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National bodies can provide systems and policies for the NHS, but safety is improved at the point of care. Lauren Mosley, Head of Patient Safety Implementation, and Donna Forsyth, Head of Investigation, describe the new Patient Safety Incident Response Framework (PSIRF).
Source: NHS Improvement, 2 July 2019
Challenging the NHS’ workplace culture is key to improving patient safety says NHS Resolution in their latest guidance: Being fair: supporting a just and learning culture for staff and patients following incidents in the NHS. The paper draws on NHS Resolution’s unique dataset to explore best practice in response to incidents resulting from claims from across the system. The guidance aims to help the NHS to create an environment to better support staff when things go wrong and to encourage learning from incidents.
PRESS RELEASE - 1 July 2019
Patient Safety Learning identifies that reduced performance in two aspects of patient experience may increase the safety risks patients face as in-patients.
The Care Quality Commission’s (CQC) recently published 2018 annual in-patient survey shows that improvement in two areas of patient experience has stalled while a range of issues that matter to patients have worsened. The charity, Patient Safety Learning, has identified that deteriorating performance in two of these issues is likely to make patient safety risks worse.
Fewer patients informed properly when discharged home
The CQC’s sixteenth annual survey of people who stayed as an in-patient in hospital was published on 20 June 2019. It shows that most people had confidence in the doctors and nurses treating them, and felt that staff answered their questions clearly.
However, the survey reports that 40% of patients were discharged from hospital without written information about how to look after themselves following treatment. This is up 2% from 2017. Of patients who had been given medication to take home, 44% were not told of possible side effects for which they should watch.
Fewer patients report being involved in their own care
Only 54% of patients report that they are involved as much as they want to be in decisions about their care and treatment, down from 56% in 2017. The number of patients reporting that their views had been sought on the quality of care they received was down by a quarter compared with 2017, from 20% to 15%.
An increasing challenge to safety
Giving patients written information about how to look after themselves on discharge is clearly a patient safety issue. If this practice is reducing, then the inherent risk to patients must be increasing.
Patient Safety Learning’s recent report, A Blueprint for Action, cited a wide range of evidence that communication with patients – listening to them and acting on what is heard – has a demonstrable effect on improving patient safety. The evidence from the CQC survey indicates, however, that such practice is reducing, not increasing, with corresponding implications for patient safety.
Patient Safety Learning Chief Executive, Helen Hughes, said, “Effective communication and engagement with patients is essential for safe care. The CQC’s survey is a valuable tool for assessing this. It is concerning that their report evidences that communication with patients is reducing in ways that have the potential to increase the risk to patient safety. Patient safety is a core part of the purpose of healthcare and action is needed to share good practice across the wider health system.” /ENDS
Note to editors
Patient Safety Learning is a charity. We help transform safety in health and social care, creating a world where patients are free from harm.
We identify the critical factors that affect patient safety and analyse the systemic reasons they fail. We use what we learn to envision safer care. We recommend how to get there. Then we act to help make it happen.
Patient Safety Learning’s latest report, A Blueprint for Action, can be downloaded here: www.patientsafetylearning.org/resources/blueprint.
For more information, contact
Margot Knight, Marketing and Communications Manager, Patient Safety Learning
E: margot@patientsafetylearning.org
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E: helen@patientsafetylearning.org
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Patients will be able to anonymously log concerns about their NHS treatment, via a phone app, as part of efforts to boost safety. The new strategy will see the creation of a centralised portal, allowing patients, their families and staff to record problems with medical devices, errors in medicines administration, or difficulties in spotting a patient’s condition deteriorating. Officials said that swift recording of such information would enable them to alert the rest of the NHS more quickly to risks of serious harm, and prevent tragedies being repeated.
Source: The Telegraph, 29 June 2019
The parents of Claire Roberts said those responsible for their daughter's care should "hang their heads in shame". Alan and Jennifer Roberts were speaking after an inquest found that the nine-year-old's death in October 1996 was caused by the treatment she received in hospital. Outside Laganside courthouse, Mr and Mrs Roberts welcomed the coroner's findings but said the public can have "no confidence in patient safety" in Northern Ireland.
Mr Roberts said that after a two decade wait the inquest had finally delivered the truth about how their daughter died. "We would like to thank the coroner for reaching a verdict after 22 years of cover-up that finally identifies the truth. The coroner has confirmed an unnatural cause of death. We have known as a family since 2004 the true cause of death - this has not been news to us but the coroner reaffirming what we have always known."
Mr Roberts also issued a demand to health officials for accountability, saying those responsible for failings in his daughter's care should "hang your heads in shame."
Source: Belfast Telegraph
NHS bosses have been accused of “burying” a damning report into child cancer services commissioned following complaints that patients were “dying in agony”. Completed in 2015, the document highlights failings at the Royal Marsden NHS Foundation Trust, one of the UK’s flagship cancer organisations. It found that, despite being supposedly a centre of excellence, children admitted for cancer treatment were routinely transferred between hospitals to get the care they needed.
Compiled by Professor Mike Stephens, the report was commissioned after a coroner found “astonishing” failures in the care of a two-year-old girl, Alice Mason, leading to her suffering irreversible brain damage and dying in 2011. It recommended a radical shake-up of the Marsden’s services. The document was never made public, however, and former NHS medical director for London, Dr Andy Mitchell, accused the head of NHS England, Simon Stevens, and Cally Palmer, England’s National Cancer Director and Chief Executive of the Royal Marsden, of suppressing its publication.
Dr Mitchell told the Health Service Journal (HJS): “I can’t imagine any other individuals having the power and influence to be able to stop this report moving forward.”
NHS England has denied that its then Medical Director, Sir Bruce Keogh, was improperly leaned on and said the report remained unpublished because it made “implausible suggestions” which would have forced children with cancer to travel further for care. But Gareth Mason, Alice’s father, said: “To write a report, shelve it and not debate it, that is a cover-up [and] it has left children since Alice and danger, and the Marsden won’t acknowledge that.”
The controversy surrounds the performance of a so-called “shared care system”, with the Marsden’s Sutton site forming part of a network for South London, Surrey, Sussex and Kent.
Critics say the format meant children were transferred between sites more regularly than they should have been and were put in danger because information was not properly shared.
Source: The Telegraph, 19 June 2019
Hospitals throughout the NHS are in such a poor state of repair that patient safety and care is being put at risk, according to an investigation by the Labour Party. A freedom of information requests sent to every hospital trust in England highlighted problems such as sewage and water leaking on to hospital wards, broken lifts and ceilings collapsing. The incidents have affected patient care, often leading to the cancellation of appointments and leaving people waiting longer for vital treatment. It is speculated that these issues are not just confined to secondary care.
Source: Nursing Notes, 5 July 2019
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Following the publication of the NHS Patient Safety Strategy this week, which argues that new technologies have the potential to transform improvements in keeping patients from harm, Sarah Scobie, Nuffield Trust's Deputy Director of Research, takes a closer look at what the possibilities are.
Source: Nuffield Trust, 2 July 2019
Patients' lives are being put at risk because of delays giving them treatment for sepsis, experts are warning. Hospitals are meant to put patients on an antibiotic drip within an hour when sepsis is suspected, but research by BBC News suggests a quarter of patients in England wait longer. However, NHS England said there were signs performance was improving and that hospitals were getting better at spotting those at risk sooner.
Dr Ron Daniels, of the UK Sepsis Trust, said the "concerning" figures showed patients were being put at risk. In some hospitals, over half of patients face delays. Dr Daniels said the one-hour window was "essential to increase the chances of surviving". "There is no reason really why it should take longer," he added.
Source: BBC News, 4 July 2019
NHS Improvement and NHS England have published their NHS Patient Safety Strategy. The publication out today describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems. The strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety.
The Nursing Times has just broken a story about the importance of safe nurse staffing levels, which has been underlined in an international white paper that calls on countries around the world to take action to ensure they have enough nurses.
The paper – launched at the International Council of Nurses’ annual conference – states evidence for a clear link between nurse staffing levels, patient safety and the quality of care is now “overwhelming and compelling”.
The culture of working without breaks is dangerous to doctors’ and patients’ wellbeing and only a cultural shift can change things, argues Heidi Edmundson.
Heidi, Consultant for Emergency Medicine at Whittington Health NHS Trust, discusses in BMJ Opinion how it has become impossible to ignore the huge cost of burnout to both individual doctors and the medical workforce. Breaks are no longer being viewed as a luxury, but as an integral part of physician wellbeing, patient safety, and workforce sustainability. However exceptional reporting and the costs associated with recruitment and retention issues mean that they are becoming a financial issue as well. Heidi ran her own departmental “public health” campaign entitled “take a break” to see if she could change this culture.
"I started this project with a desire to try and change culture and I have come to realize that changing the culture around taking breaks is really just the tip of the iceberg. What we really need is a huge cultural shift in our attitudes and behaviours towards staff wellness. This will require imagination, innovation, and investment at all levels."
Source: BMJ Opinion, 28 June 2019
Royal College of Nursing (RCN) member Tara Matare has won the coveted title of RCN Nurse of the Year 2019. She scooped the leadership category at the RCNi Nurse Awards before being crowned the overall winner. Tara has tackled short staffing, improved workplace culture and enhanced patient care at her ophthalmology unit at Whipps Cross Hospital in London. Over a 14-year mission to overhaul the unit, there have been a steady stream of challenges, including fighting ophthalmology’s corner to ensure it wasn’t overlooked in favour of higher-profile inpatient services and tackling an ingrained culture of bullying.
Source: Royal College of Nursing, 4 July 2019
The Social Partnership Forum (SPF)’s collective call to action tasks employers and trade unions in all NHS organisations to work in partnership to create positive workplace cultures and tackle bullying. To support this work, the SPF is publicising the views of NHS leaders and experts on this topic and signposting information, tools and resources and case studies which can help partnership initiatives.
Creating positive workplace cultures and tackling bullying in the NHS - a collective call to action
NHSX has just completed a major review of NHS tech spending. They have agreed to reducing the burden on clinicians and staff, so they can focus on patients; giving people the tools to access information and services directly; ensuring clinical information can be safely accessed, wherever it is needed; aiding the improvement of patient safety across the NHS; and improving NHS productivity with digital technology.
Findings from the Care Quality Commission's (CQC’s) latest annual survey of people who stayed as an inpatient in hospital show that most people had confidence in the doctors and nurses treating them and felt that staff answered their questions clearly. However, just over a third (40%) of patients surveyed left hospital without written information telling them how to look after themselves after discharge (up from 38% in 2017), and of those who were given medication to take home, 44% were not told about the possible side effects to watch out for.
Traditionally, as a group, surgeons are not well known for their bedside manner. While poor manners aren't commonly accepted in most professional circles, representations of surgeons in popular culture often link technical prowess with rude behavior, and some surgeons have even argued that insensitivity can be helpful in such an emotionally strenuous profession. However, a study published in JAMA Surgery challenges these ideas. The study, which looked at interactions between surgeons and their teams, found that patients of surgeons who behaved unprofessionally around their colleagues tended to have more complications after surgery. Surgeons who model unprofessional behavior can undermine the performance of their teams, the authors write, potentially threatening patients' safety.
Source: NPR, 19 June 2019
Doctors in Northern Ireland feel increasingly "vulnerable" to criminal proceedings in the workplace, forcing them to consider abandoning the profession, senior medic, Dr Tom Black, warns. Dr Black, chairperson of the British Medical Association Northern Ireland, says that consultants in Northern Ireland are operating in a "hostile working culture" as a result of the situation. He explains that medics are increasingly fearful of the professional repercussions if they make a medical error amid pressured case loads: "Doctors feel vulnerable to criminal and regulatory proceedings, and this creates a hostile training environment for our medical students, young doctors... This blame and sanction culture creates disrespect and mistrust. This has a price - it encourages risk avoidance behaviours in professionals, inefficient and ineffective management, increased cost for the system and deteriorating services for patients."
Source: Belfast Telegraph, 25 June 2019
After many months of development and several user workshops, we are delighted and proud to present the hub at Patient Safety Congress 2019.
the hub is one of the actions proposed by Patient Safety Learning's A Blueprint for Action. The report identifies six foundations of safe care: shared learning, leadership, professionalising patient safety, patient engagement, data and insight, and culture, and proposes a range of actions to address these foundations. the hub is Patient Safety Learning's share online learning platform, which encourages and facilitates knowledge sharing, collaboration and conversation in patient safety across the whole of health and social care. It is a platform for health and social professionals, patients and their families to share and learn from one another.
the hub is free for everyone to use. Have a browse and you will find the latest news, research, resources and events in patient safety, and lively conversations and debates. Members can share content, comment on posts and start conversations in our communities. Please use the hub, share content and let us know what you think and how we can continue to develop it.
We would like to take the opportunity to thank everyone who has contributed this far in the development of the hub. Your thoughts, ideas and critique have been invaluable. the hub is still in development and we continue to seek out user testing and feedback. Please contact us at feedback@pslhub.org with your ideas or if you would like to be a part of our user testing group.
Nearly half of care workers in care homes have been both physically and verbally abused by the residents they are supporting, according to new research.
A poll of 2,803 staff working in care homes revealed 17% have received verbal abuse from residents and 11% have been subject to physical abuse.
A spokesperson for carehome.co.uk, said: “All over the UK, care workers are doing physically and emotionally demanding jobs on often low pay and long hours. Yet at the same time, the rewards of working in a care home can be huge, as you can build strong relationships with the people you care for and make deep, emotional connections."
“Lashing out at staff is often a sign of frustration and it is vital care homes give staff dementia training so they can find the reasons behind this challenging behaviour. Care workers do such an important job and with around three-quarters of people in care homes having dementia, it is vital care workers are given adequate support and specialist training to care for them.”
Source: Carehome.co.uk, 10 May 2019
Regina Stepherson needed surgery for rectocele, a prolapse of the wall between the rectum and the vagina. Her surgeons said that her bladder also needed to be lifted and did so with vaginal mesh, a surgical mesh used to reinforce the bladder.
Following the surgery in 2010, Stepherson, then 48. said she suffered debilitating symptoms for two years. An active woman who rode horses, Stepherson said she had constant pain, trouble walking, fevers off and on, weight loss, nausea and lethargy after the surgery. She spent days sitting on the couch, she said.
In August 2012, Stepherson and her daughter saw an ad relating to vaginal mesh that mentioned 10 symptoms and said that if you had them, to call a lawyer.
Vaginal mesh, used to repair and improve weakened pelvic tissues, is implanted in the vaginal wall. It was initially — in 1998 — thought to be a safe and easy solution for women suffering from stress urinary incontinence.
But over time, complications were reported, including chronic inflammation, and mesh that shrinks and becomes encased in scar tissue causing pain, infection and protrusion through the vaginal wall.
More than 100,000 lawsuits have been filed against makers of mesh, according to ConsumerSafety.org, making it “one of the largest mass torts in history.”
Source: Washington Post, 20 January 2019
An unfortunate series of events involving a magnetic resonance imaging (MRI) machine led to the death of a man at a hospital in India.
Rajesh Maruti Maru, a 32-year-old, was thrust into the MRI machine while he was visiting an elderly relative at the BYL Nair Charitable Hospital in Mumbai, India. As the Hindustan Times reports, the man was apparently told by a junior member of staff to carry a metal cylinder of liquid oxygen into a room containing an MRI machine.
Unbeknownst to everyone, the MRI machine was turned on. This caused Maru to be suddenly jolted pulled towards the machine, causing the oxygen tank to rupture and leak. The man later died after inhaling large amounts of oxygen. His body also bled heavily as a result of the accident.
"When we [the hospital staff] told him that metallic things aren't allowed inside an MRI room, he said 'sab chalta hai, hamara roz ka kaam hai' [it's fine, we do it every day]. He also said that the machine was switched off. The doctor, as well as the technician, didn't say anything,” Harish Solanki, Maru's relative, told NDTV.
"It's because of their carelessness that Rajesh died," Solanki added.
Police are currently examining the CCTV footage of the incident and have arrested at least two members of hospital staff for the negligence. The local government has also awarded the man's family 500,000 rupees ($7,855) in compensation.
Source: IFL Science, 29 January 2018
Hospitals are having to cancel operations and cancer scans are going unread for weeks because consultant doctors have suddenly begun working to rule in a standoff over NHS pensions. Doctors say the dispute is escalating so quickly that it will send NHS services “into meltdown” and is so serious that it poses “an existential threat” to the health service’s survival.
Source: The Guardian, 8 July 2019
A public inquiry will be held to examine safety and wellbeing issues at the new children's hospital in Edinburgh and the Queen Elizabeth University Hospital in Glasgow. The inquiry will determine how vital issues relating to ventilation and other key building systems occurred. It will also look at how to avoid mistakes in future projects.
In January, it was confirmed two patients had died after contracting a fungal infection caused by pigeon droppings at the Queen Elizabeth University Hospital. Health Secretary Jeane Freeman later ordered a review of the design of the building and said there was an "absolute focus on patient safety".
Meanwhile, the new £150m Royal Hospital for Children and Young People in Edinburgh has been dogged by delays over health concerns. The hospital was supposed to open in 2017 - but will now not be ready until next autumn at the earliest - after problems with the specification of the ventilation system.
Scottish Labour's Monica Lennon said the inquiry was "the only way to get to the bottom of this outrageous series of errors". She added: "Children in Scotland are being let down because the hospitals they were promised are not fit for purpose. We have two hospitals built by the same contractor that are mired in controversy, and all the while patients are suffering. The public need to know the truth of what has gone so badly wrong at these two vital hospitals."
Source: BBC News, 17 September 2019
Suspended Belfast neurologist Michael Watt has offered his "sincere sympathy" to those affected by Northern Ireland's biggest patient recall.
Dr Michael Watt worked at the Royal Victoria Hospital as a neurologist diagnosing conditions like epilepsy and Parkinson's Disease. He was suspended after 3,000 patients were given recall appointments last year.
Dr Watt said he recognised the "distress these events have caused".
On Tuesday, a BBC Spotlight investigation found that he had carried out hundreds of unnecessary procedures on patients.
The programme also obtained details of a Department of Health report, as yet unpublished, that said one-in-five patients of the consultant neurologist were misdiagnosed.
Source: BBC News, 22 November 2019