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Patient Safety Learning

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  1. Patient Safety Learning
    The Royal College of Psychiatrists has called for a full public inquiry to uncover what is "repeatedly going wrong" in mental health facilities in the North East of England. It follows a BBC Panorama documentary which appeared to show patients at Whorlton Hall being abused.
    A worker at Darlington's Newbus Grange, which is also run by Cygnet Health Care, was also jailed for abuse.
    The college said it had written to the secretary of state.
    The Care Quality Commission (CQC) has been reviewing six facilities run by Cygnet in the North East.
    Read full story
    Source: BBC News, 2 October 2019
  2. Patient Safety Learning
    Patients' lives are being put at risk at a short-staffed A&E department where a man died amid a series of failings, coroner has said.
    John Shrosbree, 72, died a week after arriving "clearly unwell" at Milton Keynes Hospital, a report found. The seriousness of his illness was not recognised and he went into cardiac arrest, suffering brain damage, coroner Tom Osborne said.
    Hospital bosses said they had made changes to increase staffing levels.
    Mr Osborne, who oversaw the inquest into Mr Shrosbree's death, said it became clear during evidence that problems in the department were mainly the result of a lack of staff.
    "I was told that staff shortages occur on a daily basis," he said. "I believe that as a result lives of the citizens of Milton Keynes are being put at risk and the problem should be addressed as a matter of urgency."
    Read full story
    Source: BBC News, 3 October 2019
  3. Patient Safety Learning
    Today, we are proud to announce the official launch of the hub, our shared learning platform for patient safety.
    We have been hard at work since launching the hub in beta in July, continuing to develop and improve the platform. Now, the hub is officially ready to be used by everyone committed to improving safety – patients and their families, clinicians, patient safety experts, and health and social care organisations.
    the hub has been designed with clinicians, patient safety experts and patients following research by Carl Macrae, Professor of Organisational Behaviour and Psychology at Nottingham University Business School and a renowned specialist on patient safety.
    the hub will be a crucial online repository for sharing different experiences and perspectives of what has worked well, as well as case studies, research papers, blogs, investigation reports, policy guidance and toolkits. It will provide a platform where people can ask questions, seek advice and share ideas to improve patient safety.
    Registration and use of the hub are free.
    Help us work towards the patient-safe future by joining the hub, sharing your learning and hearing valuable insight from others in health and social care.
    Join the hub today
  4. Patient Safety Learning
    Every year, mental health trusts spend millions of pounds employing lawyers to represent them at inquests, where they could be found to be at fault. The relatives of those who have died, however, often get no legal aid and have to stand up and face those lawyers alone. Becky Montacute describes her bid to ensure that the lessons from her mother's death were learned.
    Read full story
    Source: BBC News, 1 October 2019
  5. Patient Safety Learning
    The NHS Long Term Plan included suggested changes to the law to help implement the Plan.  In Spring, NHS staff, partner organisations and interested members of the public were invited to give their views on the proposals.
    The NHS has published its response to the views it received during engagement and set out its recommendations to Government and Parliament for an NHS Bill. This Bill could help deliver improved patient care by removing barriers and promoting collaboration between NHS organisations and their partners.
    Read the NHS’s recommendations to Government and Parliament for an NHS Bill
    Source: NHS, 26 September 2019
  6. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) latest report highlights that mislabelling of blood samples could pose a deadly risk to patients.
    National data indicates there were 792 ‘wrong blood in tube’ near misses (where the error was spotted in time and no patient suffered harm) relating to blood transfusion samples, in 2018 across England.
    The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death. 
    Dr Stephen Drage, HSIB Director of Investigations and ICU consultant, said: “Millions of blood tests are carried out across the NHS each year, from GP surgeries to large teaching hospitals. Most happen without incident but when it does go wrong it could represent a catastrophic outcome for patients, families and staff."
    Read the full report
    Source: HSIB, 26 September 2019
  8. Patient Safety Learning
    Dr Julia Patterson of campaign group EveryDoctor tells why she quit health service "cut back to its very bones". 
    “Doctors love their jobs, and most wouldn’t do anything else,” she said. “It’s our vocation to care for our patients. However, the level of stress endured by frontline NHS staff is unbelievable. Understaffing leaves doctors feeling isolated and stretched. There is often pressure to take on more patients, to work extra shifts, to stretch themselves thinner and thinner.”
    New findings shared exclusively with the Observer by legal support service the Medical Protection Society (MPS) confirm the deep discontent in Britain’s medical profession. It has found that 52% of doctors working in the UK are dissatisfied with their work-life balance, 46% feel guilty about taking time off, and almost 40% believe their employer does not give them the support they need to do their job well.
    Read full story
    Source: The Guardian, 29 September 2019
  9. Patient Safety Learning
    NHS Highland has revealed that it will have “clear milestones” prepared for its November board meeting as part of its action plan to deal with bullying within the organisation. That is according to Human Resources Director Fiona Hogg, on the long-awaited plan that was called for in an independent report by John Sturrock QC into bullying allegations.
    The human resources department will soon share details of how the board will deal with the issue. Ms Hogg said: “Our plan from the November board meeting onwards is that it will contain an update on progress, but it will also include the revised action plan.
    The move is likely to be welcomed by whistle-blowers and victims of bullying who have been calling for it for more than a year.
    Read full story
    Source: Strathspey & Badenoch Herald, 26 September 2019
  10. Patient Safety Learning
    Plummeting learning disability student nurse numbers are leaving the specialty on the “verge of collapse”, it was warned today. Fears about the future of learning disability nursing were raised during the second annual Nursing Times Workforce Summit last week.
    Professor Mark Radford, Deputy Chief Nursing Officer for England and soon-to-be Chief Nurse at Health Education England, revealed that only around 260 learning disability nurses were expected to graduate this year – almost half the figure from previous years.
    NHS Employers Chief Executive Danny Mortimer also outlined his fears about the learning disability nurse workforce during the panel discussion. He said: “The biggest areas of risk in nursing right now are mental health and learning disability nursing. Learning disability nursing in particular is on the verge of collapse educationally and we have do some urgent things to redress that balance.”
    Read full story
    Source: Nursing Times, 25 September 2019
  11. Patient Safety Learning
    NHS hospitals are going back to the future to help patients with dementia by decorating their wards, rooms and corridors in 1940s and 1950s style – creating a calming, familiar environment which can help jog memories, reduce anxiety and distress.
    With ageing well and caring for people with dementia both key priorities in the NHS Long Term Plan, hospitals across the country have revamped their dementia ward decor, with innovations ranging from a ‘memories pub’ to 1950s style ‘reminiscence rooms’ and even a cinema booth where patients can watch old films.
    Welcoming the innovations, Alistair Burns, National Clinical Director for Dementia and Older People’s Mental Health for NHS England and NHS Improvement said: “Hospital can be a frightening place for many people but can prove a bigger challenge for people with dementia who might feel more confused and agitated in an unfamiliar environment. Having a dementia-friendly place to stay may help these patients adjust better to their surroundings, lessen the likelihood of falls and reduce their reliance on medicine."
    Read full story
    Source: NHS England, 24 September 2019
  14. Patient Safety Learning
    A no-deal Brexit presents risks to the NHS and care homes despite extensive government planning, a watchdog says. The National Audit Office (NAO) praised the government for the "enormous amount of work" that had been done but said there were still "significant" gaps.
    The extra shipping capacity government was buying to bring medicines into ports other than Dover may not be completely ready by 31 October. 
    And there was no clear evidence the care sector was ready, the NAO said. The government has arranged the stockpiling of supplies for the NHS. But for the care sector, which is fragmented in that it relies on 24,000 companies to provide services, no central arrangement has been made to stockpile equipment and supplies, such as syringes and needles, most of which come from or via the EU.
    When it comes to medicines, however, the supply of which has been organised for both the NHS and care sectors, the report acknowledges the work that has been done.
    Read full story
    Source: BBC News, 27 September 2019
  15. Patient Safety Learning
    If ever there were an industry that could reap the benefits of artificial intelligence (AI), it is healthcare. The adoption of this technology to actually make medicine better is obvious. However, with this adoption comes a slew of ethical issues. With AI, there is always a human consequence beyond the tech storyline.
    Neil Raden suggests there are two storylines to consider: the usefulness of the application, and the ultimate effect, often unintended, on people.
    Read full article
    Source: Diginomica, 19 September 2019
  17. Patient Safety Learning
    The Royal Pharmaceutical Society (RPS) in Scotland has called on the Scottish Government to give all pharmacists read and write access to patient records.
    Chair of the RPS in Scotland, Jonathan Burton, said: “World Pharmacists Day is an opportunity to celebrate the vital role of pharmacists at the forefront of healthcare.  Pharmacists across Scotland are already providing high-quality patient care, but the service could be even better if all pharmacists had access to the patient record."
    Most community pharmacists do not have access to even basic information, despite performing an increasing role in providing NHS services both in and out of hours. Mr Burton continued: "It’s time the Scottish Government enabled all pharmacists to access patient health records so that, with patient consent and in appropriate circumstances, they have all the information they require to provide the safest and highest quality of care for patients in a timely and accessible manner.’’
    Read full story
    Source: Royal Pharmaceutical Society, 25 September 2019
  18. Patient Safety Learning
    Today millions of pharmacists worldwide will celebrate World Pharmacists Day, this year themed “safe and effective medicines for all.”

    The annual day is used to highlight the value of the pharmacy profession to stakeholders and to celebrate pharmacy globally. It was originally adopted in 2009 at the World Congress of Pharmacy and Pharmaceutical Sciences.
    The theme for 2019 aims to promote pharmacists’ crucial role in safeguarding patient safety through improving medicines use and reducing medication errors.
    “Pharmacists use their broad knowledge and unique expertise to ensure that people get the best from their medicines. We ensure access to medicines and their appropriate use, improve adherence, coordinate care transitions and so much more. Today, more than ever, pharmacists are charged with the responsibility to ensure that when a patient uses a medicine, it will not cause harm”, says International Pharmaceutical Federation (FIP) President Dominique Jordan.
    Watch Dominique Jordan's video
    Source: FIP, 25 September 2019
  19. Patient Safety Learning
    Inspectors have found 28 privately run mental health units to be “inadequate” in the past three years, prompting fears that vulnerable patients are receiving poor and unsafe care.
    The disclosure of such widespread substandard care in mental health facilities run by non-NHS providers has prompted psychiatrists to call for a public inquiry to investigate.
    Read full story
    Source: The Guardian, 25 September 2019
  20. Patient Safety Learning
    Serious failings have been found at an NHS trust which performed "unacceptably delayed" and unnecessary surgery on a bladder cancer patient.
    Denis Harrison, 62, died in August 2017 after waiting six months for surgery at Warrington and Halton Hospitals NHS Foundation Trust. The Parliamentary and Health Service Ombudsman (PHSO) said the trust had "failed to act with any urgency".
    Mr Harrison's wife said the couple faced "severe mental anguish" waiting.
    The PHSO said it was not possible to know whether earlier surgery would have saved his life, but he "was not given the best possible chance of survival".
    Read full story
    Source: BBC News, 25 September 2019
  21. Patient Safety Learning
    Planned Caesarean delivery can be the safest option for women who have had a Caesarean in the past, according to new research in PLoS Medicine. Attempting a vaginal birth was linked with a small but increased chance of complications for mother and baby compared with repeat Caesareans.
    The findings come from more than 74,000 births in Scotland.
    Experts say mums-to-be should be offered a choice of how to deliver – natural or Caesarean – when possible.
    Read full story
    Source: BBC News, 25 September 2019
     
  22. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) has started a national investigation looking into insulin prescribing and administration in hospitals.
    It was launched after a patient was administered an overdose of concentrated insulin while under the care of an acute hospital. 
    The investigation will focus on factors which compromise safety when health professionals administer concentrated insulin through insulin pen devices.
    Read full story
    Source: HSIB, 24 September 2019
  23. Patient Safety Learning
    "If we truly believe in a just culture for everyone and the benefits that can bring for patient safety, it has to give equal importance to being fair to patients and families as well as to staff, and inform practice and policy at every level," says James Titcombe, Peter Walsh and Cicely Cunningham in a recent commentary in HSJ. 
    Although there is much to celebrate in the increased focus on 'just culture' – not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community – from the perspective of patients and families, the narrative to date can seem somewhat one sided. 
    From the perspective of those affected, the current system of variable quality local investigations, inquests, litigation, complaints and interactions with a host of other regulatory bodies and organisations can feel designed in such a way that ensures further harm is inevitable.
    Read full article
    Source: HSJ, 17 September 2019
     
  24. Patient Safety Learning
    The shortage of nursing staff in England is putting patient safety at risk, the Royal College of Nursing (RCN) has warned, as it launched a new campaign to encourage the public to speak out about the impact of England’s 40,000 nurse shortage. 
    The RCN’s campaign calls for legislation to be brought forward in England to help address the nursing workforce crisis. Earlier this year, nurses and support workers in Scotland secured new legislation on safe staffing levels, and a nurse staffing law was introduced in Wales in 2016.
    The 2013 Francis Report on failings of care at Stafford Hospital concluded that the main factor responsible was a significant shortage of nurses at the hospital.  Nurse numbers at NHS acute Trusts across England then increased as managers took steps to try to prevent similar scandals in the future. But a new analysis by the RCN shows that for every one extra nurse NHS acute Trusts in England have managed to recruit in the five years since 2013/14, there were 157 extra admissions to hospital as emergencies or for planned treatment. 
    Commenting on the campaign launch, Dame Donna Kinnair, RCN Chief Executive and General Secretary, said: “Today we’re issuing a stark warning that patient safety is being endangered by nursing shortages.  Staffing shortfalls are never simply numbers on a spreadsheet – they affect real patients in real communities."
    Read full story
    Source: Ekklesia, 22 September 2019
  25. Patient Safety Learning
    Health Secretary Jeane Freeman announced the launch of a Joint Learning Fellowship programme between Ireland and Scotland, as the NHS in Scotland reels from one crisis to the next.
    Ms Freeman and the Irish Health Minister, Simon Harris, announced the initiative, which will offer two three-month placements for Scottish and Irish senior policymakers or health service workers so they can learn more about what works in each system.
    However, the move came on the same day The Times reported that Glasgow's 'super-hospital' was permitted to open despite the ventilation systems failing to meet the necessary safety standards.
    Outbreaks of infection which are thought to have spread through the ventilation system at the Queen Elizabeth University Hospital (QEUH) have led to the deaths of two patients.
    Read full story
    Source: The Scotsman, 20 September 2019
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