One of the great difficulties in patient safety and health quality is keeping up to date with all the material produced nationally and internationally. This problem is becoming increasingly apparent as patient safety takes more of a centre-stage role globally, becoming recognised as a growing world problem. There are a myriad patient safety and health sources that produce useful reports, guides and tools. This information needs identifying, capturing, assessing and cascading down to busy nurses, doctors and other staff.
I have frequently mentioned this difficulty in my columns and that there is no easy solution. Busy health professionals in resource-constrained environments need easily accessible, well-written, comprehensive and authoritative patient safety information sources in a ‘one-stop’ shop, which is a challenge in the NHS. There is a need for a comprehensive global patient safety information hub.
The NHS has a range of patient safety and health quality information sources; healthcare staff have their favourites but they cannot be expected keep up to date with all of them. They need to work out which sources to prioritise and how to update themselves regularly on patient safety.
NHS Resolution
NHS Resolution (formerly the NHS Litigation Authority) has excellent patient safety and clinical negligence resources and learning materials, and should be viewed as a priority resource. The organisation is a special health authority and is a not-for-profit arm's-length body of the Department of Health and Social Care (DHSC). It has several functions, including handling negligence claims on behalf of NHS organisations and independent sector providers of NHS care in England who are members of NHS Resolution schemes. There are several indemnity schemes (including the Clinical Negligence Scheme for Trusts) for clinical (patient) claims arising from incidents since 1995 (https://tinyurl.com/nhs-resolution).
NHS Resolution has been a consistently good feature of the NHS patient safety and quality environment since its foundation in 1995. It has managed litigation against the NHS well, in my opinion, and has brought a great deal of professionalisation through specialisation in clinical negligence, patient safety and standard setting.
Safety and learning function
NHS Resolution (https://resolution.nhs.uk) also has the function of advancing safety and learning in the NHS:
‘We support members locally to better understand their claims risk profiles to target their safety activity and collaborate with others to sharing learning across the system at a national level.’
Over the years, the authority has amassed a great deal of information. When its database is interrogated for claims made against the NHS for any clinical area, several patient safety themes and trends emerge. Drawing on its experience, NHS Resolution has published several safety and learning reports, which are valuable sources on what is happening with patient safety and legal claims in specific areas. Several of these are discussed below.
Preventing needlestick injuries
Sharps injuries are a well-known risk in the health and social care sector. They have been defined as:
‘Any piercing wound caused by a hypodermic needle, or by other sharp instruments or objects such as scalpels, mounted needles, broken glassware, etc … The main risk posed by needlestick injuries is exposure to blood-borne viruses (BBV), particularly hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV). Needlestick injuries can also cause psychological distress, as the injured person may have to cope with the fear that they have been infected.’
Nurses, doctors and other staff have brought legal claims against their employers following sharps injuries. A report from NHS Resolution (2017a) illustrates the trends, themes and offers prevention advice related to these claims. In terms of litigation trends, NHS Resolution received 1833 incident claims for needlestick injuries between 2012 and 2017 (fiscal years). Of these, 1213 were successful, costing the NHS £4 077 441. This equates to 1 year's funding for 125 band 5 nurses. This harm and cost are largely avoidable:
‘Most sharps injuries can be prevented, and there are legal requirements on employers to take steps to prevent healthcare staff being exposed to infectious agents from sharps injuries.’
The staff who sued because a primary user had not disposed of the needles properly included cleaners, porters, laundry and maintenance staff. The report states that 137 successful claims were made by clinical staff in 2012-2017, identifying a number of causes (NHS Resolution, 2017a: 3):
Assault claims: insights
NHS staff are increasingly at risk of violent assault. The public service union Unison (2018) reported that in England between 2015–16 and 2016–17 there was an almost 10% increase in violent assaults against NHS staff, with a 21% jump in the acute sector.
Health Secretary Matt Hancock (DHSC, 2018) announced the first-ever NHS violence reduction strategy, which includes the NHS working with the police and the Crown Prosecution Service to help victims give evidence and take out prosecutions quickly and efficiently. The strategy also includes the Care Quality Commission looking at violence as part of its inspection regime. Improved training for staff to deal with this problem is also mentioned.
In some circumstances staff can also bring civil claims against their employer for injuries sustained.
NHS Resolution (2019) has produced a report on insights from assault cases that reveals facts, figures and trends. There is also information on common claim factors and things to consider.
Report on assaults
It is estimated that £53.4 million will be spent settling 1255 of the 3227 claims made for assault received by NHS Resolution (2019) between 2013 and 2018. This equates to employing 1700 registered nurses for 1 year. Assaults on staff have, as mentioned in the other report (NHS Resolution, 2017a), will have psychological, physical effects:
‘Assault claims result in life changing physical and psychological effects on the individual and in the most tragic cases a loss of life, impacting families and carers.
Following an assault, staff are more inclined to leave the NHS and employers can struggle to attract and retain talent to work in their organisation.’
The report states that the average damages awarded to the person assaulted was £23 000.
Patient safety learning
Common risk factors include location, mental health wards, emergency departments, clinical conditions, medication that causes confusion and aggression, and mental impairment. Common claim factors include (NHS Resolution, 2019):
Things to consider include maintaining risk-assessment records that include family and carer information. It is important to document the rationale for treatment and medication, ensure regular staff training, and encourage clear communication between care settings during investigations.
The report highlights the need to create an environment for implementing safe policy guidance, ensuring that there is a process to share risk such as a flag system in patient records for those with a history of violence. The report conveys well the human and financial costs of assault claims, along with key patient safety and learning strategies.
Saying ‘sorry’
It has become apparent to me over the years in researching, teaching and writing about patient safety that by failing to say ‘sorry’ in appropriate circumstances we encourage patients to sue and complain. Poor communication between the nurse or doctor and the patient when an adverse event occurs makes a bad situation even worse.
In my experience, when an adverse event occurs, patients primarily want an explanation, an apology and an assurance that what happened to them will not happen to anyone else. If they are met with legalistic jargon and defensive responses, that might drive them to taking more formal adversarial routes of dispute resolution. An NHS Resolution (2017b) leaflet on saying sorry offers helpful advice:
‘Saying sorry is: always the right thing to do not an admission of liability acknowledges that something could have gone better the first step to learning from what happened and preventing it recurring.’
The leaflet reminds the reader that saying sorry is not only the moral and the right thing to do, it is also a statutory, regulatory and professional requirement. It states that how you say sorry is just as important as saying it:
‘An apology should demonstrate sincere regret that something has gone wrong and this includes recognised complications referred to in the consent process. It should be confidential and tailored to the individual patient's needs. Where possible you should say sorry in person and involve the right members of the healthcare team. It should be heartfelt, sincere, explain what you know so far and what you will do to find out more.’
The leaflet goes into more detail on saying sorry and also discusses the statutory duty of candour.
Conclusion
It is possible to become overwhelmed by the sheer volume of patient safety and health quality material available. Health professionals do need to guard against information overload and the possibility that this might lead them to switch off from patient safety learning and sharing. The risk of this is compounded by the practical reality faced by nurses, doctors and other staff working in busy and resource-constrained environments.
There are legal and professional expectations that all health professionals will demonstrate that they have a personal plan to update themselves regularly on safety issues. This is the hallmark of any professional and is a principle that has been advocated by judges in several past court cases in tort law.
A balance of priorities must be drawn. The NHS Resolution materials should be regarded as essential resources on patient safety learning.