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Patient Safety Learning

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  1. News Article
    Nearly one in five pregnant women in the UK were forced to wear a face covering during labour, according to research by a charity, despite official health guidance saying they should not be asked to do so. Women described feeling unable to breathe, having panic attacks or even being sick during labour because they were made to wear a face covering. The research was carried out by the charity Pregnant Then Screwed, who surveyed 936 women who gave birth during December. It found that 160 of those who went into labour were made to wear a face covering. This goes against current joint UK
  2. News Article
    Patients have come to avoidable harm after a large private provider failed to deliver thousands of medicine prescriptions, according to a report from the Care Quality Commission. Healthcare at Home, which is based in Staffordshire but provides NHS-funded care and medicine supplies to patients’ homes across the country, has been rated “inadequate” and placed in special measures. A report published today said inspectors found more than 10,000 patients missed a dose of their medicine between October and December 2020 due to problems caused by the introduction of a new information system
  3. News Article
    The chief medical officers of the four UK nations are set to warn about a surge in admissions of severely ill, very young children later this year, due to the resurgence of a respiratory virus which has been suppressed by anti-covid measures, HSJ can reveal. Public Health England modelling shows a possible sharp rise in cases of respiratory syncytial virus (RSV), which can cause bronchiolitis, this autumn and winter, several senior sources said. The modelling shows between 20 and 50% more cases needing hospitalisation than normal, HSJ understands. Official projections conclude that s
  4. News Article
    The parents of a baby who died after medical errors are to push for a new inquest into his death, after they say a "cruel" inquest denied them justice. Hayden Nguyen died in 2016 after medics failed to treat an infection properly. However, despite the NHS trust admitting mistakes, coroner Shirley Radcliffe concluded the infant died of natural causes, after raising concerns about the hospital's initial investigation. Hayden was six days old when his parents took him to the Chelsea and Westminster hospital in west London in August 2016. He initially had a fever but rapidly deteriorated
  5. News Article
    Patients awaiting a diagnostic test are to be assessed according to risk of becoming disabled as the service tries to prioritise in the face of huge backlogs. NHS England guidance released yesterday said local teams should categorise diagnostic waits on a four-point scale so those in most urgent need are seen first. It said this would mean, “recognising that for less urgent or routine diagnostics, some patients may experience a delay”. The diagnostics data for February showed 1.15 million people waiting for a test, compared to 1.08m in February 2020 – however, the proportion of peopl
  6. Event
    The broad aim of the webinar is to promote After Action Review (AAR) as a valuable tool to promote learning and patient safety improvement. It will: • Show how AAR can support, empower and enable teams to identify learning and good practice • Share knowledge on how to apply AAR for impact • Excite potential new users to adopt this approach Judy Walker, a leading expert in AAR and its adoption for impact in healthcare, will set the scene explaining ‘What is AAR, why is it so valuable and what helps successfully embed it in organisations.” To demonstrate that AAR is a practical an
  7. Content Article
    Play video The key topics covered in this video are as follows: Why is high-reliability important in addressing avoidable harm? (at 4 mins 25 secs). How culture impacts on the implementation and use of incident reporting solutions (at 8 mins). How incident reporting rates have changed during the pandemic (at 14 mins 25 secs). Positive reporting and learning from success (at 16 mins 25 secs). The role of Board members and non-executive directors understanding of incident reporting and risk management (at 22 mins 50 secs). Considering the importance of B
  8. News Article
    The government is "fully committed to learning the lessons at every stage" of the pandemic, Prime Minister Boris Johnson has said. He told MPs an independent public inquiry into the handling of the pandemic would be held in spring 2022. The inquiry would place "the state's actions under the microscope", he added, and take evidence under oath. The inquiry's terms of reference have not yet been defined but would be published in "due course", he said, adding that the devolved administrations would be consulted. Mr Johnson acknowledged many bereaved families would want the inquiry t
  9. News Article
    Covid has left a toxic legacy for the NHS, with hospitals facing a huge backlog, putting lives at risk, patient groups and staff are warning. And in-depth analysis by BBC News has found: waiting lists have ballooned at some hospitals in England, with more than one out of every 10 of patients in a quarter of trusts left at least a year without treatment major disruption to cancer services, with some hospitals struggling to treat half of their patients within the target time of two months concern growing for 45,000 "missing cancer patients", after drops in GP referrals and
  10. News Article
    The East of England has been revealed as the worst-performing region for long ophthalmology waits, with almost half the waiting list at one acute trust already breaching the 52-week milestone. Eleven per cent of the region’s 59,000 ophthalmology patients had already been waiting more than a year for treatment at the end of February, compared to 6 per cent in London, the best performing region. West Suffolk Foundation Trust — which is in health and social care secretary Matt Hancock’s local constituency — had by far the biggest problem on this measure of any trust in England, with 42%
  11. News Article
    Virtual wards, at-home antibiotic kits and using artificial intelligence in GP surgeries are among new initiatives to be trialled as part £160m funding to tackle waiting lists in the NHS. NHS England announced the funding to aid in the health service’s recovery after the pandemic, after figures last month revealed the number of people waiting to begin hospital treatment in England had risen to a new record. A total of 4.7 million people were waiting to start treatment at the end of February - the highest figure since records began in August 2007. But NHS England said indicators sugge
  12. News Article
    A major trial to detect one of the most elusive and deadly cancers - ovarian - has failed to save lives, after two decades of work. The researchers, at University College London, said the results were a disappointment - and thanked the 200,000 people who participated. The trial had looked promising, with annual blood tests detecting cases of ovarian cancer earlier. But routine screening for the cancer is now a distant prospect. Ovarian cancer is tricky to diagnose because the symptoms are easily mistaken for less serious health problems. "Some women are diagnosed so late th
  13. Event
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    This webinar, moderated by Dr Charlotte Tai, will discuss the lessons learnt and advances in practice in diagnosis, treatment, and prevention of Ventilator-associated Pneumonia. Speakers: The role of the oral cavity and the endotracheal tube in the aetiology of VAP Dr Matt Wise, Consultant Adult Critical Care, University Hospital of Wales Relationship between VAP and mortality Professor Saad Nseir, Professor of Critical Care at the Medical School of Lille, France Ventilator-associated pneumonia in critically ill patients with COVID-19 Dr Andrew Conway Morris, Honorary Co
  14. News Article
    Every adult who has tested positive for COVID-19 in Scotland is to be invited to take part in a major new study into the effects of long Covid. Researchers hope to identify how many people in Scotland continue to be unwell after having the virus. The Covid in Scotland Study (CISS) will ask people what their symptoms are and how it affects their lives. Those taking part will be asked to use a phone app to answer questions about their health before and after Covid. Early estimates suggest as many as 6,000 people in Scotland were experiencing long term symptoms after the first wave
  15. News Article
    New research examining the effect of minimum nurse-to-patient ratios has found it reduces the risks of those in care dying by up to 11%. The study, published in The Lancet, also said fewer patients were readmitted and they had shorter stays in hospital. It compared 400,000 patients and 17,000 nurses working in 27 hospitals in Queensland, Australia to 28 other hospitals. The state has a policy of just one nurse to every four patients during the day and one to seven at night, in a bid to improve safety and standards of care. The research said savings made from patients having a s
  16. News Article
    The government has confirmed its commitment to bring in new health legislation during this Parliament, but social care reform has again been ‘kicked into the long grass’. Today’s Queen’s Speech confirmed that planned, radical changes to the Health and Social Care Bill 2012 will be laid before Parliament this year. The changes, first outlined in the government’s proposals this February, will put integrated care systems on a statutory footing, dissolve clinical commissioning groups, water down the internal market within the NHS and increase the powers the health secretary has over NHS
  17. News Article
    The Department of Health and Social Care (DHSC) is facing being taken to court over an inquiry it launched into the deaths of dozens of mental health patients in Essex. Last year, the government said it would commission an independent inquiry into at least 36 inpatient deaths in Essex, which had taken place over the last two decades. However, more than 70 families are calling for a full statutory public inquiry, which can compel witnesses to give evidence. They have lodged judicial review proceedings at the High Court against the government to that effect. The DHSC said it could
  18. News Article
    Major change is required if Northern Ireland's emergency departments are to avoid another "exceptionally difficult" winter, a senior consultant has warned. Dr Brendan Lavery, who works for the Western Health Trust, said "standing still is not an option". He described the system as currently operating on a "knife edge". The Department of Health said it was "a very challenging time" for staff "with COVID-19 restrictions impacting on an already fragile system". Speaking to BBC News NI, Dr Lavery likened the situation to "Groundhog Day" with decade-long problems like capacity and st
  19. Event
    COVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management. Join this Patient Safety Association's virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. Resources from professionals trained to handle stress will be provided. Register
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