Keeping up to date with practice changes and developments is an intrinsic part of any health professional's role, but it presents challenges. There are numerous national and international patient safety stakeholders producing reports on a regular basis, and these stakeholders all maintain their own, sometimes conflicting, agendas. All this information needs to be carefully sifted and analysed for suitability of use within the NHS. This is a complex task given the size and complexity of NHS care delivery.
A legal and professional duty
It will be impossible for any nurse or doctor to analyse everything that is relevant to their clinical practice area. They do, however, owe patients a legal duty of care and part of this will be the need to keep reasonably informed and updated. We can expect health professionals to demonstrate a reasonable, systematic regimen for keeping up to date.
There are study days, conferences, online courses, clinical information websites, blogs, online newspapers, journals, stakeholder, professional association websites and so on. All this forms part of the nurse or doctor's professional updating mix. They need to make a reasonable selection from these and others. Factors that will feed into an assessment of reasonableness will be varied and depend on the facts of the case in question. Likely considerations could be what other health professionals do regarding updating in the relevant clinical speciality, professional, employer expectations, professional revalidation requirements, level of post occupied, expectations of role, importance of topic to be updated, on, impact of topic on patient care, degree of change, where the information can be found, ease of access, speciality, general journal, and so on. These are just some initial thoughts and more considerations on how to determine reasonableness in a legal context will no doubt apply.
Several cases have gone to court on the issue of clinical guidelines and professional updating of healthcare staff. A recent case on the use and status of clinical guidelines in negligence actions is O'Brien (administratrix of the estate of John Berry (deceased)) v Guy's and St Thomas’ NHS Trust [2022] EWHC 2735 (KB). There is a detailed discussion of clinical guidelines and Bolam-negligence in the case. His Honour Judge Tindal made an important distinction between local and national guidelines and their status (at paragraph 78).
‘Nevertheless, in my judgement, an “inhouse guideline” – even spanning several hospitals and tens, if not hundreds, of clinicians – is not of the same status as a national guideline. Of course, it may (indeed, quite often will) reflect a wider reasonable “Bolam-compliant” body of clinical opinion, but it is unlikely by itself to constitute one.’
This is an important judgment for nurses, doctors, and others as it is an in-depth analysis of key issues relating to the use of clinical guidelines in health care, which form an essential part of professional updating. Clinical guidelines change and are updated and there is a need to be aware of this in terms of professional practice and updating.
A change in expectations
Given the greater accessibility of online and electronic patient safety learning resources there will most likely be an increased judicial expectation that nurses and other health professionals should be more able to demonstrate a reasonable and systematic regimen for regular professional updating than previously was the case:
‘It is arguable that the existence of the Internet, making research more readily available, will mean that doctors will be expected to be more up to date than they were in the past.’
Also, there is now a focus on evidence-based health care, which requires research and updating:
‘The practice of medicine has, however, become increasingly based on principles of scientific elucidation and report, which has been referred to as “evidence-based medicine”. As a result of such developments, the pressure on doctors to keep abreast of current developments is now considerable, rather than just relying on long clinical experience.’
Professionals in all disciplines cannot switch off from keeping up to date with changes in their specialty by arguing that they are too busy. Being a professional incorporates a professional and legal duty to update skills and knowledge. Professional and ethical codes for nurses, doctors and allied health professionals also incorporate this duty.
Useful resources for updating
There is no shortage of good patient safety policy and practice resources and I share here some that I use.
Patient Safety Learning
The charity Patient Safety Learning (https://www.patientsafetylearning.org) seeks to be an independent voice for improving patient safety and provides some excellent patient safety education and training resources. It has the Hub, which is an online patient safety platform that shares learning. There are patient safety tools, resources, case studies and other materials available. It is also a place where people can discuss patient safety matters, and membership is free.
NHS Resolution
NHS Resolution has played a fundamental role in NHS patient safety and litigation since its inception in 1995. It has undergone several changes since then and has extended its remit. The organisation has several roles, including managing litigation brought against NHS trusts and other organisations. Its pivotal role in the NHS provides it with unique perspectives on the causes of litigation, patient safety and the necessary steps to improve care.
Through its clinical negligence case work it can identify patient safety and litigation trends, and can offer practical advice and training. Its annual report and accounts publications catalogue its activities, analyse clinical negligence case trends and provide an update on the cost of claims. Some important clinical negligence and other health-related court cases of the year are also discussed.
The 2023/2024 NHS Resolution annual report and accounts are due to be published shortly. The report for 2022/2023 provided an excellent overview of NHS clinical negligence and patient safety trends in the NHS:
‘The top four categories of clinical claims reported by volume this year were obstetrics, emergency medicine, orthopaedic surgery, and general surgery. The top four categories remain broadly the same as last year although obstetrics is now the largest category by volume.’
Data are also provided in relation to the costs of clinical negligence claims:
‘Payments against all our clinical schemes for 2022/23 were £2.73 billion (£2.4 billion in 2020/21) in total – which comprised damages paid to claimants of £1992 million (£1775.3 million in 2021/23), claimant legal costs of £490.9 million (£470.9 million in 2021/22) and NHS legal costs of £158.8 million (£156.6 million in 2021/22).’
Another go-to patient safety resource available from NHS Resolution is its Faculty of Learning (https://resolution.nhs.uk/faculty-of-learning). Here, there can be found several educational learning products and resources. Topics for learning modules include consent, maternity and response to harm (for patients and families). Other resources include case studies, fact sheets, insight reports, and webinars.
Care Quality Commission
The Care Quality Commission (CQC) produces a significant amount of patient safety-related material (https://www.cqc.org.uk/publications). Its inspection reports on NHS trusts provide useful information on patient safety practices. The CQC also produces guidance on regulation and regular reports taking an overall view of care in England. These include the annual State of Care report, or on specific topics such as the safer management of controlled drugs. The CQC also publishes surveys, and external reports and research.
In terms of my patient safety research, I found its seminal publication, Opening the Door to Change (CQC, 2018), enlightening, especially in relation to the amount of information coming from various sources that NHS trusts and staff have to deal with on a daily basis – the concept of patient safety information overload:
‘Trusts receive too many safety-related messages from too many different sources. The trusts we spoke to said there needed to be better communication and coordination between national bodies, and greater clarity around the roles of the various organisations that send these messages.’
This publication is as relevant today as when it was published. The Never Events discussion is excellent in terms of patient safety strategies. Sections in the report include patient safety and the challenges for NHS trusts, patient safety in the wider healthcare system, education and training for staff on safety systems and processes.
Healthcare Safety Investigation Branch (HSIB)/Health Services Safety Investigations Body (HSSIB)
The HSIB started work in 2017 and the organisation changed to become the HSSIB in October 2023. The central role of the HSSIB is to carry out independent patient safety investigations. The body's investigation reports and recommendations are essential reading for all those concerned with NHS patient safety policy making and practice (https://www.hssib.org.uk/patient-safety-investigations). Recent topics include keeping children and young people with mental health needs safe on paediatric wards, and continuous observation in patients at risk of self-harm.
It has an education team, which has developed a suite of programmes around the Patient Safety Incident Response Framework and it also offers training in related skills such as how to write effective learning reports. Details of these are outlined in its electronic prospectus (HSSIB, 2024).
Conclusion
There is a lot going on in NHS patient safety in terms of frequency of reports and publications. There is no sign that this will abate because the problem is too important, with well-documented patient safety failings causing serious injury and death.
Keeping skills and knowledge up to date is both a legal and a professional duty for nurses, doctors and other health professionals. Clinicians must always demonstrate a reasonable and systematic updating regimen. There are many excellent sources of patient safety and legal information on health care available, as is clear from those highlighted in this article.
Care Quality Commission. Opening the door to change: NHS safety culture and the need for transformation. 2018. https://www.cqc.org.uk/sites/default/files/20181224_openingthedoor_report.pdf (accessed 8 July 2024)