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Patient Safety Learning

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  1. Patient Safety Learning
    NHS Chief Executive Simon Stevens has announced that a new taskforce will be set up to improve current specialist children and young people’s inpatient mental health, autism and learning disability services in England.
    The NHS Long Term Plan sets out an ambitious programme to transform mental health services, autism and learning disability; with a particular focus on boosting community services and reducing the over reliance on inpatient care, with these more intensive services significantly improved and more effectively joined up with schools and councils.
    The NHS Chief Executive said: “This taskforce will place a spotlight on services and care for some of the most vulnerable young people in our society, bringing together families, leading clinicians, charities, and other public bodies to help make these services as effective, safe and supportive as possible for thousands of families."
    “The NHS Long Term Plan lays out a package of measures which will mean more than two million extra children and adults get the mental health care they need and while early intervention to stop ill health escalating is a priority, we are also determined to provide the strongest possible safety net for families living with the most acute conditions.”
    Read full story
    Source: NHS England, 10 October 2019
  2. Patient Safety Learning
    The British Medical Association (BMA) is calling on employers to sign up to a wellbeing charter to improve doctors’ working lives. 
    The association commissioned qualitative research to establish which factors contributed to poor mental health among doctors. Researchers conducted 30 interviews with doctors from a range of specialties and levels of seniority, as well as two online focus groups with medical students and junior doctors.
    Read full story (paywalled)
    Source: BMJ, 10 October 2019
  3. Patient Safety Learning
    As a doctor himself, Jonathan Phillips knows how isolating the job can be, which is why he is raising awareness of mental wellbeing at his trust.
    Jonathan first heard of his daughter Lauren’s disappearance in the early hours of the morning on 1 March 2017. Her car was found abandoned near a beach in Devon after she had been reported missing from her job in the A&E department of a NHS trust.
    Lauren was 26 and in her third year as a junior doctor in the south-west of England when she took her own life.
    "From the moment they start, all newly qualified doctors encounter sexism, racism and verbal, physical and sexual abuse, as well as extremes of distress, rage and despair. They are in a highly stressful working environment where mistakes may prove fatal to their patients and career," says Jonathan. "Young trainees are individuals with differing life experiences, resulting in varying strengths and vulnerabilities; some will need shielding from certain situations at the start of their careers. If we are lucky enough to identify someone in a crisis we should not merely signpost the route to help, but guide and accompany them along the path to recovery."
    Prompted by his own experience and other junior doctor suicides, Jonathan and colleagues constructed a wellbeing and resilience training day for foundation year doctors at his trust. It was delivered by senior doctors with a responsibility and interest in junior doctor training and supervision, and was quite separate from the already congested induction programme.
    Read full story
    Source: Guardian, 10 October 2019
     
  4. Patient Safety Learning
    Today is World Mental Health Day. An opportunity for all of us to raise awareness of mental health issues and advocate against social stigma. This year's theme, set by the World Federation for Mental Health, is suicide prevention. 
    Every year close to 800,000 people globally take their own life and there are many more people who attempt suicide. Every suicide is a tragedy that affects families, communities and has long-lasting effects on the people left behind. It's the leading cause of death among young people aged 20-34 years in the UK and is the second leading cause of death among 15-29 year-olds globally.
    Read more
    Source: Mental Health Foundation, 10 October 2019
  5. Patient Safety Learning
    The Royal College of Nursing's (RCN) new parity of esteem initiative encourages members to take a holistic approach to patient care.
    “Currently, people with severe mental illnesses die 15–20 years earlier than the general population,” said Tim Coupland, who leads the RCN parity of esteem project.
     
    “We can all play our part in changing this by addressing people’s mental health with the same urgency as we do physical health and ensuring that people with complex mental health issues are supported to look after their physical well-being. We also need to consider how physical health issues affect our patients’ mental health.” 

    Tim and the rest of our parity of esteem group have been looking at how mental and physical health feed into one another and what nursing staff can do to make parity a reality. Their week-long campaign shares key insights and actions to help you make changes in your workplace.
    Read full story
    Source: RCN, 7 October 2019
  6. Patient Safety Learning
    For the occasion of World Mental Health Day 2019, on the theme of suicide prevention, WHO’s Director-General, Dr Tedros Adhanom Ghebreyesus, gives a video message for the suicide prevention campaign. Every 40 seconds, someone loses their life to suicide. Every single loss is a tragedy.
    View video
    Further information about WHO’s suicide prevention work
  7. Patient Safety Learning
    Former health secretary, Jeremy Hunt, has set up a patient safety charity which will establish data he can use to report on levels of avoidable harm in healthcare.
    The charity, Patient Safety Watch, will commission research from leading universities on the scale of patient harm, with the aim to create an agreed methodology that will allow trends in the level of harm in healthcare to be tracked over time.
    Mr Hunt said he wanted to fill a gap in hard data on safety issues: "The bit of the jigsaw that is missing is the hard data on the number of avoidable deaths, avoidable harm, is it going up is it going down, and taking a view across the whole system," he said.
    "We intend the remit of the charity to be a narrow one which is about establishing credible data around patient safety issues".
    Read full story (paywalled)
    Source: HSJ, 9 October 2019
    Patient Safety Learning's response:
    We welcome today's announcement by Jeremy Hunt MP that he is setting up a new charity, Patient Safety Watch. At Patient Safety Learning we are committed to providing an independent voice for improving patient safety and collaborating with healthcare organisations, charities and patients to drive system-wide change. 

    In our report, A Blueprint for Action, we set out the six foundations of safe care for patients and the practical actions needed to deliver these. Improved data and insight is one of these foundations and has a key role to play in helping to raise patient safety standards across health and social care. Highlighting examples of good practice and shortfalls in patient safety performance is needed not to blame, but to learn and improve. Patient Safety Watch's proposed focus on improving research and reporting into levels of patient safety incidents and avoidable harm in the NHS can play an important role in making the case for improvement and change. We look forward to working with Patient Safety Watch and on the actions needed to make the patient-safe future a reality.  
  8. Patient Safety Learning
    The NHS in England is to roll out dedicated support for members of staff who raise the alarm on unsafe practice.
    Following successful pilots, the NHS will soon offer practical support to any doctor, nurse, or other worker across the country who needs additional support to build their career after raising concerns at work, as part of the NHS Long Term Plan to improve care and treatment.
    The move to ramp up support for whistle-blowers is part of a package of measures to put a renewed focus on the wellbeing of patients under NHS care and follows publication earlier this year of a world-first patient safety strategy, which included a requirement for every local health service to have a dedicated patient safety specialist.
    Evidence shows that health services delivering a higher quality of patient care are more likely to have a positive speaking up culture.
    Simon Stevens, NHS Chief Executive said: “NHS staff raise concerns because they care about our patients, and every member of our workforce – midwife, therapist, cleaner, surgeon or receptionist – who spots and reports poor practice should be supported to help put things right."
    Read full story
    Source: NHS England, 8 October 2019
  9. Patient Safety Learning
    Liberal Democrat MP Sir Norman Lamb has called on the Solicitors Regulation Authority (SRA) to investigate national law firm Hill Dickinson over claims it failed to disclose a crucial document in a whistleblowing dispute involving the NHS.
    The SRA said it had received “a number of reports” about the matter and would be “seeking further information before deciding on any next steps”.
    Read full story
    Source: Legal Futures, 2 October 2019
  10. Patient Safety Learning
    Eight in ten hospital chief executives fear their wards will be unable to cope within a year, amid a growing social care crisis. 
    A damning report today says most of those running NHS trusts are worried about short staffing and a lack of investment in services to keep the elderly out of hospital. Six in ten trust chief executives and chairmen said a lack of doctors and nurses is endangering decent patient care, with almost 100,000 staff vacancies across the NHS. Eight in ten of those running hospitals said they feared they would not be able to cope with demand within the next 12 months.
    The report by NHS Providers, which represents trusts, warned of deteriorating performance across hospitals, with key targets repeatedly missed.
    Read full story
    Source: The Telegraph, 8 October 2019
     
  11. Patient Safety Learning
    Many patients with Parkinson’s disease say they are not always given their drugs on time when in hospital, leaving some unable to walk or talk, according to the charity Parkinson's UK. Hospitals were too often unsafe for people with the disease, leaving them scared of ending up there.
    Almost two in three people with Parkinson’s do not always get their medication on time while receiving inpatient care, according to the charity’s research.
    Of the 700 patients questioned between May and July this year, 78% said their health had suffered as a result of poor medication management in hospital. Setbacks included tremors, anxiety and losing the ability to walk or talk.
    Lloyd Tingley, the Parkinson's UK senior policy and campaigns adviser, said: “It’s clear that hospitals aren’t always the safest places for people with Parkinson’s, with many sharing with us that they’re terrified of ever having to be admitted.”
    Read full story
    Source: The Guardian, 8 October 2019
  12. Patient Safety Learning
    There is a "very long way to go" before maternity services at Cwm Taf health board can be declared safe, an independent review panel has said.
    The panel was appointed after a damning review earlier this year prompted by the death of a number of babies. It also revealed it would review more than 100 extra cases between 2016 and 2018 where it believed lessons could be learnt, although not all were serious.
    However, it said the health board was beginning to make improvements.
    In April, a review led by the Royal College of Gynaecologists unearthed a catalogue of serious failings and highlighted many distressing examples of where mothers and babies had likely been harmed as a result of poor care. It uncovered failings at the Royal Glamorgan Hospital in Llantrisant, Rhondda Cynon Taff, and Prince Charles Hospital in Merthyr Tydfil.
    Overall maternity services were described as "dysfunctional" and way below acceptable standards.
    Read full story
    Source: BBC News, 8 October 2019
  13. Patient Safety Learning
    Dr Suzette Woodward describes in her latest book a more positive approach to patient safety that seeks to learn how things normally happen in order to understand why they failed in that instance.
    "The book aims to provide a significantly more positive approach to patient safety because it moves people away from focusing people on their shortcomings, which doesn’t enable learning, it in fact impairs it.  It also moves us away from spending all of our time identifying failure as we see it and giving people feedback about how to avoid it, telling them to stop making mistakes."
    "The book also provides examples of how we can move from the rhetoric to action including the extremely useful methods for how we can study work-as-done and the adjustments and adaptions people make every day."
    Read full story (paywalled)
    Source: HSJ, 7 October 2019
  14. Patient Safety Learning
    A  national campaign aimed at raising awareness of speaking up is running throughout October.
    Speak Up Month, led by the National Guardian's Office (NGO), aims to increase NHS organisations' commitment to fostering a strong speaking up culture and make Freedom to Speak Up (FTSU) guardians more visible.   
    There is a FTSU guardian available in each NHS trust in England, who can support staff to speak up. Last year 11,958 cases were raised to FTSU guardians.
    The NGO has produced a suite of resources that can be used to support Speak Up Month in your organisation. You can also follow the conversation throughout the month on Twitter, by searching #SpeakUptoMe. 
    Read full story
    Source: NHS Employers, 30 September 2019
  16. Patient Safety Learning
    Mental health patients are at risk of suicide because so many of the units they are treated in are dangerously decrepit, say NHS chiefs.
    Crumbling old buildings are unsafe as they offer opportunities for mentally vulnerable people with conditions such as depression and schizophrenia to try to hang themselves or fall from a height, according to mental health trusts in England.
    New figures show that patient safety incidents in mental health units caused by problems with staffing, facilities or the enviroment in which people are treated have risen by 8%. In all, 19,088 such incidents occurred in 2018-19 compared with 17,693 the year before.
    In a stark warning, NHS Providers, which represents health trusts, categorises the risk to patient safety from “infrastructure failures in mental health trusts” as severe. “Continued under-prioritisation of the mental health estate is having a real impact on patients,” it says. “Mental health trusts continue to be neglected despite clear evidence that critical improvements are required. Mental health trust leaders are increasingly concerned that the lack of investment places their patients at increased risk.”
    Read full story
    Source: The Guardian, 6 October 2019
  17. Patient Safety Learning
    Last week two nurses lost their lives while driving home from work.
    Kerrie Browne, a 26-year-old nurse working at University Hospital Kerry in Tralee, died in a road traffic collision Wednesday morning. It is understood she was on her way home after finishing her night shift when the accident occurred on the N21 at Meenleitrim, Castleisland.
    The news comes only hours after the death of another young nurse, Laurie Jones, from Wales.
    Tributes to both the young nurses have filled social media alongside calls for health services to take urgent action to ensure there are no more deaths. One registered nurse said; “Sometimes I am so tired I don’t remember how I get home”.
    Read full story
    Source: Nursing Notes, 3 October 2019
  18. Patient Safety Learning
    A Scottish mum has made an emotional plea to other parents to push for blood tests for their children if they feel ‘something isn’t right’ after her son’s leukaemia symptoms were dismissed numerous times by doctors.
    Jayke Steel, aged 5 years, was diagnosed with acute lymphoblastic leukaemia (cancer of the blood) in February after months of being ill.
    His mum Cara took him to the doctor on various occasions but time and time again she was told he was fine and it was “probably just a virus”.
    When he started getting night sweats,  instead of the doctor Cara him to Forth Valley Hospital where they ran tests and said they believed he was suffering from leukaemia.
    “He was then transferred to Glasgow’s Queen Elizabeth Hospital where they immediately took a bone marrow test which showed he definitely had leuklaemia."
    Read full story
    Source: The Scotsman, 15 September 2019
  19. Patient Safety Learning
    Dozens of residents and staff at a care home have been diagnosed with the latent form of tuberculosis (TB) after a nurse was found to have the disease.
    Tests are being carried out at The Grange in Gloucestershire to see if any of the people diagnosed have developed the active form of the infection.
    Public Health England (PHE) said the nurse had since been treated and was no longer infectious.
    Read full story
    Source: BBC news, 3 October 2019
  20. Patient Safety Learning
    An NHS cancer hospital has such crumbling buildings, out-of-date equipment and staffing problems that patients’ safety and quality of care are at risk, a report for health service bosses has warned.
    Patients at the Mount Vernon Cancer Centre who are acutely unwell or dying are receiving substandard care because it lacks the medical expertise and facilities needed to manage them properly, and its services need to be moved, an inquiry has found.
    The group of experts who undertook the urgent review on behalf of NHS bosses have concluded that Mount Vernon has been neglected for so long that it can no longer operate safely as an important regional centre of cancer care, is unviable and as a result its services need to be moved and rebuilt from scratch elsewhere.
    “Maintaining safety of patients cannot be guaranteed in the near future. Status quo is not an option. There is a need for urgent action. Current estate is not fit for purpose, particularly ward buildings for acutely unwell and end of life inpatients,” the report says.
    Read full story
    Source: The Guardian, 3 October 2019
  22. Patient Safety Learning
    “Little progress” has been made improving patient safety in the NHS over the past 20 years, said the Chief Inspector of Hospitals at the Care Quality Commission (CQC). 
    Professor Ted Baker yesterday revealed he receives between 500 and 600 reports of “never events” a year, incidents that are wholly preventable whatever the circumstances.
    This includes an occasion where surgeons operated on the wrong eye of a patient.
    Speaking at Patient Safety Learning's annual conference, he said that hospital managers routinely hide evidence from the CQC, because they regard the organisation as out to blame them.
    The chief inspector called for a fundamental change in culture whereby NHS bosses drove safety improvements for their own sake, rather than in order to pass an inspection.
    Read full story
    Source: The Telegraph, 2 October 2019
  23. Patient Safety Learning
    New rules will mandate trusts to supply references when NHS directors are given a new job, in a bid to stop the so-called “revolving door” for those who have failed.
    Officials at the Department of Health and Social Care are working on the proposal, originally made by Tom Kark QC in his report to the department, published in February, on the fit and proper person test regulations.
    Speaking at Patient Safety Learning's Annual Conference in London yesterday, Mr Kark, said he had been informed earlier this week that government had now accepted his recommendation for mandatory references.
    Read full story (paywalled) 
    Source: HSJ 2 September 2019
  24. Patient Safety Learning
    Mental health charity, Mind, have found in their annual survey that people are being prescribed medication for mental health issues without being told of the side effects.
    In response, the charity is calling for more mental health training to be made available for GPs. 
    Mind’s Big Mental Health Survey, asks people currently battling with mental health issues to disclose experiences of care and services they have received. More than 12,000 participants found that, when prescribed new medication, only 21% said that they were definitely given an explanation about the potential side effects. It showed that 50% of people didn’t receive enough information about the purpose of any new medication.
    More than 40% of all doctors’ appointments are related to mental health, yet GPs receive no mandatory, practise-based training.
    Mind wants GPS to have a wide range of training available to them, ensuring they have the confidence to provide quality support for those struggling with mental health.
    Read full story
    Source: National Health Executive, 2 October 2019
  25. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) have started a new national investigation looking into medication omission in mental health hospitals.
    It was launched after they were notified by the parent of a young adult service user with a learning disability that he was regularly not offered prescribed medication whilst on a long-stay mental health ward.
    The investigation will focus on information transfer within the prescribing and administration of medication in mental health hospitals to reduce omissions.
    Follow the progress on the medication omission in mental health hospitals investigation page.
    Source: HSIB, 30 September 2019
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