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Keep up to date with the latest news, research and activity in patient safety.

More women and newborns survive than ever before

Developments in healthcare mean more women and babies are surviving than ever before, a new study has found.
The report, published by the World Health Organisation and the United Nations Children’s Fund (Unicef), found maternal deaths have decreased by more than a third since 2000. Deaths of children were found to have fallen by almost half in the same time period.
There was a 56% decrease in deaths of children younger than 15 since 1990 – from 14.2 million deaths to 6.2 million in 2018. 
But the research still found a pregnant woman or a newborn baby dies every 11 seconds from causes that are predominantly preventable and avoidable – with 2.8 million estimated to die every year.
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Source: The Independent, 19 September 2019
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Thousands of US nurses tired of working with too many patients will walk out of hospitals in a four-state strike

Over 6,500 nurses in hospitals around California, Arizona, Florida, and Illinois will strike today. The strike will mark the first ever nurse strike in Arizona, and the first hospital registered nurse strike in Florida's history.
Nurses who are part of the National Nurses United union are asking for better nurse retention and nurse-to-patient ratios. 
"The strike is first and foremost about patient care and patient advocacy," Dominique Hamilton, a registered nurse at St. Mary's Hospital in Arizona, said. "We want the hospital to invest in the nursing staff, and we want to have more input into the recruitment and retainment of experienced [registered nurses]."
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Source: Business Insider, 
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Social media sites act on NHS call for greater online protection

The Chief Executive of NHS in England has called on all social media firms to crack down on potentially harmful material after two of the biggest sites confirm they plan to act on health service demands for action.
Facebook and Instagram have announced that they will remove posts promoting ‘miracle’ cures and get-slim-quick products, which are known to have limited benefits with possible damaging side-effects.
The move follows a series of requests from health service chiefs, including NHS Chief Executive Simon Stevens, to act responsibly and protect users from content that could cause physical or mental harm.
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Source: NHS England, 19 September 2019
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Nurses need to be kinder to each other or patients will be negatively affected, warns Senior Nurse

Teams that face rudeness experience a 12% drop in diagnostic and procedural performance.
University Hospital Southampton NHS Foundation Trust (UHS) has launched the “Reminder to be Kinder” project which was designed to recognise the importance of civility on patient care. The “Reminder to be Kinder” project encourages nurses and allied healthcare professions to be kinder to each other in order to improve patient safety.
Launched to coincide with World Patient Safety Day, the project will see the introduction of a range of action cards which include reminders to celebrate colleagues’ achievements, thank someone for their work and do something to make life easier for a colleague.
Juliet Pearce, Deputy Director of Nursing at UHS, said; “The way we interact with each other can have a surprising effect on patient safety,” 
“People who witness rudeness show reduced performance and are 50% less likely to help others. If a patient was to see this happen, you could understand why they would feel anxious dealing with staff and have less trust in the organisation.”
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Source: Nursing Notes, 19 September 2019
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Jeane Freeman launches partnership between Ireland and Scotland amid ongoing health crisis in NHS Scotland

Health Secretary Jeane Freeman announced the launch of a Joint Learning Fellowship programme between Ireland and Scotland, as the NHS in Scotland reels from one crisis to the next.
Ms Freeman and the Irish Health Minister, Simon Harris, announced the initiative, which will offer two three-month placements for Scottish and Irish senior policymakers or health service workers so they can learn more about what works in each system.
However, the move came on the same day The Times reported that Glasgow's 'super-hospital' was permitted to open despite the ventilation systems failing to meet the necessary safety standards.
Outbreaks of infection which are thought to have spread through the ventilation system at the Queen Elizabeth University Hospital (QEUH) have led to the deaths of two patients.
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Source: The Scotsman, 20 September 2019
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Patient safety at risk in England unless nurse numbers increase, RCN warns

The shortage of nursing staff in England is putting patient safety at risk, the Royal College of Nursing (RCN) has warned, as it launched a new campaign to encourage the public to speak out about the impact of England’s 40,000 nurse shortage. 
The RCN’s campaign calls for legislation to be brought forward in England to help address the nursing workforce crisis. Earlier this year, nurses and support workers in Scotland secured new legislation on safe staffing levels, and a nurse staffing law was introduced in Wales in 2016.
The 2013 Francis Report on failings of care at Stafford Hospital concluded that the main factor responsible was a significant shortage of nurses at the hospital.  Nurse numbers at NHS acute Trusts across England then increased as managers took steps to try to prevent similar scandals in the future. But a new analysis by the RCN shows that for every one extra nurse NHS acute Trusts in England have managed to recruit in the five years since 2013/14, there were 157 extra admissions to hospital as emergencies or for planned treatment. 
Commenting on the campaign launch, Dame Donna Kinnair, RCN Chief Executive and General Secretary, said: “Today we’re issuing a stark warning that patient safety is being endangered by nursing shortages.  Staffing shortfalls are never simply numbers on a spreadsheet – they affect real patients in real communities."
Read full story
Source: Ekklesia, 22 September 2019
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A just culture for both staff and patients

"If we truly believe in a just culture for everyone and the benefits that can bring for patient safety, it has to give equal importance to being fair to patients and families as well as to staff, and inform practice and policy at every level," says James Titcombe, Peter Walsh and Cicely Cunningham in a recent commentary in HSJ. 
Although there is much to celebrate in the increased focus on 'just culture' – not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community – from the perspective of patients and families, the narrative to date can seem somewhat one sided. 
From the perspective of those affected, the current system of variable quality local investigations, inquests, litigation, complaints and interactions with a host of other regulatory bodies and organisations can feel designed in such a way that ensures further harm is inevitable.
Read full article
Source: HSJ, 17 September 2019
 
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Investigation into insulin prescribing in hospitals starts

The Healthcare Safety Investigation Branch (HSIB) has started a national investigation looking into insulin prescribing and administration in hospitals.
It was launched after a patient was administered an overdose of concentrated insulin while under the care of an acute hospital. 
The investigation will focus on factors which compromise safety when health professionals administer concentrated insulin through insulin pen devices.
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Source: HSIB, 24 September 2019
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Repeat Caesareans 'often safer birth option'

Planned Caesarean delivery can be the safest option for women who have had a Caesarean in the past, according to new research in PLoS Medicine. Attempting a vaginal birth was linked with a small but increased chance of complications for mother and baby compared with repeat Caesareans.
The findings come from more than 74,000 births in Scotland.
Experts say mums-to-be should be offered a choice of how to deliver – natural or Caesarean – when possible.
Read full story
Source: BBC News, 25 September 2019
 
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Warrington cancer patient died after "unacceptable delay"

Serious failings have been found at an NHS trust which performed "unacceptably delayed" and unnecessary surgery on a bladder cancer patient.
Denis Harrison, 62, died in August 2017 after waiting six months for surgery at Warrington and Halton Hospitals NHS Foundation Trust. The Parliamentary and Health Service Ombudsman (PHSO) said the trust had "failed to act with any urgency".
Mr Harrison's wife said the couple faced "severe mental anguish" waiting.
The PHSO said it was not possible to know whether earlier surgery would have saved his life, but he "was not given the best possible chance of survival".
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Source: BBC News, 25 September 2019
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Inspectors discover poor standards at 28 mental health units

Inspectors have found 28 privately run mental health units to be “inadequate” in the past three years, prompting fears that vulnerable patients are receiving poor and unsafe care.
The disclosure of such widespread substandard care in mental health facilities run by non-NHS providers has prompted psychiatrists to call for a public inquiry to investigate.
Read full story
Source: The Guardian, 25 September 2019
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World Pharmacists Day

Today millions of pharmacists worldwide will celebrate World Pharmacists Day, this year themed “safe and effective medicines for all.”

The annual day is used to highlight the value of the pharmacy profession to stakeholders and to celebrate pharmacy globally. It was originally adopted in 2009 at the World Congress of Pharmacy and Pharmaceutical Sciences.
The theme for 2019 aims to promote pharmacists’ crucial role in safeguarding patient safety through improving medicines use and reducing medication errors.
“Pharmacists use their broad knowledge and unique expertise to ensure that people get the best from their medicines. We ensure access to medicines and their appropriate use, improve adherence, coordinate care transitions and so much more. Today, more than ever, pharmacists are charged with the responsibility to ensure that when a patient uses a medicine, it will not cause harm”, says International Pharmaceutical Federation (FIP) President Dominique Jordan.
Watch Dominique Jordan's video
Source: FIP, 25 September 2019
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Pharmacist access to records is the key to even better patient care

The Royal Pharmaceutical Society (RPS) in Scotland has called on the Scottish Government to give all pharmacists read and write access to patient records.
Chair of the RPS in Scotland, Jonathan Burton, said: “World Pharmacists Day is an opportunity to celebrate the vital role of pharmacists at the forefront of healthcare.  Pharmacists across Scotland are already providing high-quality patient care, but the service could be even better if all pharmacists had access to the patient record."
Most community pharmacists do not have access to even basic information, despite performing an increasing role in providing NHS services both in and out of hours. Mr Burton continued: "It’s time the Scottish Government enabled all pharmacists to access patient health records so that, with patient consent and in appropriate circumstances, they have all the information they require to provide the safest and highest quality of care for patients in a timely and accessible manner.’’
Read full story
Source: Royal Pharmaceutical Society, 25 September 2019
Patient Safety Learning

AI advancements in healthcare – two sides to the story

If ever there were an industry that could reap the benefits of artificial intelligence (AI), it is healthcare. The adoption of this technology to actually make medicine better is obvious. However, with this adoption comes a slew of ethical issues. With AI, there is always a human consequence beyond the tech storyline.
Neil Raden suggests there are two storylines to consider: the usefulness of the application, and the ultimate effect, often unintended, on people.
Read full article
Source: Diginomica, 19 September 2019
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