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Patient Safety Learning

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  2. 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
  4. Patient Safety Learning
    Initiatives to increase staff engagement and make leadership teams more approachable have helped to improve NHS trusts’ ratings from the health and social care watchdog, a report by NHS Providers has found.
    Trusts’ performance has gradually improved, showed the results of inspections by the Care Quality Commission (CQC). In 2014, the year that the CQC began rating trusts, 24 of 35 trusts inspected (68%) were designated “requires improvement” or “inadequate.” Five years later, most of the 224 trusts inspected (59%) were rated “good” or “outstanding.”
    Read full story (paywalled)
    Source: BMJ, 10 October 2019
  5. Patient Safety Learning
    This summer was the worst for A&E waiting times in England since the four-hour target was introduced.
    Analysis by BBC Newsnight and the Nuffield Trust found an average of 86% of patients were admitted, transferred or discharged from A&E within four hours in the six months to September.
    This is the worst performance in that period since the 95% target was brought in in 2004.
    Doctors warned that the system was "running out of resilience" and that winter in A&Es was going to be "really difficult".
    In September, there were 41,000 more people treated in A&Es within four hours, but there were 64,921 patients waiting more than four hours from decision to their actual admission to further care. Of these patients, 455 waited more than 12 hours. This is a 195.5% increase from the previous year. These are known as trolley waits, because patients are left on trolleys in temporary waiting areas while a bed is found.
    "Lying on a trolley is not good for you in any way," said Dr Katherine Henderson, President of the Royal College of Emergency Medicine. "We know these patients can suffer harm because they're in the department for so long."
    Read full story
    Source: BBC News, 10 October 2019
  6. Patient Safety Learning
    One in four patients with secondary breast cancer had to visit their GP three or more times before they got a diagnosis, a survey suggests.
    The breast cancer charity, Breast Cancer Now, said there should be more awareness that the disease can spread to other parts of the body. In the UK, 35,000 people are living with the incurable form of the disease.
    GPs said they were doing their best for patients but symptoms could be difficult to spot.
    Breast Cancer Now said it was "unacceptable" that some people whose cancer had spread were not getting early access to treatments which could alleviate symptoms and improve their quality of life.
    Prof Helen Stokes-Lampard, from the Royal College of GPs, called for GPs to have better access to the right diagnostic tools and training to use them.
    Read full story
    Source: BBC News, 11 October 2019
  7. 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
  9. 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
  10. 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
     
  11. 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
  12. 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
  13. 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
  15. 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.  
  16. 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
  17. 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
  18. 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
  19. 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
     
  20. 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
  21. 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
  22. 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
  24. 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
  25. 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

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