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Patient Safety Learning

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  1. News Article
    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]." Read full story Source: Business Insider,
  2. News Article
    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. Read full story Source: The Independent, 19 September 2019
  3. News Article
    All safety alerts issued by national bodies are to be standardised under a single template in an effort to eradicate confusion and reduce the burden on NHS organisations. Read full story (paywalled) Source: HSJ, 19 September 2019
  4. Content Article
    View video (3:23 )
  5. News Article
    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." Read full story Source: The Guardian, 19 September 2019
  6. News Article
    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." Read full story Source: BBC News, 18 September 2019
  7. News Article
    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." Read full story Source: BBC News, 17 September 2019
  8. News Article
    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." Read full story Source: The Guardian, 18 Setpember 2019
  9. News Article
    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. Read full story Source: Practice Business, 17 September 2019
  10. News Article
    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. Read full story Source: BBC News, 16 September 2019
  11. News Article
    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. Read full story Source: The Hill, 11 September 2019
  12. News Article
    The word ‘crisis’ is used often in nursing but the current massive workforce shortage cannot really be described any other way, says Patient Safety Learning Trustee Alison Leary in a recent interview in the Nursing Times. Read full story Source: Nursing Times, 5 September 2019
  13. Content Article
    The College’s vision of patient safety: Compassionate professional leadership that supports a strong safety culture across all areas of service delivery including the importance of teamwork, staff psychological safety and wellbeing, and openness and support for learning. Increased capability and capacity for continuous improvement of safety and quality of care across the pathology workforce. Networked learning so that success and failures identified in one part of the system can be readily accessed, understood and built into others. Representation and involvement of pathology in local and national initiatives to improve patient safety. The voices of patients, their families and carers are heard at every level of the service.
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