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Patient Safety Learning

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  1. Patient Safety Learning
    Teams that face rudeness experience a 12% drop in diagnostic and procedural performance.
    University Hospital Southampton NHS Foundation Trust (UHS) has launched the “Reminder to be Kinder” project which was designed to recognise the importance of civility on patient care. The “Reminder to be Kinder” project encourages nurses and allied healthcare professions to be kinder to each other in order to improve patient safety.
    Launched to coincide with World Patient Safety Day, the project will see the introduction of a range of action cards which include reminders to celebrate colleagues’ achievements, thank someone for their work and do something to make life easier for a colleague.
    Juliet Pearce, Deputy Director of Nursing at UHS, said; “The way we interact with each other can have a surprising effect on patient safety,” 
    “People who witness rudeness show reduced performance and are 50% less likely to help others. If a patient was to see this happen, you could understand why they would feel anxious dealing with staff and have less trust in the organisation.”
    Read full story
    Source: Nursing Notes, 19 September 2019
  3. Patient Safety Learning
    The Chief Executive of NHS in England has called on all social media firms to crack down on potentially harmful material after two of the biggest sites confirm they plan to act on health service demands for action.
    Facebook and Instagram have announced that they will remove posts promoting ‘miracle’ cures and get-slim-quick products, which are known to have limited benefits with possible damaging side-effects.
    The move follows a series of requests from health service chiefs, including NHS Chief Executive Simon Stevens, to act responsibly and protect users from content that could cause physical or mental harm.
    Read full story
    Source: NHS England, 19 September 2019
  4. Patient Safety Learning
    Over 6,500 nurses in hospitals around California, Arizona, Florida, and Illinois will strike today. The strike will mark the first ever nurse strike in Arizona, and the first hospital registered nurse strike in Florida's history.
    Nurses who are part of the National Nurses United union are asking for better nurse retention and nurse-to-patient ratios. 
    "The strike is first and foremost about patient care and patient advocacy," Dominique Hamilton, a registered nurse at St. Mary's Hospital in Arizona, said. "We want the hospital to invest in the nursing staff, and we want to have more input into the recruitment and retainment of experienced [registered nurses]."
    Read full story
    Source: Business Insider, 
  5. Patient Safety Learning
    Developments in healthcare mean more women and babies are surviving than ever before, a new study has found.
    The report, published by the World Health Organisation and the United Nations Children’s Fund (Unicef), found maternal deaths have decreased by more than a third since 2000. Deaths of children were found to have fallen by almost half in the same time period.
    There was a 56% decrease in deaths of children younger than 15 since 1990 – from 14.2 million deaths to 6.2 million in 2018. 
    But the research still found a pregnant woman or a newborn baby dies every 11 seconds from causes that are predominantly preventable and avoidable – with 2.8 million estimated to die every year.
    Read full story
    Source: The Independent, 19 September 2019
  7. Patient Safety Learning
    Following Boris Johnson's confrontation by an angry father at Whips Cross University Hospital yesterday, a doctor gives anonymous account of chronic understaffing and lack of resources at Whipps Cross. 
    "The hospital is held together only by the hard work and dedication of its healthcare workers but it cannot be sustained for much longer under these pressures."
    "I’m so glad that Omar Salem  said the things he did. He was just telling the truth about what it is like to be on the receiving end of poor staffing levels and under-resourcing."
    "I’ve been thinking about it all day and felt I had to say something because NHS hospitals today can be unsafe places. Whipps Cross is particularly understaffed and under-resourced so people don’t get the care that they need as promptly as they need."
    Read full story
    Source: The Guardian, 19 September 2019
  8. Patient Safety Learning
    A woman who died after waiting almost two hours for an ambulance was let down by "systemic" failings with a computer call-handling system, a coroner said.
    Daisy Filby, 90, was one of three people who died after delays in receiving care from the South East Coast Ambulance Service (Secamb). Coroner Alan Craze said a human would have "realised what was going on" and prioritised the calls differently. 
    Mrs Filby, from Seaford, died in June 2017 as a result of an "accident contributed to by neglect," Mr Craze concluded at the Hasting's Coroner's Court inquest. "If an ambulance or anybody with or without medical knowledge had been able to reach this poor lady before her death, the situation would have been different," he added.
    Mr Craze said: "The problem is not the actions of any one individual in Secamb Trust. The problem is ultimately systemic and at the heart of the call-taking and decision-making system."
    A spokesman for the ambulance service said: "We are very sorry for the service they received. We have listened very closely to the coroner throughout and we are committed to making further improvements where necessary."
    Read full story
    Source: BBC News, 18 September 2019
  9. Patient Safety Learning
    A public inquiry will be held to examine safety and wellbeing issues at the new children's hospital in Edinburgh and the Queen Elizabeth University Hospital in Glasgow. The inquiry will determine how vital issues relating to ventilation and other key building systems occurred. It will also look at how to avoid mistakes in future projects.
    In January, it was confirmed two patients had died after contracting a fungal infection caused by pigeon droppings at the Queen Elizabeth University Hospital. Health Secretary Jeane Freeman later ordered a review of the design of the building and said there was an "absolute focus on patient safety". 
    Meanwhile, the new £150m Royal Hospital for Children and Young People in Edinburgh has been dogged by delays over health concerns. The hospital was supposed to open in 2017 - but will now not be ready until next autumn at the earliest - after problems with the specification of the ventilation system.
    Scottish Labour's Monica Lennon said the inquiry was "the only way to get to the bottom of this outrageous series of errors". She added: "Children in Scotland are being let down because the hospitals they were promised are not fit for purpose. We have two hospitals built by the same contractor that are mired in controversy, and all the while patients are suffering. The public need to know the truth of what has gone so badly wrong at these two vital hospitals."
    Read full story
    Source: BBC News, 17 September 2019
  10. Patient Safety Learning
    Prime Minister Boris Johnson has been confronted by an angry father at a hospital who told him his baby daughter had nearly died because the ward on which she was treated was “not safe for children” after years of austerity.
    In an encounter caught on camera, Omar Salem said the care given to his seven-day-old daughter at Whipps Cross university hospital, in north-east London, was “not acceptable”. He told the prime minister: “There are not enough people on this ward, there are not enough doctors, there’s not enough nurses, it’s not well organised enough.”
    Salem told Boris Johnson: “My daughter nearly died yesterday. And I came here, the A&E guys were great but we then came down to this ward here and it took two hours and that is just not acceptable. This ward is not safe for children."
    Read full story
    Source: The Guardian, 18 Setpember 2019
  11. Patient Safety Learning
    The British Medical A has outlined its vision for an ‘unsafe’ NHS with a culture of bullying.  
    According to the BMA, doctors are working in hospitals and GP Practices that are hugely understaffed, where bullying and a culture of blame is the norm and where patient care is often unsafe. These are the findings of a year-long study – ‘Caring Supportive Collaborative: Doctors Vision for Change‘ – into the state of the NHS.
    The chair of the BMA Council, Dr Chaand Nagpaul said: “Nine in 10 doctors tell us that staffing levels are inadequate and that they work in environments where they fear the toxic combination of ever-increasing demand for services and lack of staff capacity will lead to mistakes."
    “They tell us there is a persistent culture of fear across the NHS, where blame stifles learning, contributing to the vicious cycle of low morale so staff leave and then there’s a problem of recruitment."
    “This unsafe, underfunded environment is as damaging for patients as it is for doctors. Radical change is clearly needed.”
    From the report comes a manifesto, which has today been sent to MPs, as well as the secretary of state for health and social care.
    Read full story
    Source: Practice Business, 17 September 2019
  12. Patient Safety Learning
    NHS governors have called for a police investigation into the urology department of a health service trust following accusations that patients died and were harmed after a string of clinical errors and malpractice. 
    Morecambe Bay NHS Foundation Trust (UHMBT) has now agreed to an external review after dozens of patients, relatives and staff have came forward following the publication of a book by whistleblower surgeon Peter Duffy, which exposed poor care in the unit. 
    The call for a police investigation came at a meeting of the council of governors of the trust earlier this month. Governor Dave Welton told the meeting that the council had “very serious concerns about the shocking revelations.”
    A former theatre nurse has also come forward claiming to have witnessed countless errors made by surgeons, while another healthcare worker said she was now speaking out to prevent further harm to patients.
    Read full story
    Source: BBC News, 16 September 2019
  13. Patient Safety Learning
    The US Senate has an unprecedented opportunity to remove a ban that has stifled efforts to establish a nationwide unique patient identifier. 
    In June, the U.S. House of Representatives passed an amendment that would remove a ban that has stifled efforts to establish a nationwide unique patient identifier. Now, it is up to the US Senate to move this issue forward by rejecting inclusion of outdated rider language in their appropriations bill that prohibits the U.S. Department of Health and Human Services from spending any federal dollars to promulgate or adopt a national patient identifier.
    According to a 2016 study of health care executives, misidentification costs the average health care facility $17.4 million per year in denied claims and potential lost revenue. More importantly, there are patient safety implications when data is matched to the wrong patient and when essential data is lacking from a patient’s record due to identity issues. 
    Read full story
    Source: The Hill, 11 September 2019
     
  16. Patient Safety Learning
    The World Health Organization’s creation of an annual World Patient Safety Day is key to helping raise awareness and focus minds on improving the safe delivery of healthcare. BD fully supports this initiative and is partnering with care providers to ensure patient safety is prioritised, and efforts to reduce avoidable harm are enabled. 
    "Patient Safety is integral to everything we do at BD and we believe it should be at the forefront of everyone’s minds when thinking about healthcare..."
    Read full story
    Source: BD, 17 September 2019
  17. Patient Safety Learning
    Monuments and fountains will be lit up across the globe today to herald the first ever World Patient Safety Day, organised by the World Health Organisation (WHO). 'Speak up for
    patient safety' is the universal call as the spotlight is put on this global health priority. With the supporting strapline that “No one should be harmed in health care” the day brings
    together patients, families, carers, communities, health workers, health care leaders and policy makers to show commitment to patient safety.
    Patient Safety Learning's commitment to patient safety can be found in 'A Blueprint for Action', which we launched earlier this summer, which advocates six evidence-based foundations for action to address the causes of unsafe care. One of the six foundations is shared learning.  At the heart of our commitment to shared learning is the creation the hub, a community where people can share learning about patient safety problems, experiences and solutions.
    Read more about Patient Safety Learning's commitment to patient safety in Chief Executive Helen Hughes' blog, Speaking up for patient safety on World Patient Safety Day
    To mark World Patient Safety Day, Patient Safety Learning has released a series of short videos:
    Patient safety is a purpose of health and social care
    Shared learning for patient safety
    Leadership for patient safety
    On 2 October this year, we will be hosting in London our second annual conference attended by senior health and social care leaders, clinicians, patient safety experts, patients’ groups
    and individuals who have experienced at first hand the traumas of losing a loved one where the quality of care has fallen down. We will also be officially launching the hub.
  18. Patient Safety Learning
    Millions of patients are harmed each year due to unsafe health care worldwide resulting in 2.6 million deaths annually in low-and middle-income countries alone.  Most of these deaths are avoidable. The personal, social and economic impact of patient harm leads to losses of trillions of US dollars worldwide. The World Health Organization (WHO) is focusing global attention on the issue of patient safety and launching a campaign in solidarity with patients on the very first World Patient Safety Day on 17 September.
    Read full story
    Source: WHO, 13 September 2019
  19. Patient Safety Learning
    Hundreds of patients have suffered due to NHS blunders so serious they should never happen, new data shows.
    Some 621 'never events' occurred in NHS hospitals between April 2018 and July this year – the equivalent of nine patients every week, according to data obtained by PA news agency. The figures show doctors have operated on the wrong body parts and left surgical tools (including surgical gloves, chest drains and drill bits) inside patients many times over.
    Rachel Power, Chief Executive of the Patients Association, said: “Wrong site surgery incidents are preventable safety instances that can have devastating consequences for the patient and their family." “People who suffer harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS."
    Professor Derek Alderson, president of the Royal College of Surgeons, said: “While these cases are very rare, never should mean never."
    “NHS staff are there to care for patients, so knowing you have caused harm is incredibly distressing. It is vital that all theatre staff use, and are involved in, the World Health Organisation pre- and post-operative checklist process, as these have been designed to help prevent serious incidents."
    “It is also important that the NHS continues to promote a culture of openness and transparency, both in terms of publishing surgeons’ outcomes and the number of ‘never events’ that, sadly, occur."
    Read full story
    Source: ITV News, 16 September 2019
     
  20. Patient Safety Learning
    Surgeons are retiring early because of back problems caused by modern surgical techniques, experts have warned. 
    Keyhole surgery, where an operation is carried out through a small hole in the patient’s body, has become increasingly common because it helps patients recover more quickly and has less pain, complications and scarring than conventional operations.But in order to carry out the procedures through a tiny opening, surgeons often have to contort themselves into awkward positions for hours at a time.
    Now a new report says one in five surgeons say they will have to retire early because they have developed back injuries from carrying out modern surgical techniques. This could mean patients face even longer waits for operations, thanks to the loss of 4,500 senior doctors, the research suggests. 
    Read full story
    Source: The Telegraph, 15 September 2019
  21. Patient Safety Learning
    The BMA has written to the government to call for new legislation to ensure accountability for safe staffing levels and that “individual clinicians are not blamed when the system places them under unmanageable pressure.”
    The call came as the BMA published a year long study looking at the changes needed to improve care of patients and the working lives of doctors in the NHS, alongside a “manifesto for change” outlining all the recommendations.
    Read full story (paywalled)
    Source: BMJ, 13 September 2019
  22. Patient Safety Learning
    At one time or another, most of us have experienced feeling frustrated by bureaucratic processes, outdated IT systems or unsatisfactory interactions with administrative staff. 
    As in many other parts of our lives, when the administrative aspects of a service seem poor (and when they seem good) it can have a significant impact on how we feel about our experience of using it overall. In the case of healthcare, this often comes at a time when we are already feeling anxious. In some cases, administration can also have an impact on the care we receive – for example, if an appointment is delayed. For these reasons alone (though there are many others) NHS administration is important.
    Despite this, there has been very little research into NHS administration and its impact on service users, and it is not routinely captured in NHS data. The King’s Fund are kicking off a project to explore patients’ experiences of NHS administration in more detail. As a first step, they reviewed a random sample of over 300 comments written on the Care Opinion website between 2016 and 2018.
    This analysis is just the beginning. Over the next few months, The King's Fund will speak to patients and NHS staff to understand the issues around NHS administration in more detail. For more information, see their project page.
    Read full story
    Source: The King's Fund, 13 September 2019
  23. Patient Safety Learning
    Cancer survival in the UK is on the up, but is still lagging behind other high-income countries, analysis suggests.
    Five-year survival rates for rectal and colon cancer improved the most since 1995, and pancreatic cancer the least. Advances in treatment and surgery are thought to be behind the UK's progress.
    But the UK still performed worse than Australia, Canada, Denmark, Ireland, New Zealand and Norway, the study in Lancet Oncology found. Cancer Research UK said the UK could do better and called for more "investment in the NHS and the systems and innovations that support it".
    Read full story
    Source: BBC News, 12 September 2019
  24. Patient Safety Learning
    Pregnancy-related deaths and maternal morbidity continue to rise in the US. A major factor is large areas of the country, 'maternity deserts' have little or no proper maternity care, officials say.
    So 30 health systems are teaming up to implement digital tools and new care models to help close gaps in care for mothers and infants. Those digital solutions include screening tools to identify pregnant women with comorbidities like diabetes and hypertension to intervene earlier and using telehealth to connect expectant mothers to doulas. 
    Read full story
    Source: FierceHealthcare, 12 September 2019
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