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Patient Safety Learning

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  1. 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
  2. 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
  3. 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    An NHS cancer hospital has such crumbling buildings, out-of-date equipment and staffing problems that patients’ safety and quality of care are at risk, a report for health service bosses has warned.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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  15. 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
  16. 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
  17. 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
  18. 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
  21. 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
  22. 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
  25. 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

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