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Patient Safety Learning


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  1. News Article
    The family of a man who bled to death during kidney dialysis treatment at Royal Shrewsbury Hospital have said they believe lessons have been learned. Mohammed Ismael Zaman, known as Bolly, died after hospital staff failed to check the connection on his dialysis machine, despite it sounding an alarm after the catheter had become disconnected. During Mr Zaman’s treatment at the Royal Shrewsbury Hospital on October 18, 2019, his dialysis machine set off a venous pressure alarm. An unidentified member of staff reset the alarm without checking that the connection was still secure. As a result of the reset, Mr Zaman bled out for seven minutes losing 49% of his blood circulating volume. He was found unconscious in a pool of blood and despite resuscitation attempts, died two hours later. The coroner, Mr John Ellery concluded that the death was due to systems failure and individual neglect on the part of the unidentified staff member. Read full story Source: Shropshire Star, 16 January 2021
  2. Event
    This webinar from the Westminster Health Forum focuses on the ongoing research into the long-lasting effects of COVID-19 and the priorities for coordinating effective care provision and treatment. The conference follows NICE guidance being published on managing the long term effects of COVID, and NHS England setting up long COVID assessment centres across the country. Key areas for discussion include: progress of research so far and priority focus areas going forward the development of guidance for long COVID improving patient awareness, supporting self-management and the importance of patient-centred care delivery the role of long COVID assessment centres and early lessons from their development supporting primary care in responding effectively to long COVID, integrated working and priorities for the use of multidisciplinary teams in assessment and rehabilitation. Register
  3. Event
    The Chartered Institute of Ergonomics & Human Factors (CIEHF)'s first HF Masterclass of 2021, and a great chance for some quality CPD, starts with Systems Engineering Initiative for Patient Safety (SEIPS), a tool that helps improve understanding about the interaction of the system factors influential in delivering safe and effective healthcare. SEIPS looks at the sociotechnical work system involved in healthcare delivery including the interaction of the patient and healthcare professional and their parts in the process. It also takes into account the process outcomes from the point of view of the patient, the healthcare professional and the organisation and the effects of adaptations in the process. It’s a great way to investigate and analyse a complex system, identifying and bringing out all components for scrutiny. In this webinar, you’ll gain knowledge and insights about practical use of SEIPS from three experienced CIEHF members who’ll be taking you through the details about when and how to use the tool and what it enables you to learn about the system you’re interested in. You’ll also hear about case studies where SEIPS has been used to great effect. Register
  4. News Article
    A London hospital is being forced to send patients back to ambulances for treatment due to an ‘overwhelming’ number of Covid patients on ICU wards, according to a frontline doctor. The medic, who asked to remain anonymous, said A&E staff are "running" into waiting ambulances to treat patients there until space becomes available. He said: "It’s not the fault of the staff, but the sheer numbers are so unprecedented and being full like this means that you just have to do your best to adapt. But it’s not the standard (of care) I signed up to." "It’s extremely stressful for us to be doing our best but knowing that significant patient harm is happening because there isn’t space and the patient load is too high." He raised concerns that "significant patient harm" was occurring due to a lack of beds available and the emergency system means medics are limited in the care they can provide. Read full story Source: The Metro, 14 January 2021
  5. News Article
    The growth in covid positive hospital patients is rapidly slowing in every English region and appears to have stopped in the south east. The weekly increase in covid inpatients across England fell to 8% yesterday, the first time it had dropped to single figures since 12 December. A week earlier, on 10 January, the growth rate stood at 23%. There are now 33,352 covid hospital patients in English hospitals, an increase of 2,594 in the last seven days. The previous week had seen a rise of 5,801. The weekly growth rate of covid positive hospital patients in the seven English regions currently ranges from 26% in the south west to zero in the south east. In every region, the growth rate is seven to 20 percentage points lower than recorded on 10 January. London’s weekly growth rate is now three per cent and the east’s is 2%. There has been no substantive change in the south east total in the past week. It is likely covid patients will be seen to have peaked in these three regions between 13 to 15 January. The slowing in the growth of national covid patient numbers means the total is likely to peak during the next seven days at a level lower than many had feared and expected. HSJ has seen internal NHS England projections from last week that saw growth continuing into February and total covid patient numbers rising well above 40,000, this now seem very unlikely. Read full story Source: HSJ, 18 January 2021
  6. News Article
    Emergency legislation is needed to protect doctors and nurses from “inappropriate” legal action over critical Covid treatment decisions made amid the pressures of the pandemic, health organisations have argued. A coalition of health bodies has written to Matt Hancock, the health secretary, calling for the law to be updated so medical workers do not feel “vulnerable to the risk of prosecution for unlawful killing” when treating coronavirus patients “in circumstances beyond their control”. The letter, coordinated by the Medical Protection Society (MPS), states there are no legal safeguards for coronavirus-related issues such as when there are “surges in demand for resources that temporarily exceed supply”. The coalition, which includes the British Medical Association and Doctors’ Association UK, wrote: “With the chief medical officers now determining that there is a material risk of the NHS being overwhelmed within weeks, our members are worried that not only do they face being put in this position but also that they could subsequently be vulnerable to a criminal investigation by the police. “There is no national guidance, backed up by a clear statement of law, on when life-sustaining treatment can be lawfully withheld or withdrawn from a patient in order for it to benefit a different patient, and if so under what conditions. The first concern of a doctor is their patients and providing the highest standard of care at all times.” Read full story Source: The Guardian, 16 January 2021
  7. News Article
    A mental health trust prosecuted for failings after 11 patients died must make further safety improvements, the Care Quality Commission (CQC) said. Inspectors found safety issues on male wards and psychiatric intensive care units run by Essex Partnership University NHS Foundation Trust (EPUT). The Trust said it had taken "immediate action" to remedy the concerns. In November, EPUT pleaded guilty to safety failings related to patient deaths between 2004 and 2015. The CQC's report followed inspections in October and November last year at the Finchingfield Ward - a 17-bed unit in the Linden Centre in Chelmsford which provides treatment for men experiencing acute mental health difficulties. The CQC said the visit was prompted "due to concerning information raised to the commission regarding safety incidents leading to concerns around risk of harm". The inspection, which looked at safety only, found the following concerns: Some staff did not follow the required actions to maintain patient safety. Closed-circuit television showed staff who were meant to be observing were not present, and this contributed to an incident of patient absconding. Staff did not keep accurate records of patient care and managers did not check the quality and accuracy. of notes. Shifts were not always covered by staff with appropriate experience and competency Stuart Dunn, head of hospital inspection at the CQC, said EPUT had "responded quickly to concerns raised" including improving security measures. Read full story Source: BBC News, 14 January 2021
  8. News Article
    Advisers from the Scientific Advisory Group for Emergencies (Sage) have raised fresh concerns over Covid vaccine uptake among black, Asian and minority ethnic communities (BAME) as research showed up to 72% of black people said they were unlikely to have the jab. Historical issues of unethical healthcare research, and structural and institutional racism and discrimination, are key reasons for lower levels of trust in the vaccination programme, a report from Sage said. The figures come from the UK Household Longitudinal Study, which conducts annual interviews to gain a long-term perspective on British people’s lives. In late November, the researchers contacted 12,035 participants to investigate the prevalence of coronavirus vaccine hesitancy in the UK, and whether certain subgroups were more likely to be affected by it. Overall, the study found high levels of willingness to be vaccinated, with 82% of people saying they were likely or very likely to have the jab – rising to 96% among people over the age of 75. Women, younger people and those with lower levels of education were less willing, but hesitancy was particularly high among people from black groups, where 72% said they were unlikely or very unlikely to be vaccinated. Among Pakistani and Bangladeshi groups this figure was 42%. Eastern European groups were also less willing. “Trust is particularly important for black communities that have low trust in healthcare organisations and research findings due to historical issues of unethical healthcare research,” said the Sage experts. “Trust is also undermined by structural and institutional racism and discrimination. Minority ethnic groups have historically been underrepresented within health research, including vaccines trials, which can influence trust in a particular vaccine being perceived as appropriate and safe, and concerns that immunisation research is not ethnically heterogenous.” Read full story Source: The Guardian, 16 January 2021
  9. Content Article
    In this study, Kim et al. analysed 1,189 patient safety event reports using a safety science and resilience engineering approach, which focuses on identifying processes to discover errors before they reach the patient so these processes can be expanded. They analysed the general care processes in which wrong-patient errors occurred, the clinical process step during which the error occurred and was discovered, and whether the error reached the patient. For those errors that reached the patient, they analysed the impact on the patient, and for those that did not reach the patient, we analysed how the error was caught. The results demonstrate that errors occurred across multiple general care process areas, with 24.4% of wrong-patient error events reaching the patient. Analysis of clinical process steps indicated that most errors occurred during ordering/prescribing and most errors were discovered during review of information. Patients were primarily impacted by inappropriate medication administration and the wrong test or procedure being performed. When errors were caught before reaching the patient, this was primarily because of nurses, technicians, or other healthcare staff. The differences between the general care processes can inform wrong-patient error risk mitigation strategies. Based on these analyses and the broader literature, this study offers recommendations for addressing wrong-patient errors using safety science and resilience engineering, and it provides a unique lens for evaluating HIT technology wrong-patient errors.
  10. Content Article
    Tuesday 12 January – APPG Coronavirus Oral Evidence Hearing Video, first half is speakers living with Long COVID and second half is Professor Danny Altmann and Dr Nisreen Alwan Thursday 14 January – Long COVID Backbench Business debate in parliament: transcript Thursday 14 January – APPG Coronavirus Q&A with Professor Danny Altmann, Dr Nisreen Alwan, Dr Mike Galsworthy and Layla Moran M
  11. Event
    How Brighton & Sussex University Hospitals engaged staff to transform quality and free up time for patient care. Perfect Ward & Good Governance Institute will be joined by Carolyn Morrice, Chief Nurse and Matt Hutchinson, Head of Nursing - Quality and Safety from Brighton and Sussex Hospitals who will explain their own situation and how they engaged staff to transform quality and release time for patient care. Perfect Ward is a specialist provider in digital quality improvement and safety solutions across health and social care. Working with leading hospitals and care providers in the UK, Australia and South Africa, Perfect Ward is designed to make health and quality inspections easier and more efficient for frontline staff. Register