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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Gallery Image
    Bupivacaine alongside sodium choloride.jpg
    Bupivacaine solution, a medication used to decrease feeling in a specific area, alongside sodium chloride used as a saline solution. What could go wrong?! Another example of almost identical packaging/labelling.
  2. News Article
    Elderly people who call for help after a fall at home will no longer be left waiting for hours on the floor, the head of the NHS has said, as she bids to keep patients out of hospital and stop the service being overwhelmed this winter. Amanda Pritchard said she would start a new national service within weeks under which community teams would offer immediate help to people who had had an accident but had avoided serious injury. Pritchard, who took over as chief executive of NHS England last year, said a quarter of less severe 999 calls in January involved falls. The new teams could stop 55,000 elderly people a year being taken to hospital, she said. All NHS areas will be told this week to establish the service before a “very, very, very challenging winter” for the health service. Read full story (paywalled) Source: The Times, 16 October 2022
  3. News Article
    The chief executive of an NHS trust at the centre of a maternity scandal where there were at least seven preventable baby deaths has warned staff to prepare for a "harrowing report" into what happened. In an email seen by Sky News, East Kent Hospitals University NHS Foundation Trust chief executive Tracey Fletcher told her staff to expect a "harrowing report which will have a profound and significant impact on families and colleagues, particularly those working in maternity services". An independent investigation into the trust, stretching back over a decade, will be published this week and is expected to expose a catalogue of serious failings. It is also expected to say the avoidable baby deaths happened because recommendations that were made following reports into other NHS maternity scandals were not implemented. The East Kent review is led by obstetrician Dr Bill Kirkup, who also chaired the investigation into mother and baby deaths in Morecambe in 2015. Dawn Powell's newborn son Archie died in February 2019 aged four days. In an emotional interview, Mrs Powell told Sky News she will never get over the loss of her son, who would be alive today if she or Archie had been given a routine antibiotic. "For families like us, where your child has been taken away, you have forever got that hole in your life that you will never heal," Mrs Powell said. Read full story Source: Sky News, 16 October 2022
  4. News Article
    Hundreds of patients with metallic implants narrowly avoided death or serious injury after being wrongly referred for MRI scans, an investigation revealed yesterday. The powerful magnets used in the machines can displace and damage metallic items such as pacemakers, ear implants and aneurysm clips. Doctors should question patients and check medical records before requesting a scan because of the risk of injury. But hospitals in England recorded 315 near-misses from April 2020 to March 2022 involving patients sent for an MRI. An MRI scan at Mid Yorkshire Hospitals Trust was ditched after staff confirmed the skin over the patient’s pacemaker had begun heating up. Another patient – at Wrightington, Wigan and Leigh Trust – told staff about a metal plug implanted in their nose only after the scan had begun. Many of the incidents involved forms being filled out incorrectly on behalf of elderly and disoriented patients. At East Kent Hospitals University Trust, a patient described as ‘not compos mentis’ was given the all-clear by a care home nurse and again by a clinician for MRI – only for staff to realise at the last moment that metal clips were implanted in their chest. Information about the incidents was obtained using freedom of information requests. Helen Hughes of Patient Safety Learning, said: "It is vital that near-misses are regularly reported, their causes understood, and that this learning is acted on to prevent future avoidable harm." Read full story Source: MailOnline, 15 October 2022
  5. News Article
    NHS hospitals have claimed that babies born alive were stillborn, a Telegraph investigation has found, prompting accusations they were trying to avoid scrutiny. Six children who died before they left hospital were wrongly described as stillborn. Several of the children lived for minutes and one lived for five days. Coroners are not able to carry out inquests into stillbirths, leaving some families unable to get answers until the error was corrected. In one case, an obstetrician told a coroner in Stockport that he had been pressured by an NHS manager to say a baby he had delivered had definitely been stillborn, in order to be “loyal” to the trust. His comments are likely to raise fears that some NHS trusts in England have used the stillbirth label to avoid having coroners examine any errors that may have been made by staff. The revelations raise questions over transparency at some NHS trusts. The babies identified by The Telegraph should have been recorded as neonatal deaths, but staff claimed they were stillbirths – babies that never had any signs of life outside the mother’s body, even for a single moment. All the NHS trusts that wrongly classified neonatal deaths as stillbirths have apologised to the babies’ parents, and say they have changed their practices. Read full story (paywalled) Source: The Telegraph, 16 October 2022
  6. Content Article
    A thematic review can identify patterns in data to help answer questions, show links or identify issues. Thematic reviews typically use qualitative (e.g, open text survey responses, field sketches, incident reports and information sourced through conversations and interviews) rather than quantitative data to identify safety themes and issues. Thematic reviews can sometimes use a combination of qualitative data with quantitative data. Quantitative data may come from closed survey responses or audit, for example. These top tips support health and social care staff to carry out thematic reviews, but organisations may take different approaches, depending on the purpose and scope of their review. 
  7. News Article
    Patients up and down the country are set to benefit from innovative new treatments and improved delivery of health and care services following significant funding to support ground-breaking experimental medicine research and advance the UK’s response to patient safety challenges. £790 million to support breakthroughs in new treatments, diagnostics and medical technology to improve patients’ lives and bolster the economy. £25 million for research on patient safety to improve the safe delivery of health and care and better address health challenges, such as cancer treatment and reducing medication error. Exceeds funding commitments to boost research across all areas of the country, levelling up innovation and addressing health inequalities. The government has announced that over £800 million of funding, to be allocated by the National Institute for Health and Care Research (NIHR), will go to support specialist research facilities bringing together scientists to create an environment where experimental medicine and patient safety research can thrive. This boost to the country’s research infrastructure will see further investment in scientific expertise which supports access to innovative technology and novel research projects. As well as this, it will improve regional economic growth through employment opportunities, giving private sector organisations confidence to continue to invest in research across the country. Read full story Source: GOV.UK, 14 October 2022
  8. Content Article
    Improving the quality of products or services and maintaining acceptable levels of performance are critical factors in the success of any organisation. There are many improvement methods available which include Six Sigma, Lean Management, Lean Six Sigma, Total Quality Management, Model for Improvement and Kaizen just to mention a couple. These methods have differences in approach and application, normally stemming from the differing focus of the methods. The choice of which improvement method to use can sometimes be divisive. One single method is not necessarily better than another, with their strengths lying in different areas. LifeQI have put together a cheatsheet for you to help you choose the most appropriate one for your project and organisation. This Improvement methods cheatsheet compares the different methods according to multiple aspects which you can use as guidelines to help your decision-making process. Note: You will need to fill in your details to download the cheatsheet.
  9. Content Article
    Surgical menopause is the removal of both ovaries (bilateral oophorectomy) before a woman goes through biological menopause. Symptoms of surgical menopause are generally similar to that of a natural or chemically induced menopause, with a few established differences. Due to the sudden loss of ovarian function in surgical menopause, pre-menopausal women might experience more severe consequences, including increased rates of overall mortality, coronary heart disease, stroke, cognitive impairment, osteoporosis and sexual dysfunction. Surgical menopause can have significant consequences both short term and long term. Clear information and advice should be provided both before and after surgery to both the patient and their primary care team.
  10. Content Article
    These stories provide examples of how people with pancreatic cancer are diagnosed, the treatment they have, their experiences and how they take care of themselves. Everyone diagnosed with pancreatic cancer will be different in terms of how they received their diagnosis and how they respond to and cope with treatment.
  11. Content Article
    Long Covid is now estimated to affect 2 million people in the UK, and almost 145 million globally. It’s a complicated diagnosis to receive and those affected have to cope with both the physical symptoms and the psychological strain of having an illness that is not yet well understood and does not have well-established treatments. Three Long Covid patients share with the Guardian on how they navigated this journey.
  12. Content Article
    The journalist Merope Mills voices her anger at her daughter Martha's preventable death in this Woman's Hour programme.
  13. Content Article
    People with myalgic encephalomyelitis, or ME, have long felt disregarded by some medical professionals who believed their pain and exhaustion to be a psychological disorder. More recently, patient activism, combined with new data on the underlying biology of the illness, has resulted in changes in treatment guidelines and a renewed focus on ME as a biologically grounded post-viral disease. This article in the Irish Times highlights patients' experiences and the challenges they face.
  14. Content Article
    A themed review may be useful in understanding common links, themes or issues within a cluster of investigations or incidents. It will seek to understand key barriers or facilitators to safety using reference cases (e.g. individual datix incidents or previous investigations). 
  15. Content Article
    MBRRACE-UK is commissioned by the Healthcare Quality Improvement Partnership (HQIP) to undertake the Maternal, Newborn and Infant Clinical Outcome Review Programme (MNI-CORP). The aims of the MNI-CORP are to collect, analyse and report national surveillance data and conduct national confidential enquiries in order to stimulate and evaluate improvements in health care for mothers and babies. This report focuses on the surveillance of perinatal deaths from 22+0 weeks’ gestational age (including late fetal losses, stillbirths, and neonatal deaths) of babies born between 1 January and 31 December 2020.
  16. News Article
    Research suggests there are higher rates of stillbirth and neonatal death for those living in deprived areas and minority ethnic groups. A report from a team at the University of Leicester shows that while overall stillbirth and neonatal mortality rates have reduced, inequalities persist. MBRRACE-UK, the team that carried out the research, said it had looked at outcomes for specific ethnic groups. The report showed the stillbirth rate in the UK had reduced by 21% over the period 2013 to 2020 to 3.33 per 1,000 total births. Over the same period the neonatal mortality rate has reduced by 17% to 1.53 per 1,000 births. However despite these improvements, the authors found inequalities persisted, with those living in the most deprived areas, minority ethnic groups and twin pregnancies all experiencing higher rates of stillbirth. Elizabeth Draper, professor of perinatal and paediatric epidemiology at the university, said: "In this report we have carried out a deeper dive into the impact of deprivation and ethnicity on stillbirth and neonatal death rates. "For the first time, we report on outcomes for babies of Indian, Pakistani, Bangladeshi, Black Caribbean and Black African, rather than reporting on broader Asian and black ethnic groups, who have diverse backgrounds, culture and experiences. "This additional information will help in the targeting of intervention and support programmes to try to reduce stillbirth and neonatal death." Read full story Source: BBC News, 14 October 2022
  17. News Article
    The Government’s national obesity campaign risked turning fat-shaming into "wilful political strategy", said two humanities researchers in a new paper published in Sociology of Health and Illness. The Tackling Obesity campaign, launched by the Government "to improve health and protect the NHS during the COVID-19 pandemic", was "unproductive", "ineffective", "irresponsible", and could have led to "fat-shaming", they said. Moreover, the Government "perpetuated the neoliberal view that good health is essentially a matter of individual achievement earned through lifestyle choices and behaviour" - ignoring "the multiple structural and socioeconomic factors that contribute to obesity". Co-authors Dr Tanisha Spratt, lecturer in sociology in the School of Humanities and Social Sciences at the University of Greenwich, London, and Luna Dolezal, associate professor in philosophy and medical humanities at the University of Exeter, said they were using the Tackling Obesity campaign "as an illustration" to explore "the dynamics between fat shaming, neoliberalism, ideological constructions of health and the 'obesity epidemic' within the UK". They said that fat shaming was a practice that "encourages open disdain for those living with excess weight [and] operates as a moralising tool to regulate and manage those who are viewed as 'bad' citizens". They regarded this as an example of "how the ideological underpinnings of 'health' have been transformed under neoliberalism". Fat shaming discourses that are often used as tools to promote 'healthy' lifestyle choices are "problematic", they said. Prof Dolezal, a principal investigator on the Wellcome-funded Shame and Medicine project, also co-authored a paper published earlier this month saying that the health and care system "should be more sensitive to people's 'shame'". Read full story Source: Medscape, 13 October 2022
  18. Content Article
    The Australian Institute of Health Innovation conducts world-class research to catalyse health service and systems improvements in Australia and internationally. Its research generates highly practical evidence-based recommendations and information that health services can implement or use now. The Health Innovation Series supports clinicians, hospitals, policy makers and developers to apply this evidence to enhance the health system and services. The Health Innovation Series communicates research evidence in an easy-to-read, short format with clear recommendations, covering a wide range of topics. 
  19. Content Article
    This article* is an update from Dr Henrietta Hughes, Patient Safety Commissioner for England.
  20. News Article
    The blood-donation service has been inundated with offers of help after putting out an alert, on Wednesday, warning NHS stocks were running critically low in England. More than 10,000 appointments to donate blood over the next few weeks have been booked in the past 24 hours. The NHS usually has six days' worth of blood to use for operations and transfusions but levels are currently due to fall below two. Type-O blood is in particular demand. O positive is the most common and anyone can receive O negative in an emergency or if their blood type is unknown. Blood supplies have been challenging since the Covid pandemic, because of staff shortages and sickness, and a change in people's behaviour means they are less likely to visit donation centres in towns and cities, according to NHSBT. Individual hospitals must decide how to manage the shortage - for example, by postponing some non-urgent operations. "This is an amazing response from the public and we have been reminded in the last 24 hours of the incredible goodwill and spirit of the public towards helping patients in times of great difficulty," an NHSBT official said. Read full story Source: BBC News, 13 October 2022
  21. News Article
    At 9.16am Florence Wilkinson gave birth to a healthy baby boy by planned caesarean section. The team of NHS doctors and midwives worked like a well-oiled machine, performing what to them was a standard operation, while also showing real kindness. After a short stint in a close observation bay, Florence was moved onto the postnatal ward. Still anaesthetised, Florence was completely reliant on her partner Ben to help her recover from the birth and feed her son in his first hours of life. Yet just a few hours later, the scene was very different. Due to Covid protocol, Ben was not able to stay overnight. At 8pm, midwives bustled around briskly ejecting fathers and birth partners from the ward – and what followed was one of the hardest, most frightening nights of Florence's life. She was alone with a newborn, yet during the course of that night she only saw a midwife once. She was still recovering from my operation and unable to pick up her baby. An exhausted healthcare assistant told Florence she didn’t have time to help and the newborn didn’t feed for seven hours. There simply weren’t enough staff to look after the mothers, but no partner to advocate for them either. A review of the maternity policies listed on the websites of 90 hospital trusts in England reveals that 54% still restrict partners from staying overnight after birth. While a few trusts have always limited access at night, many admit to bringing in restrictions during the pandemic which they continue to implement to this day. “It is deeply concerning to hear that some Trusts are continuing to implement restrictions on visiting, such as limited postnatal visiting overnight, under the premise of Covid, particularly at this stage in the pandemic,” says Francesca Treadaway, director of engagement at the charity Birthrights. “There is overwhelming evidence, built up since March 2020, of the impact Covid restrictions in maternity had on women giving birth. It must be remembered that blanket policies are rarely lawful and any policies implemented should explicitly consider people’s individual circumstances.” Read full story (paywalled) Source: The Telegraph, 13 October 2022
  22. News Article
    An 88-year-old woman with dementia was physically and mentally abused at a luxury care home charging residents close to £100,000 a year, the Guardian can reveal. Staff misconduct was exposed by secret filming inside the home run by Signature Senior Lifestyle, which operates 36 luxury facilities mostly in the south of England. It has admitted that Ann King was mistreated at Reigate Grange in Surrey earlier this year. Distressing footage from a covert camera inside her room shows: Care staff handling King roughly, causing her to cry out in distress. On one occasion she was left on the floor for 50 minutes. King being taunted, mocked and sworn at when she was confused and frightened. The retired nurse being assaulted by a cleaner, who hits her with a rag used to clean a toilet while she is lying in bed. The cleaner threatening to empty a bin on the pensioner’s head and making indecent sexual gestures in her face. The abuse was exposed by King’s children, Richard Last and Clare Miller. They became so concerned about her wellbeing at the care home, where she lived from January 2021 to March 2022, that they installed a hidden camera on her bedside table. They have shared the footage because they fear what happened to their mother may not be an isolated incident, and because: “She has always been horrified by this type of thing and we felt she would have wanted us to show this is going on.” Read full story Source: The Guardian, 13 October 2022
  23. News Article
    A French study of adverse drug reactions has a highlighted a link between drug shortages and medication error. Data from the French Pharmacovigilance Database show that medication errors were identified in 11% of the 462 cases mentioning a drug shortage. The researchers found that medication errors usually occurred at the administration step and involved a human factor. “A drug shortage may lead to a replacement of the unavailable product by an alternative,” the researchers wrote. “However, this alternative may have different packaging, labelling, dosage and sometimes a different route of administration that may increase the risk of a medication error.” Read full story (paywalled) Source: The Pharmaceutical Journal, 11 October 2022
  24. News Article
    There were ’obfuscations, difficulties and failures’ in a scandal-hit trust’s handling of a baby’s death, a damning review has found, although it cleared the organisation’s former chair of ’serious mismanagement’. A fit and proper person review into the conduct of former Shrewsbury and Telford Hospital Trust chair Ben Reid, who left in August 2020, has been published by the board. The report follows complaints about Mr Reid’s conduct from the family of baby Kate Stanton-Davies, who died in the trust’s care and whose case – alongside that of Pippa Griffiths – sparked the original Ockenden inquiry. In March 2022, the final Ockenden report into maternity services at Shrewsbury found poor maternity care had resulted in almost 300 avoidable baby deaths or brain damage cases in the most damning review of maternity services in the NHS’s history. Report author Fiona Scolding KC said she does not believe Mr Reid “lied” or acted unethically in his handling of complaints from the family and therefore this does not disqualify him from holding office within the terms of such a review. However, the report is highly critical of the trust, with Ms Scolding concluding it is “undoubtedly true” the provider had not dealt with Kate’s father Richard Stanton and her mother Rhiannon Davies in an “open and honest” way in respect of their daughter’s death. Read full story (paywalled) Source: HSJ, 13 October 2022
  25. Event
    The NHS Patient Safety Conference, in partnership with Patient Safety Learning, is a long-standing virtual and in-person event series that has welcomed over 1500 NHS professionals through its doors. In February 2021, further updates and changes were made to the NHS Patient Safety Strategy. The most significant strategy update is the new commitment to address patient safety inequalities, with a new objective added to the safety system strand of the strategy. This event series provides a timely platform to discuss these changes. Key event topics are run across 3 key pillars: Insight Adopt and promote fundamental safety measurement principles and use culture metrics to better understand how safe care is. Use new digital technologies to support learning from what does and does not go well, by replacing the National Reporting and Learning System with a new safety learning system. Introduce the Patient Safety Incident Response Framework to improve the response to an investigation of incidents and implement a new medical examiner system to scrutinise deaths. Improve the response to new and emerging risks, supported by the new National Patient Safety Alerts Committee Share an insight from litigation to prevent harm. Involvement Establish principles and expectations for the involvement of patients, families, carers, and other lay people in providing safer care. Create the first system-wide and consistent patient safety syllabus, training, and education framework for the NHS. Establish patient safety specialists to lead safety improvement across the system. Ensure people are equipped to learn from what goes well as well as to respond appropriately to things going wrong. Ensure the whole healthcare system is involved in the safety agenda. Improvement Deliver the National Patient Safety Improvement Programme, building on the existing focus on preventing avoidable deterioration and adopting and spreading safety interventions. Deliver the Maternity and Neonatal Safety Improvement Programme to support a reduction in stillbirth, neonatal and maternal death, and neonatal asphyxia brain injury by 50% by 2025. Develop the Medicines Safety Improvement Programme to increase the safety of those areas of medication use currently considered the highest risk. Deliver a Mental Health Safety Improvement Programme to tackle priority areas, including restrictive practice and sexual safety. Work with partners across the NHS to support safety improvement in priority areas such as the safety of older people, the safety of those with learning disabilities and the continuing threat of antimicrobial resistance. Work to ensure research and innovation support safety improvement. All organisations are committed to patient safety, but how do leaders ensure that they’re doing all they can to deliver safe and effective care? Join Dr Sanjiv Sharma, Executive Medical Director at Great Ormand Street Hospital for Children, and Helen Hughes, Chief Executive of Patient Safety Learning for a presentation at 9.05am. Dr Sharma will outline their ambitious patient safety transformation journey, how they are designing and delivering an innovative safety systems approach. Embedding Patient Safety Learning’s new standards for patient safety, hear how GOSH’s self assessment has informed the development of prioritised action plans, strengthened governance and leadership engagement and cross organisation collaboration. Helen Hughes, Chief Executive of Patient Safety Learning, will outline why a standards based approach to patient safety is needed and the benefits it can bring. Register
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