A just culture guide

A just culture guide


This guide encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way. It supports a conversation about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely.


See the guide at: https://improvement.nhs.uk/resources/just-culture-guide/

Nutrition and hydration

These resources from NHS Improvement on using nutrition and hydration to reduce the incidence of pressure ulcers and promote good wound healing, include evidence and recommendations for assessment and action when assessing an individual’s risk of developing a pressure ulcer; five top tips to prevent pressure ulcers; and three case studies.

NIHR Signal Biological therapies for psoriasis do not increase serious infection risk

People with psoriasis who take an immune-modulating treatment are no more likely to get serious infections than people taking standard therapies.inf




There are fears that these biological therapies raise the risk of serious infections and this has discouraged their use. They are recommended by NICE for moderate to severe psoriasis. Previous studies have reached conflicting conclusions, making it hard to advise on the true risk.




This study used a large database of people with psoriasis from the UK and Ireland. It compared serious infection risk of the biological therapies (etanercept, adalimumab or ustekinumab) with non-biological therapies, after accounting for factors such as other illnesses. It found none of the biological therapies studied had a higher risk of infection compared to non-biological therapies or compared to each other.




From the NIHR Dissemination Centre

NIHR Signal National tobacco control policies linked to improvements in children’s health

National smoke-free legislation in advanced economies is linked to reduced rates of preterm birth, asthma hospitalisations and serious throat and chest infections in children. Comprehensive smoke-free policies appear to be more effective than policies with only partial or selective introduction.


Smoking increases health risks for the smoker and others through second-hand exposure. Although the number of people smoking in the UK is falling, eight million UK adults still smoke, and an estimated five million children are exposed to second-hand smoke. Children are vulnerable to smoke due to their small, developing lungs and immune systems.


From the NIHR Dissemination Centre

Revised Never Events policy and framework for the NHS

The Never Events policy and framework sets out the NHS’s policy on Never Events. It explains what they are and how staff providing and commissioning NHS-funded services should identify, investigate and manage the response to them. It is relevant to all NHS-funded care.
Read more at https://improvement.nhs.uk/resources/never-events-policy-and-framework/

Fatigue and sleep deprivation – the impact of different working patterns on doctors

This briefing from the British Medical Association highlights why doctors are at risk of fatigue and the acute and long-term impacts this can have. It also presents a framework for how Government, organisations and doctors themselves can manage this risk.

Falls risk screening tools ‘not accurate’ new report warns

The Royal College of Physicians’ National Audit for Inpatient Falls assessed 5,000 falls, and shows that although prevention across England and Wales has improved slightly, many patients are not receiving the right assessments that can help prevent harm.

The audit reveals that since 2015, many trusts and Local Health Boards (LHBs) have stopped using ‘falls risk screening or prediction tools’ (a drop from 74 per cent in 2015 to 34 per cent).

Lintern's Risk Register: We need better workforce data

Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under the radar stories. Contact me in confidence. Shaun Lintern, patient safety senior correspondent.

Seeing the bigger picture

It is extremely encouraging to see organisations like the Health Foundation, Nuffield Trust and King’s Fund focusing their big brains on the issues affecting the NHS workforce.
NHS Providers will be joining the party soon with a new report, and its chief executive Chris Hopson has already done a laudable amount of drum banging over what is now widely regarded as the biggest pressure facing the service and the one keeping managers up at night.


To obtain this article copy and paste the post into an email and send to libraryw@uhcw.nhs.uk

NIHR Signal Older people with acute coronary syndromes may benefit from routine invasive therapy

Routine invasive therapy for people aged over 75 with non-ST-elevation acute coronary syndromes reduced the risk of dying, having a heart attack or stroke, and need for further intervention. However, there was a higher risk of major bleeding compared to treating people with medication.


This is the largest review to date to gather the evidence on treatments for older people with smaller heart attacks or severe angina (chest pain). NICE recommend treating these “non-ST-elevation acute coronary syndromes” either with stents, to open narrowed arteries, or with medication depending on the person’s risk. These treatments are quite commonly used in younger people, but older people are less likely to receive them and these researchers wanted to see if there was evidence that they are missing out on the benefits.


The findings suggest that age is not a barrier to invasive therapy, but greater clarity is needed around the balance of risks and benefits for this group of people.


From NIHR Dissemination Centre

Radiation risk with digital mammography in breast screening

This review estimates the risks and benefits of breast screening in terms of number of deaths due to radiation-induced cancers and the number of lives saved due to digital breast screening in the NHS Breast Screening Programme (NHSBSP) in England.

Major vascular injuries during lumbar disc surgery

The Association of Anaesthetists of Great Britain and Ireland (AAGBI) is passing on important information following the death of a patient:

There is a 1:4000 risk of abdominal vessel injury during lumbar spine discectomy. Teams delivering such surgery should know about this rare but life-threatening complication and be prepared and able to manage the situation.

The Society of British Neurological Surgeons (SBNS) and the Royal College of Anaesthetists (RCoA) received instruction from the Coroner to act to prevent future death. Teams delivering this service are asked to address matters of consent, education, continuing professional development as well as the organisation of timely and safe supportive services.

SIGN 149 • Risk estimation and the prevention of cardiovascular disease

This guideline deals with the management of cardiovascular risk, both primary prevention, defined as the potential for intervention prior to the disease presenting through a specified event (any incident linked to critical disruption of blood flow that may cause damage to the heart, brain or peripheral tissues), and secondary prevention, defined as the potential for intervention after an event has occurred.

Chartered Society of Physiotherapy provides new guidance on fentanyl patches in physiotherapy practice

The CSP has published guidance for members who treat patients who wear transdermal fentanyl patches, which are prescribed to treat severe pain.

The document aims to increase awareness among physiotherapists about potential risks associated with the patches.

It includes a recommendation that physios should carefully monitor patients who wear transdermal patches while having aquatic hydrotherapy.

Managing risk in social care

Managing risk is one of the most important and complex areas of social work practice. When risk isn’t correctly handled and responded to, the consequences can be catastrophic. For team managers, being responsible for the risks your social workers are holding, and knowing how to support and challenge their practice, can be daunting.

Preventing Patient Falls

This guide from Hospitals in Pursuit of Excellence describes the types of risks that lead to patient falls, the root causes for those risks and the solutions designed to reduce them. Several case studies in the guide highlight individual hospitals and their experiences preventing falls.

The tipping point: patients predisposed to Clostridium difficile infection and a hospital antimicrobial stewardship programme

The aim of this study was to develop a predictive model that identifies patients at high risk for CDI at the time of hospitalization. This approach to early identification was evaluated to determine if it could improve upon a pre-existing AMS programme.

Journal of Hospital Infection 94 (2016) 242e248

Managing risk in social media

Social media is a powerful marketing tool for organisations but it is not without risk. These risks can have a major impact on you, your career and your organisation. And they can happen whether or not you are using social media.

Managing risk in social media helps you analyse and prepare your organisation for the problems that may occur when using social media. It helps you understand how to handle internal social accounts and deal with external social media activity which your organisation may become involved in.

This e-learning course will not only help you to understand, identify and manage risks, but will also guide you in preparing to protect your organisation from damage that may be caused.

HAIRS risk assessment: squirrel Bornavirus

Public Health England has published an assessment of the zoonotic potential of novel squirrel Bornavirus. Three fatal cases of encephalitis were reported in 2015 which had occurred between 2011 and 2013 in Germany and were associated with a novel Bornavirus species. This risk assessment was carried out to determine the zoonotic potential and level of risk in the UK.

What are the risks of using antidepressants together with NOACs and how should these risks be managed?

Article from South West Medicines Information and Training

QTUG for assessing falls risk and frailty

NICE has developed a medtech innovation briefing (MIB) on the Quantitative Timed Up and Go (QTUG).

The technology described in this briefing is the Quantitative Timed Up and Go (QTUG). It uses body-worn sensors and a mobile software app to assess mobility, falls risk and frailty. It is used during the standard Timed Up and Go (TUG) test.