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Patient Safety Learning

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  1. Content Article
    Accidents at work and occupational diseases are neither predetermined nor unavoidable – they always have causes. By building a strong prevention culture, these causes can be eliminated and work related accidents, harm and occupational diseases be prevented. 'Vision Zero' is a transformational approach to prevention that integrates the three dimensions of safety, health and well-being at all levels of work. Safe and healthy working conditions are not only a legal and moral obligation – they also pay off economically. International research on the return on investments in prevention proves that every dollar invested in safety and health generates a potential benefit of more than two dollars in positive economic effects. Healthy working conditions contribute to healthy business. The International Social Security Association (ISSA)'s Vision Zero concept is flexible and can be adjusted to the specific safety, health or well-being priorities for prevention in any given context. Thanks to this flexibility, Vision Zero is beneficial to any workplace, enterprise or industry in all regions of the world. The Vision Zero campaign has energised companies and organisations worldwide with the ambition to strive towards a world of work without accidents and illness. Behind every organization stand extraordinarily engaged people, and on these pages we give them visibility.  Vision Zero ambassadors are outstanding individuals from the world of politics, science and sports who are engaged in safety, health and wellbeing. The ISSA has developed a range of resources to support the Vision Zero Campaign and the seven golden rules of Vision Zero.
  2. Content Article
    The aim of the project was to introduce and evaluate a Call for Concern (C4C) service that provides patients and relatives with direct access to the Critical Care Outreach (CCO) team, to give patients and relatives more choice about who they can consult with about their care, and facilitate the early recognition of the deteriorating ward patient. The project involved two phases: a six month pilot phase to evaluate the C4C service for feasibility, and its effects on patients, relatives and the health care teams. a three month phase implementing the C4C service onto two surgical wards to test and evaluate the findings of the feasibility phase in preparation for expansion to all hospital wards. Between 1st Sept 2009 and 23rd Sept 2010, the CCO team received 37 C4C referrals representing 0.5% of total CCO activity. Critical deterioration of a patient was prevented in at least two cases, and the service received positive feedback from patients and relatives. In the words of a relative, C4C provided: ‘…a better quality of care…and…reduces the risk of death.’
  3. Content Article
    Thomas Walters, a Senior Research Nurse from London, describes his experience of going back to ICU and how that’s renewed his appreciation for research. Part of the National Institute for Health Research (NIHR) COVID-19 Research Voices series.
  4. News Article
    The development of separate emergency units to help acute trusts manage demand during the covid pandemic may risk increasing “discrimination” against mental health patients, a royal college has warned. In a report shared with HSJ, the Royal College of Psychiatrists said separate emergency assessment units being set up by mental health trusts offered a calmer environment for mental health patients and reduced pressure on emergency departments. But the report, based on 54 survey responses from liaison psychiatry teams, also warned there was a “potential to increase the stigmatisation of mental illness by emergency department staff”. It added: “Within a general hospital there is a risk that prejudicial attitudes amongst staff translate into discriminatory behaviour towards patients. The provision of a separate mental health emergency assessment facility on another site may reinforce the erroneous view that the assessment and management of mental health problems is not a role for an emergency department.” Read full story (paywalled) Source: HSJ, 11 August 2020
  5. News Article
    The deaths of hundreds of NHS and social care workers infected with coronavirus are under investigation by medical examiners, The Independent has learnt. Ministers have asked medical examiners in England and Wales to review all deaths of frontline health and social care staff infected with the virus to determine whether the infection was caught as a result of their work. The review, which started last month, is likely to cover more than 620 deaths including nurses, doctors and care home staff across England and Wales, since the beginning of March. It could trigger a number of investigations by hospitals, the Health and Safety Executive, and coroners into the protection, or lack of, for staff during the pandemic when many hospitals ran out of protective masks and clothing for staff. Hospitals have already been ordered to risk assess workers who may be more susceptible to the virus, such as those from a black and minority ethnic backgrounds or those with existing health conditions. Read full story Source: The Independent, 12 August 2020
  6. News Article
    A new study has highlighted the number of NHS staff who can be infected with coronavirus but be completely unaware they are a risk to their colleagues and patients. The research by doctors at University College London Hospitals (UCLH) found a third of staff working in two maternity departments at UCLH and St George’s Hospital tested positive for the virus but had no symptoms. Overall, one in six staff who had not previously been diagnosed with the virus were tested for COVID-19 antibodies and were found to be positive for infection. Prof Keith Neal, emeritus professor of epidemiology of infectious diseases at the University of Nottingham, who was not involved in the research, said: “Asymptomatic healthcare workers with COVID-19 pose a risk of spreading the virus depending on the personal protective equipment in use. We know many cases were acquired in hospital. “Regular testing of healthcare workers is clearly warranted.” Read full story Source: The Independent, 12 August 2020
  7. News Article
    Doctors are seeing a rise in people reporting severe mental health difficulties, a group of NHS leaders says. It follows a more than 30% drop in referrals to mental health services during the peak of the pandemic. But there are predictions that the recent rise will mean demand actually outstrips pre-coronavirus levels - perhaps by as much as 20%. The NHS Confederation said those who needed help should come forward. But the group, which represents health and care leaders, said in a report that mental services required "intensive support and investment" in order to continue to be able to help those who needed it. Read full story Source: BBC News, 12 August 2020
  8. Content Article
    Stewart Munro, Managing Director of Pentland Medical Ltd, highlights some of the current procurement problems within the NHS and explains why this needs to change if we want to improve patient and staff safety.
  9. Content Article
    In this article Patient Safety Learning responds to a recent news story about an Ambulance Service reviewing their defibrillators after receiving two warnings from Coroners Prevention of Future Deaths reports. It considers the specific circumstances around this and how this case highlights a broader problem of failing to harness learning from these coroners reports for patient safety.
  10. Content Article
    Pippa Kent is one of those people who were told that from 1 August they no longer needed to shield to protect themselves from the coronavirus. While you might assume that, having been trapped inside her house for the past 18 weeks, she would embrace this newfound freedom with enthusiasm, the reality remains far from it. For those whose pre-existing medical conditions greatly increase the risk from COVID-19, there, naturally, is hesitation to embrace this sweeping change. Read Pippa's blog, published in the Guardian, on her first trips out and the fears she felt.
  11. News Article
    Over 8 out of 10 (84%) of members of the Medical Protection Society thinks a face covering should be mandatory when attending any healthcare setting. This was the finding of a survey including 562 of the GP indemnity providers' members, out of which 473 said masks should be mandated by law as they are on public transport and in shops. Effective from 13 July, PHE guidance says all clinical and non-clinical staff as well as patients should wear a face mask in areas of GP practices that cannot be made 'Covid-secure' through social distancing, optimal hand hygiene, frequent surface decontamination, ventilation and other measures. But NHS England has said GPs cannot refuse to treat patients who present at the practice without a face covering because they are not legally required to wear them. In response to its member survey, MPS has urged political leaders to ‘reconsider’ this decision. Medicolegal lead for risk prevention Dr Pallavi Bradshaw stressed that ‘it cannot be right’ for frontline healthcare workers to be put at ‘unnecessary risk by patients who refuse to wear a face mask’. Read full story Source: Pulse, 8 August 2020
  12. News Article
    Health Secretary Matt Hancock has announced one of the world’s largest comprehensive research studies into the long-term health impacts of coronavirus on hospitalised patients. Backed by an award of £8.4m in funding by the Government, through UK Research and Innovation (UKRI) and the National Institute for Health Research (NIHR), the study is expected to include around 10,000 across the UK and will support the development of new measures to treat NHS patients with coronavirus. The study will be led by the NIHR Leicester Biomedical Research Centre, a partnership between the University of Leicester and University Hospitals of Leicester NHS Trust and will draw on the expertise of a consortium of leading researchers and doctors from across the UK. They will assess and publish findings on the impact of COVIDd-19 on patient health and their recovery, including looking at potential ways to help improve the mental health of patients hospitalised with the virus and how individual characteristics such as gender and ethnicity influence recovery. Patients on the study from across the UK will be assessed using techniques such as advanced imaging, data collection and analysis of blood and lung samples, creating a comprehensive picture of the impact COVID-19 has on longer-term health outcomes. The findings will support the development of new strategies for clinical and rehabilitation care, including personalised treatments based on the particular disease characteristics that a patient shows, to improve their long-term health. Read full story Source: National Health Executive, 10 August 2020
  13. News Article
    Boris Johnson has said the government will allocate £300m to NHS trusts to upgrade A&E facilities ahead of a potential spike in coronavirus cases this winter. The funding, which will be split between 117 trusts, comes alongside attempts to reassure members of the public that it is safe to visit A&E departments during the COVID-19 pandemic. “Thanks to the hard work and tireless efforts of NHS staff throughout the pandemic, our A&Es have remained open for the public,” the prime minister said in a statement. “It is vital that those who need emergency treatment this winter access it, and for those who remain concerned about visiting hospitals, let me assure you that the NHS has measures in place to keep people safe.” Hospitals will be able to use the funding to expand waiting areas and increase the number of treatment cubicles to boost A&E capacity, while social distancing rules and hygiene measures are in place to protect patients from COVID-19. Read full story Source: The Independent, 10 August 2020
  14. News Article
    Dozens of surgeons have reported being told by the NHS employer to stop discussing shortages of personal protective equipment (PPE) during the coronavirus crisis. The Confederation of British Surgery (CBS) said almost 70 surgeons working in major hospitals around the country had been warned off discussing a lack of PPE by their trust. A third of surgeons said the supply of PPE was inadequate at their hospital, with many complaining of inconsistent guidance, rationing of supplies and poor quality PPE when it was available. When asked if their concerns were dealt with satisfactorily, nearly a third said they were not addressed, or not effectively. A survey of 650 surgeons by the union found many were now considering changes to the way they worked as a result of the crisis – with more than half, 380, saying they would be avoiding face-to-face meetings with patients in the future. More than 40 surgeons, around 7%, said they were now considering leaving surgery altogether. Read full story Source: The Independent, 10 August 2020
  15. Content Article
    It has become received wisdom that the NHS struggles to adopt digital innovation, with many government reports and research papers highlighting barriers to the spread of technology. Yet during the COVID-19 pandemic, many NHS providers have moved services online at astonishing pace. This paper, commissioned by the Academic Health Science Network, looks at four digital innovations in health services from the UK and the Nordic countries: the TeleCare North programme, which provides remote treatment for people with chronic obstructive pulmonary disease (COPD); the Patients Know Best portal and electronic health record; remote diabetes monitoring for children at Helsinki University Hospital; and the Huoleti app that connects patients with a support network.
  16. Event
    until
    COVID-19 has transformed the delivery of health care services, bringing about unprecedented change in very little time. Changes that were thought to require years of careful planning happened in many cases overnight, with technology proving to be a key factor in supporting patients and staff in the delivery of care. In this four-day event, the King's Fund are bringing together top experts from the NHS and other parts of the digital health system to discuss the lessons from the COVID-19 pandemic. From the benefits of emergency data gathering in order to work on new treatments, to the transfer of primary care services online, COVID-19 has been the catalyst bringing about the long-discussed digital revolution. With almost every part of the system shaken by Covid-19, was all digital change positive and what are the challenges still left to tackle? Join to hear the views of NHS and industry leaders who played a central role in bringing about the new digital reality for health care. It will explore how they managed to adapt to the pressing needs of the pandemic, which cutting-edge innovative solutions they wish to retain as the system returns to ‘normal’ and what problems this speedy digital transformation has created. View programme and register
  17. Event
    David Sellu FRCS, distinguished Consultant Colorectal Surgeon, will be joining RSM President Professor Roger Kirby for an extraordinary discussion about his unfair trial, his imprisonment, and his subsequently quashed conviction for Gross Negligence Manslaughter. He will be talking about his highly acclaimed and candid book, Did He Save Lives? A Surgeon's Story, patient safety and the practice of defensive medicine, as well as what the future now looks like for him. In February 2010, David operated on a patient and despite his efforts, the patient died two days later. There followed a sequence of extraordinary events that led to David being convicted of Gross Negligence Manslaughter. He served 15 months in prison and eventually released on licence. His licence to practise medicine was suspended, his career cut short. It was later discovered that David's trial was unfair, and with Dr Jenny Vaughan leading the campaign along with friends, family and colleagues, David won the appeal against his conviction and is now a free man. The shock waves caused by David’s conviction has led more medical professionals to practise defensive medicine. This could have a huge impact on patient care in the future as our population ages and their health needs become more complex. Register
  18. Event
    A panel of cross sector experts will explore how the pandemic has hugely altered the treatment of patients with chronic conditions, and specifically delayed the pain treatments of an estimated 150,000 people. It will discuss how best we can look after the increased number of ‘left behind’ patients requiring pain management, and how we can build clinician understanding and education on the available solutions. It will examine what post-Covid pain management could look like, how we can use technology to appropriately care for complex patients (e.g. taking controlled drugs, needing care at home) and how we can address unmet clinical needs. Register
  19. Community Post
    World Patient Safety Day on Thursday 17 September this year focuses on staff safety. In her latest blog, Eve Mitchell writes about the new impact COVID-19 is having on the mental health and wellbeing of healthcare staff: compassion fatigue has resulted in frontline staff now having to absorb the anger of the public, patients, and their carers. If you have been affected by the issues raised in this blog and want your voice to be heard, please share by replying to the topic below. If you prefer to remain anonymous, please email info@pslhub.org and we will ensure confidentiality. Patient Safety Learning will use such insights to highlight the staff safety issues and call for action.
  20. News Article
    Ambulance chiefs are looking at alternative defibrillators after coroners highlighted confusion over how to correctly use their existing machines. London Ambulance Service (LAS) Trust has received two warnings from coroners since 2016 after the delayed use of Lifepak 15 defibrillators “significantly reduced” the chances of survival for patients, including a 15-year-old boy. Coroners found some paramedics were unaware the machines had to be switched from the default “manual” mode to an “automatic” setting. The first warning came after the death of teenager Najeeb Katende in October 2016. A report by coroner Edwin Buckett said the paramedic who arrived had started the defibrillator in manual mode and did not detect a heart rhythm that was appropriate for administering the device, so it was not used until an advanced paramedic arrived on scene 24 minutes later. The report stated the defibrillator had been started in manual mode but it needed to be switched to automatic to detect a shockable heart rhythm. The coroner warned LAS that further deaths could occur if action was not taken to prevent similar confusion. But another warning was issued to the LAS in March this year, following the death of 35-year-old Mitica Marin. Again, a coroner found the paramedic, who was on her first solo shift, had started the machine in manual mode and had not detected a shockable rhythm. It was suggested this caused a four minute delay in the shock being administered. Coroner Graeme Irvine said this was “not an isolated incident” for LAS and noted the trust had reviewed other cases of delayed defibrillation. They found that the defibrillator’s manual default setting was a “contributing factor” to the delays. Read full story (paywalled) Source: HSJ, 10 August 2020
  21. Content Article
    First used by the US army on combat missions, the after action review is a structured approach for reflecting on the work of a group and identifying strengths, weaknesses and areas for improvement. This NHS Improvement document explains what an after action review and when and how to use it.
  22. Content Article
    In the UK and Ireland men are three to four times more likely to die by suicide than women. Research also tells us that men who are less well-off and living in the most deprived areas are up to 10 times more likely to die by suicide than more well-off men from affluent areas .Middle-aged men in the UK and Ireland also experience higher suicide rates than other groups, a fact that has persisted for decades. The Samaritans carried out in-depth ethnographic interviews with 16 less well-off middle aged men across the UK and Ireland to find out the challenges they faced and the events which lead them to crisis point. The study explored what these men said worked for them when they came into contact with with support services. This is the first of two connected reports. The second report, due to be released later in 2020, will set out recommendations of how services can effectively engage and support men earlier in their lives, before they reach crisis
  23. Content Article
    Findings from the APPG for Whisltblowing's report show that whistleblowing cases continue to have a low success rate, with whistleblowers suffering more and for longer than before, writes Mary Robinson.  Whilst there are laws in place to protect whistleblowers, the overwhelming evidence is that they have failed to address the principal issues they face. Politicians have a duty to confront the most difficult things, including the barriers to justice and the fear of retaliation that make it impossible or futile for people across all sectors to speak up safely. Mary, the Conservative MP for Cheadle and chair of the APPG for whistleblowing, says that a system that works with whistleblowers instead of against them, would serve to protect employees and would empower them to do the right thing. Although the UK was the first in Europe to introduce legislation with Public Interest Disclosure Act 1998, we are in danger of falling behind global best practice. In this blog, Mary proposes and urgent reform of existing legislation and the introduction of an Office of the Whistleblower is needed to reset the gold standard.
  24. News Article
    Up to 750,000 unused coronavirus testing kits are being recalled due to safety concerns. The UK's medicines and healthcare products regulator (MHRA) asked Randox to recall the kits sent out to care homes and individuals. The government said it was a "precautionary measure" and the risk to safety was low. It comes weeks after the health secretary said Randox kits should not be used until further notice. A spokeswoman said: "We have high safety standards for all coronavirus tests. Following the pausing of Randox kits on 15 July, Randox have now recalled all test kits as a precautionary measure." Care home residents or staff with symptoms of coronavirus can continue to book a test, she said. Read full story Source: BBC News, 8 August 2020
  25. News Article
    All NHS hospitals in England have been told to destroy a powerful medicine mistakenly used by staff because its packaging looks the same as another drug. A national safety alert was issued following several incidents, including two deaths of babies, in which patients were inadvertently given a dose of sodium nitrite – which is used as an antidote to cyanide poisoning – rather than sodium bicarbonate. The errors are thought to have been caused by similarities between the labelling and drug packaging used by manufacturers. Now hospitals have been told to check all wards and medicine storage areas for sodium nitrite and to destroy any of the unlicensed product. The drug should only be available in emergency departments and may have been supplied to medical wards by mistake. There are an estimated 237 million medication errors in the NHS every year – with a third linked to packaging and labelling. Read full story Source: The Independent, 9 August 2020
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