Archive | April, 2016

Patient Safety as Carrot or Stick?

27 Apr

by Gavin Daker-White , Research Fellow in Multimorbidity theme

Junior Doctors Strike

In the patient safety literature, it is widely recognised that a team learning culture is crucial in reducing the incidence of errors or harms in health care settings. Thus, developing a “safety culture” lies at the heart of the NHS approach to improving patient safety, as exemplified by the National Reporting and Learning Service (NRLS). Drawing on other industries, including aviation, it has been shown that a, “blame-free environment where individuals are able to report errors or near misses without fear of reprimand or punishment” is an important component of patient safety culture. However, it has also been shown that a blame culture persists, as evident in a recent literature review undertaken in our research centre.

Anyone who has been following the ongoing dispute between the British Medical Association (BMA) and the government over a proposed new employment contract for junior doctors will know that “patient safety” is a term that is regularly used to further arguments on both sides. The current Health Secretary, Jeremy Hunt, has argued that a 7-day NHS will improve patient safety. On the other side, the BMA argues that the proposed new contract will lead to junior doctors working unsafe hours. Over the last two days, media reports such as those here and here, have focused on what the effect on patient safety is of the industrial action itself. Again, a variety of views are discernible representing both sides in the dispute.

It is not the purpose of this piece to explain the nature of this industrial action; nor to take sides. As a patient safety researcher and sociologist, what interests me is the way that all sides seem to use “patient safety” as an explanation for policies or actions, or as an apparent stick with which to beat the other side. We know from clinically focused studies that “blame” is not helpful when attempting to promote learning cultures that can improve the safety of patients using health services. Whilst this might point to a potential to transfer notions of “safety culture” from the health service shop floor to policy making arenas,  what is more interesting to me is the way that the term “patient safety” seems to be forming a kind of trope in rhetoric around health policy and practice.

The term “Patient Safety” is increasingly a lens used to explain, evaluate and argue for or against issues in health care delivery. Where previous generations might have been concerned about survival rates, waiting times for appointments, or costs of care; the contemporary focus seems to be about degrees of safety. Even a cursory glance at the media surrounding the junior doctors’ dispute reveals a focus on patient safety, although it appears wedded to a ‘blame’ culture which is unlikely to work if the goal is to reduce the incidence of errors or harms.

Is this dispute really about patient safety?

The NIHR Greater Manchester PSTRC Community Pharmacy Patient Safety Collaborative: part one

20 Apr

by Penny Lewis, Medication Safety theme

Comm Pharm Pt Safety Collaborative

The community pharmacy patient safety collaborative has reached six months of age. Over this period, ten pharmacists who work across Greater Manchester have come together regularly with research staff from the Greater Manchester PSTRC to learn about quality and safety improvement.

The collaborative members’ first assignment has been to create a ‘safety case’ for their pharmacies. Safety cases are a recognised approach to safety management in other safety critical industries (such as aviation and petrochemicals) but are relatively new to healthcare. As far as we are aware, this is the first time that safety cases have been used in community pharmacy. In order to write their cases, the collaborative members have learned how to use risk assessment techniques such as Failure Modes Effect Analysis (FMEA), Systematic Human Error Reduction and Prevention Analysis (SHERPA), Proactive Risk Monitoring for Organisational learning (PRIMO), Hierarchical Task Analysis (HTA) along with Plan Do Study Act (PDSA) cycles to explore potential and actual patient safety issues in pharmacies.  As well as familiarising themselves with a ridiculously large number of acronyms, the collaborative has used their newly acquired knowledge to investigate and deal with the risks associated with community pharmacy activities such as medication dispensing, provision of monitored dosage systems and delivery services.

In addition to hearing from Greater Manchester PSTRC researchers, the collaborative has also had a guest presentation from Professor Todd Boyle of St Francis Xavier University, Canada, who talked about his work in quality improvement across pharmacies in Canada, and Sarah Ingleby, lead nurse in acute care at Central Manchester University Hospital, who popped over to talk about her involvement in producing a safety case for sepsis in secondary care.

The next few months will hopefully see the recruitment of more collaborative members, including pharmacy technicians. In future meetings we will be exploring further risk management techniques and finding out more about the initiatives that have already been implemented.   In future blogs you will hear from members of the collaborative, who will share their experiences of being involved in patient safety research.  For now, the team at the Greater Manchester PSTRC would like to thank all those who have contributed to the success of the collaborative so far.

Read part two of the blog series.

Read part three of the blog series.

Keep taking the tablets: part one

11 Apr

by Max Scott

Part six of the blog series “The desperate fight to be heard, and supported, when living with the invisible struggles of Multimorbidity”

Introduction to the blog series is here

MaxScottMedsBox_photo_blogApr16

Regular (daily) medications:

VENTOLIN EVOHALER 10 micrograms (µg) as needed

SYMBICORT TURBOHALER 200µg, two puff morning and night

LEVOTHYROXINE TABLETS 50 µg, one every morning

LEVOTHYROXINE TABLETS 25µg, one every morning

OMEPRAZOLE TABLETS 20 milligrams (mg), one morning and night

TESTOSTERONE GEL 50 mg, one sachet each morning

FLUOXETINE 40mg, by way of two 20mg tablets every morning

PRAVASTATIN TABLETS, 20mg, one every night

GENOTROPHIN GROWTH HORMONE INJECTIONS, 5.3mg, one every night

PREGABALIN CAPSULES 300mg, one at night (for sleep disorders)

PREGABALIN CAPSULES 150mg, one in the morning (for meralgia paresthetica and back pain)

CLONAZEPAM TABLETS, 0.5mg, progressing to 1mg tablet and to be gradually raised to 2mg, at night

FOLIC ACID TABLETS 5mg, one at night


Other (sometimes taken) medicines:

MICOLETTE MICRO-ENEMAS, approx once a week

PARACETAMOL TABLETS 500mg, one-two when needed

CO CODAMOL TABLETS 8/500mg, one-two when needed

CODEINE TABLETS 30mg, one-two when needed

TRAMADOL TABLETS 50mg, rarely

DIAZEPAM TABLETS 5mg, when needed

ANUSOL SUPPOSITORIES, when needed (for haemorrhoids)

Various creams, intermittently, not regularly


So far in this series, I have concentrated on the many experiences and difficulties of living with multimorbidity, and somehow making sure that you are listened to, believed, and respected by medical professionals. By the very nature of the condition, professionals will be faced with a patient who is complex and will, more than likely, have conditions which are invisible to the eye, making trust that much more important.  I will continue on this theme in the future, but for this article I am going to focus more on an inevitable price to pay for having multimorbidity – and that is having to take multiple medications.

I am presently on thirteen regular daily medications for my varied health issues, and I have to take several more intermittently when the need arises. Let me explain some of the problems this can cause. Firstly, for me, the patient. Then (in part two) with the GPs and Consultants.

The Patient

The first of my present medications I ever took were my asthma inhalers, and I have been on these for longer than I can remember. Taking them became a way of life many years ago. Later, gastritis led to me taking Omeprazole. These were joined by the odd Diazepam here and there for anxiety, and sometimes I needed to use a nasal spray for rhinitis. All fairly straightforward at this stage. Then came my Pituitary surgery in 2005. Along with my life in general, that is when taking medications became more complex. I have included a list of my medications above but, to clarify, the ones I take as a result of my tumour removal/hypopituitarism are Levothyroxine 50 and 25 mg, Testosterone gel, and nightly injections of Genotrophin Growth Hormone. Hydrocortisone tablets have been needed on occasion, but this remains an ambiguity of extreme curiousness, which I shall raise again later in this blog. Such things as foot operations; pain from trapped nerves, osteoarthritis, slipped discs etc; and complex sleep disorders have all added to the list.

It’s not just about the amount of medications that I am now on, but the amount of tablets I have to take, when, and how. Remember, anyone who has seen any of my other blogs on here, I have short term memory loss, plus cognitive and executive disorders, which make it all the more easy to make mistakes. I have had to get various “Daily Pill Boxes”, example photo also included here, which should give you an idea of the sheer amount.

I mentioned a moment ago about making mistakes. Well, the drug companies do not make things any easier by manufacturing capsule shells, containing different medications, that look so similar. For example, two of my medications – one for my gastritis, the other an anticonvulsant medication also used for pain and sleep disorders – are both contained in a small, totally white capsule. How ridiculous, and potentially hazardous, is this?  This may be one thing when still in their original boxes (which, incidentally, chop and change their designs and colours so that you never build up a familiarity with them, often seemingly copying the packaging of other drug brands) but when separated into my “daily pill box” can become a nightmare…I have to put my strongest reading glasses on, to find some tiny dark lettering on one of them, and that is the only way I can tell these two, radically different, medications apart. So, basically, I am now on so many medications that just taking the tablets, at the right time, and making sure they are the right ones, has become an art-form all unto itself!

A final point in this part one, and it is a very strange one. One medication that I have not had to take following the Pituitary surgery has been Hydrocortisone, needed when there is a deficiency of ACHC, the hormone that stimulates the production of hydrocortisone by the Adrenal Gland. This hormone often does need to be replaced with patients who have had Pituitary surgery, and, as so much of the after-effects of my Pituitary surgery has been severe, life-changing chronic fatigue, it would have been logical to expect me to be deficient in this. But not so. That is until recently, when I had a series of blood samples taken later in the day than usual: after mid-day, when I am really beginning to flounder as my body and mind wind down towards my afternoon sleep.  THIS time, my hydrocortisone level was found to be very low, and an emergency phone call came that I must start taking hydrocortisone tablets IMMEDIATELY. Ahh, an answer to a problem, I thought. But no. A couple of weeks later, I had another series of tests, which astonishingly showed that I do NOT need to take Hydrocortisone after all. The last test was taken earlier in the morning than the other one. Relevant? Well, all I can say is that there are times like this when I begin to feel like a human guinea-pig!