requires organizations to investigate and report radiation dose-related incidents.
6. Freedom to Speak Up (Whistleblowing Framework)
- Purpose: Encourages NHS staff to report patient safety concerns or workplace issues without fear of retaliation.
- Features:
- Freedom to Speak Up Guardians available in NHS trusts to provide support.
- Promotes transparency and accountability.
7. Healthcare Safety Investigation Branch (HSIB)
- Purpose: Conducts independent investigations into serious patient safety incidents with systemic implications.
- Focus Areas:
- Maternity investigations.
- National patient safety incidents requiring complex analysis.
- Output: Recommendations for improving system-wide safety.
8. Duty of Candour
- Purpose: Legal obligation requiring NHS organizations to be open and transparent with patients when things go wrong.
- Requirements:
- Informing patients and families about incidents causing harm.
- Providing explanations and apologies.
- Reporting and investigating incidents to learn from mistakes.
9. Safeguarding Incident Reporting
- Purpose: Reporting incidents involving potential or actual abuse, neglect, or safeguarding concerns.
- Managed by: Local safeguarding boards and NHS safeguarding teams.
- Significance: Ensures protection of vulnerable patients and adherence to safeguarding protocols.
10. Medical Device Incident Reporting
- Purpose: Reports adverse events or faults related to medical devices.
- Managed by: MHRA.
- Significance: Ensures patient safety through regulatory oversight of devices.
Key Updates for 2024:
- Transition to LFPSE: The NRLS was decommissioned in June 2024, and LFPSE is now the central national system for patient safety event reporting.
- Local-National Integration: Local systems like Datix now integrate with LFPSE for seamless data flow and enhanced safety analysis.
- Focus on Real-Time Learning: LFPSE promotes quicker responses and improved learning opportunities across the NHS.
These systems collectively ensure that the NHS can effectively monitor, learn from, and respond to incidents, ultimately improving patient safety and care quality.
Hot Topic of the Week
Monday 18th November 2024
Monday 18th November 2024
What is The Medical Examiner System in the UK?
The Medical Examiner (ME) system in the NHS is revolutionising the way deaths are reviewed, providing independent scrutiny, promoting transparency, and driving improvements in patient care.
Fully implemented as of September 2024, this system ensures that all deaths not already under coroner investigation are reviewed with accuracy and integrity.
What Does a Medical Examiner Do?
Medical Examiners are senior doctors who:
1. Review Death Certificates: They verify the accuracy of the Medical Certificate of Cause of Death (MCCD) and ensure consistency with clinical findings.
2. Support Families: MEs engage with bereaved families to provide explanations, address concerns, and ensure their voices are heard.
3. Identify Cases for Referral: They determine when a death should be referred to the coroner for further investigation.
What Types of Deaths are Referred to the Coroner?
Medical Examiners work closely with coroners to identify cases requiring formal inquiry. Deaths that must be referred to the Coroner include:
- Unnatural Deaths: Including accidents, suicides, or suspected neglect.
- Deaths Due to Violence or Trauma: Such as injuries from falls or assaults.
- Unexplained Deaths: Where the cause is unclear or unknown.
- Deaths in Custody or Under State Detention: For example, in prisons or under Mental Health Act sections.
- Procedural Deaths: Where concerns arise around medical or surgical interventions.
- Deaths Occurring Soon After Admission to Hospital: Raising questions about diagnosis or treatment delays.
This collaborative process ensures thorough investigations while streamlining the referral process, avoiding unnecessary delays.
Why Does the ME System Matter?
1. Accuracy and Integrity: Ensures the correct cause of death is identified and recorded.
2. Learning Opportunities: Highlights systemic issues or trends in patient care that can inform national safety strategies.
3. Support for Families: Builds trust through open communication and transparency in healthcare.
A Step Towards a Safer NHS?
By integrating the Medical Examiner system with coronial investigations, the NHS reinforces its commitment to accountability and continuous learning. This system not only ensures every death is reviewed but also provides valuable insights to improve patient safety for the future.
Hot Topic of the Week
Monday 11th November 2024
What is the Medical Appraisal Guide 2022 from the Academy of Medical Royal Colleges?
The Medical Appraisal Guide is designed to support doctors in reflecting on their work, identifying areas for growth, and ensuring they stay in line with GMC standards. Appraisals are more than formal assessments; they are a key tool for doctors to focus on professional development, celebrate achievements, and set meaningful goals.
The process is straightforward and consists of three main stages:
Inputs: This is the preparatory stage, where doctors gather information about their roles, responsibilities, and any feedback received over the past year. The idea is to create a complete picture of your work, making it easier to discuss with your appraiser. This may include reviewing your development goals from last year, reflecting on achievements and challenges, and compiling feedback from patients and colleagues.
The Confidential Appraisal Discussion: At the heart of appraisal is this confidential conversation with a trained appraiser, where you reflect on the past year and discuss plans for improvement. It’s a supportive, safe space meant to facilitate personal and professional reflection, not to scrutinise.
Outputs: The final step involves setting a Personal Development Plan (PDP) that outlines specific goals for the coming year. You’ll work with your appraiser to ensure these are realistic, relevant, and actionable. This stage also includes the appraiser’s statements to support the revalidation process.
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