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Keep up to date with the latest news, research and activity in patient safety.
The BMA has written to the government to call for new legislation to ensure accountability for safe staffing levels and that “individual clinicians are not blamed when the system places them under unmanageable pressure.”
The call came as the BMA published a year long study looking at the changes needed to improve care of patients and the working lives of doctors in the NHS, alongside a “manifesto for change” outlining all the recommendations.
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Source: BMJ, 13 September 2019
Surgeons are retiring early because of back problems caused by modern surgical techniques, experts have warned. 
Keyhole surgery, where an operation is carried out through a small hole in the patient’s body, has become increasingly common because it helps patients recover more quickly and has less pain, complications and scarring than conventional operations.But in order to carry out the procedures through a tiny opening, surgeons often have to contort themselves into awkward positions for hours at a time.
Now a new report says one in five surgeons say they will have to retire early because they have developed back injuries from carrying out modern surgical techniques. This could mean patients face even longer waits for operations, thanks to the loss of 4,500 senior doctors, the research suggests. 
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Source: The Telegraph, 15 September 2019
Hundreds of patients have suffered due to NHS blunders so serious they should never happen, new data shows.
Some 621 'never events' occurred in NHS hospitals between April 2018 and July this year – the equivalent of nine patients every week, according to data obtained by PA news agency. The figures show doctors have operated on the wrong body parts and left surgical tools (including surgical gloves, chest drains and drill bits) inside patients many times over.
Rachel Power, Chief Executive of the Patients Association, said: “Wrong site surgery incidents are preventable safety instances that can have devastating consequences for the patient and their family." “People who suffer harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS."
Professor Derek Alderson, president of the Royal College of Surgeons, said: “While these cases are very rare, never should mean never."
“NHS staff are there to care for patients, so knowing you have caused harm is incredibly distressing. It is vital that all theatre staff use, and are involved in, the World Health Organisation pre- and post-operative checklist process, as these have been designed to help prevent serious incidents."
“It is also important that the NHS continues to promote a culture of openness and transparency, both in terms of publishing surgeons’ outcomes and the number of ‘never events’ that, sadly, occur."
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Source: ITV News, 16 September 2019
 
Millions of patients are harmed each year due to unsafe health care worldwide resulting in 2.6 million deaths annually in low-and middle-income countries alone.  Most of these deaths are avoidable. The personal, social and economic impact of patient harm leads to losses of trillions of US dollars worldwide. The World Health Organization (WHO) is focusing global attention on the issue of patient safety and launching a campaign in solidarity with patients on the very first World Patient Safety Day on 17 September.
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Source: WHO, 13 September 2019
Monuments and fountains will be lit up across the globe today to herald the first ever World Patient Safety Day, organised by the World Health Organisation (WHO). 'Speak up for
patient safety' is the universal call as the spotlight is put on this global health priority. With the supporting strapline that “No one should be harmed in health care” the day brings
together patients, families, carers, communities, health workers, health care leaders and policy makers to show commitment to patient safety.
Patient Safety Learning's commitment to patient safety can be found in 'A Blueprint for Action', which we launched earlier this summer, which advocates six evidence-based foundations for action to address the causes of unsafe care. One of the six foundations is shared learning.  At the heart of our commitment to shared learning is the creation the hub, a community where people can share learning about patient safety problems, experiences and solutions.
Read more about Patient Safety Learning's commitment to patient safety in Chief Executive Helen Hughes' blog, Speaking up for patient safety on World Patient Safety Day
To mark World Patient Safety Day, Patient Safety Learning has released a series of short videos:
Patient safety is a purpose of health and social care
Shared learning for patient safety
Leadership for patient safety
On 2 October this year, we will be hosting in London our second annual conference attended by senior health and social care leaders, clinicians, patient safety experts, patients’ groups
and individuals who have experienced at first hand the traumas of losing a loved one where the quality of care has fallen down. We will also be officially launching the hub.
The World Health Organization’s creation of an annual World Patient Safety Day is key to helping raise awareness and focus minds on improving the safe delivery of healthcare. BD fully supports this initiative and is partnering with care providers to ensure patient safety is prioritised, and efforts to reduce avoidable harm are enabled. 
"Patient Safety is integral to everything we do at BD and we believe it should be at the forefront of everyone’s minds when thinking about healthcare..."
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Source: BD, 17 September 2019
The US Senate has an unprecedented opportunity to remove a ban that has stifled efforts to establish a nationwide unique patient identifier. 
In June, the U.S. House of Representatives passed an amendment that would remove a ban that has stifled efforts to establish a nationwide unique patient identifier. Now, it is up to the US Senate to move this issue forward by rejecting inclusion of outdated rider language in their appropriations bill that prohibits the U.S. Department of Health and Human Services from spending any federal dollars to promulgate or adopt a national patient identifier.
According to a 2016 study of health care executives, misidentification costs the average health care facility $17.4 million per year in denied claims and potential lost revenue. More importantly, there are patient safety implications when data is matched to the wrong patient and when essential data is lacking from a patient’s record due to identity issues. 
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Source: The Hill, 11 September 2019
 
NHS governors have called for a police investigation into the urology department of a health service trust following accusations that patients died and were harmed after a string of clinical errors and malpractice. 
Morecambe Bay NHS Foundation Trust (UHMBT) has now agreed to an external review after dozens of patients, relatives and staff have came forward following the publication of a book by whistleblower surgeon Peter Duffy, which exposed poor care in the unit. 
The call for a police investigation came at a meeting of the council of governors of the trust earlier this month. Governor Dave Welton told the meeting that the council had “very serious concerns about the shocking revelations.”
A former theatre nurse has also come forward claiming to have witnessed countless errors made by surgeons, while another healthcare worker said she was now speaking out to prevent further harm to patients.
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Source: BBC News, 16 September 2019
The British Medical A has outlined its vision for an ‘unsafe’ NHS with a culture of bullying.  
According to the BMA, doctors are working in hospitals and GP Practices that are hugely understaffed, where bullying and a culture of blame is the norm and where patient care is often unsafe. These are the findings of a year-long study – ‘Caring Supportive Collaborative: Doctors Vision for Change‘ – into the state of the NHS.
The chair of the BMA Council, Dr Chaand Nagpaul said: “Nine in 10 doctors tell us that staffing levels are inadequate and that they work in environments where they fear the toxic combination of ever-increasing demand for services and lack of staff capacity will lead to mistakes."
“They tell us there is a persistent culture of fear across the NHS, where blame stifles learning, contributing to the vicious cycle of low morale so staff leave and then there’s a problem of recruitment."
“This unsafe, underfunded environment is as damaging for patients as it is for doctors. Radical change is clearly needed.”
From the report comes a manifesto, which has today been sent to MPs, as well as the secretary of state for health and social care.
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Source: Practice Business, 17 September 2019
Prime Minister Boris Johnson has been confronted by an angry father at a hospital who told him his baby daughter had nearly died because the ward on which she was treated was “not safe for children” after years of austerity.
In an encounter caught on camera, Omar Salem said the care given to his seven-day-old daughter at Whipps Cross university hospital, in north-east London, was “not acceptable”. He told the prime minister: “There are not enough people on this ward, there are not enough doctors, there’s not enough nurses, it’s not well organised enough.”
Salem told Boris Johnson: “My daughter nearly died yesterday. And I came here, the A&E guys were great but we then came down to this ward here and it took two hours and that is just not acceptable. This ward is not safe for children."
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Source: The Guardian, 18 Setpember 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."
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Source: BBC News, 17 September 2019
A woman who died after waiting almost two hours for an ambulance was let down by "systemic" failings with a computer call-handling system, a coroner said.
Daisy Filby, 90, was one of three people who died after delays in receiving care from the South East Coast Ambulance Service (Secamb). Coroner Alan Craze said a human would have "realised what was going on" and prioritised the calls differently. 
Mrs Filby, from Seaford, died in June 2017 as a result of an "accident contributed to by neglect," Mr Craze concluded at the Hasting's Coroner's Court inquest. "If an ambulance or anybody with or without medical knowledge had been able to reach this poor lady before her death, the situation would have been different," he added.
Mr Craze said: "The problem is not the actions of any one individual in Secamb Trust. The problem is ultimately systemic and at the heart of the call-taking and decision-making system."
A spokesman for the ambulance service said: "We are very sorry for the service they received. We have listened very closely to the coroner throughout and we are committed to making further improvements where necessary."
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Source: BBC News, 18 September 2019
Following Boris Johnson's confrontation by an angry father at Whips Cross University Hospital yesterday, a doctor gives anonymous account of chronic understaffing and lack of resources at Whipps Cross. 
"The hospital is held together only by the hard work and dedication of its healthcare workers but it cannot be sustained for much longer under these pressures."
"I’m so glad that Omar Salem  said the things he did. He was just telling the truth about what it is like to be on the receiving end of poor staffing levels and under-resourcing."
"I’ve been thinking about it all day and felt I had to say something because NHS hospitals today can be unsafe places. Whipps Cross is particularly understaffed and under-resourced so people don’t get the care that they need as promptly as they need."
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Source: The Guardian, 19 September 2019
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