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Patient Safety Learning

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  1. Event
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    Browne Jacobson are delighted to invite you to their next Learning from Deaths forum. This forum will explore the barriers to successful implementation of the Learning from Deaths Guidance and what you can do within your organisation to help overcome these in order to successfully implement change and improve patient safety. In addition, the role of Medical Examiners will be looked at, and, if published, a discussion on the introductory version of the Patient Safety Incident Response Framework (PSIRF) which will eventually replace the Serious Incident Framework, as outlined in the NHS Patient Safety Strategy, in 2021. The session will have a practical focus with an opportunity for delegates to share good practice. Further information and registration
  2. Content Article
    The United Nations 2015 Millennium Development Goals targeted a 75% reduction in maternal mortality. However, in spite of this goal, the number of maternal deaths per 100,000 live births remains unacceptably high across Sub-Saharan Africa. Because many of these deaths could likely be averted with access to safe surgery, including cesarean delivery, Epiu et al. set out to assess the capacity to provide safe anaesthetic care for mothers in the main referral hospitals in East Africa. The authors identified significant shortages of both the personnel and equipment needed to provide safe anaesthetic care for obstetric surgical cases across East Africa. There is a need to increase the number of physician anaesthetists, to improve the training of non-physician anaesthesia providers, and to develop management protocols for obstetric patients requiring anaesthesia. This will strengthen health systems and improve surgical outcomes in developing countries. More funding is required for training physician anaesthetists if developing countries are to reach the targeted specialist workforce density of the Lancet Commission on Global Surgery of 20 surgical, anaesthetic, and obstetric physicians per 100,000 population by 2030.
  3. Content Article
    The Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) have collaborated to create the video resource Capnography: No Trace = Wrong Place.  Presented by Professor Tim Cook, the video shares the important message that during cardiac arrest, if a capnography trace is completely flat, oesophogeal intubation should be assumed until proven otherwise. 
  4. News Article
    Babylon Health use AI to provide health care to UK patients – even Health Secretary Matt Hancock uses it. But experts have questioned whether there’s enough evidence of the safety of its AI chatbot service. Watch the BBC Newsnight report
  5. News Article
    An 87-year-old woman died after her carers gave her the wrong medication, a coroner was told. Heather Planner, from Butler's Cross in Buckinghamshire, died at Wycombe Hospital on 1 April from a stroke. Senior coroner Crispin Butler heard three staff from Carewatch Mid Bucks had failed to spot tablets handed over by the pharmacy were for a male patient. Mr Butler said action should be taken to prevent similar deaths. A hearing in Beaconsfield on Thursday, where he issued a Prevention of Future Deaths report, followed an inquest in November. In the report he said he was told at the inquest that the carers from Carewatch Mid Bucks gave widow Mrs Planner the wrong medication four times a day for two and a half days. She suffered a fatal stroke because she did not receive her proper apixaban anticoagulation medication. Mr Butler said he would send his concerns to the chief coroner and the Care Quality Commission. He said there was no procedure in place to ensure individual carers read and specifically acknowledged any medication changes. Read full story Source: BBC News, 27 February 2020
  6. News Article
    There is a “strong association” between staff experience of senior management and whether an organisation acts on error reporting, exclusive analysis for HSJ of the staff survey data suggests. Analysis by health and social care charity Picker Institute examined statistical relationships between responses to staff survey questions regarding staff communication with managers and those relating to error reporting. The analysis, which included all trust types, looked at the relationships between statements such as “communication between senior managers and staff is effective” and “I know who the senior managers are here” to “When errors, near misses or incidents are reported, my organisation takes action to ensure they do not happen again” and other similar indicators. A high correlation to the questions does not categorically prove a direct causal relationship but the data suggested “strong associations”, Picker Institute chief statistician Steve Sizmur told HSJ. He said: “There are a number of strong associations in the latest staff survey data, to the extent that there is likely to be a link between staff experiences of senior management and their views about error reporting and whether the organisation addresses their concerns.” Read full story (paywalled) Source: HSJ, 27 February 2020
  7. News Article
    NHS patients could be denied lifesaving care during a severe coronavirus outbreak in Britain if intensive care units are struggling to cope, senior doctors have warned. Under a so-called “three wise men” protocol, three senior consultants in each hospital would be forced to make decisions on rationing care such as ventilators and beds, in the event hospitals were overwhelmed with patients. The medics spoke out amid frustration over what one said was the government’s “dishonest spin” that the health service was well prepared for a major pandemic outbreak. The doctors, from hospitals across England, said the health service’s existing critical care capacity was already overstretched and “would crumble” under the demands of a pandemic surge in patients who may all need ventilation to help them breathe. Those denied intensive care beds could be those suffering with coronavirus or other seriously ill patients, with priority given to those most likely to survive and recover. Doctors said this would lead to “tough decisions” needing to be made about the wholesale cancellation of operations to free-up beds. Read full story Source: Independent, 28 February 2020
  8. Content Article
    NORD’s RareEDU™ released this video, Gene Therapy: Your Questions Answered, in order to address a vital topic to today's rare disease community. The goal of this video is to address the questions, hopes and concerns that patients and caregivers, across many different diseases, have about gene therapy. Since more than 80% of rare diseases are believed to be genetic, this video serves as a helpful resource for the rare disease community.
  9. Content Article
    Patient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
  10. Event
    A one day event at Bangor University that show-cases the immense opportunity of working with patients to create safer healthcare. There has never been a time where opportunities have been greater to transform healthcare than today. At the same time the complexity of diseases and treatments is making it more difficult to deliver safe care. Patient safety experts and affected patients and relatives will initiate conversations how we can make care safer with the power, insights and skills of patients. We will explore challenges to deliver safe care around key topics of co-production, shared risk and enabling technology. Further information and registration
  11. News Article
    From July, hospitals will be able to refer patients who would benefit from extra guidance around new prescribed medicines to their community pharmacy. Patients will be digitally referred to their pharmacy after discharge from hospital. The NHS Discharge Medicines Service will help patients get the maximum benefits from new medicines they’ve been prescribed by giving them the opportunity to ask questions to pharmacists and ensuring any concerns are identified as early as possible. This is part of the Health Secretary’s ‘Pharmacy First’ approach to ease wider pressures on A&Es and general practice. Read full story Source: Department of Health and Social Care, 23 February 2020
  12. News Article
    Controversial healthcare app maker Babylon Health has criticised the doctor who first raised concerns about the safety of their AI chatbot. Babylon Health’s chatbot is available in the company’s GP at Hand app, a digital healthcare solution championed by health secretary Matt Hancock. The chatbot aims to reduce the burden on GPs and A&E departments by automating the triage process to determine whether someone can treat themselves at home, should book an online or in-person GP appointment, or go straight to a hospital. A Twitter user under the pseudonym of Dr Murphy first reached out to us back in 2018 alleging that Babylon Health’s chatbot was giving unsafe advice. Dr Murphy recently unveiled himself as Dr David Watkins and went public with his findings at The Royal Society of Medicine’s “Recent developments in AI and digital health 2020“ event. Over the past couple of years, Dr Watkins has provided countless examples of the chatbot giving dangerous advice. In a press release (PDF) on Monday, Babylon Health calls Dr Watkins a “troll” who has “targeted members of our staff, partners, clients, regulators and journalists and tweeted defamatory content about us”. Read full story Source: AI News, 26 February 2020
  13. News Article
    Just six of the English NHS’s more than 200 private patient units (PPUs) are signed up to the independent complaints adjudicator, HSJ has learned. The figures follow the publication of the Paterson Inquiry earlier this month. The inquiry’s report warned patients treated in private units, including PPUs, which are not regulated by the Independent Sector Complaints Adjudication Service (ISCAS) “will not have access to independent investigation or adjudication of their complaint”. ISCAS is the main independent adjudicator for the private healthcare sector and takes on approximately 125 adjudications each year on unresolved patient complaints. Most standalone independent providers have signed up to the watchdog. However, ISCAS membership is not mandatory and it is concerned patients wishing to complain about care at PPUs will have little choice but to pursue costly legal action. The government is now considering the inquiry’s recommendation that all private patients are given the right to a mandatory independent resolution of their complaint. Read full story Source: HSJ, 26 February 2020
  14. News Article
    Hundreds of elderly and vulnerable social care residents have allegedly been sexually assaulted in just three months, a shock new report from the care regulator has revealed. According to the Care Quality Commission there were 899 sexual incidents reported by social care homes between March and May 2018. Almost half were categorised as sexual assault. In 16% of the cases members of staff or visiting workers were accused of carrying out the abuse. The watchdog said it was notified of 47 cases of rape and told The Independent local authorities were informed and 37 cases were referred to police for investigation. Kate Terroni, Chief Inspector of adult social care at the regulator, said: “Supporting people as individuals means considering all aspects of a person’s needs, including sexuality and relationships. However, our report also shows all too starkly the other side of this – the times when people are harmed in the very place they should be kept safe. This is utterly devastating, both for the people directly affected and their loved ones." “It is not good enough to put this issue in a ‘too difficult to discuss’ box. It is particularly because these topics are sensitive and complex that they should not be ignored.” Read full story Source: The Independent, 27 February 2020
  15. Content Article Comment
    @janieb Hi Jane. I'll email them over to you now. I've also added a pdf version of the powerpoint which is a smaller file size so should be easier to download.
  16. News Article
    Following a doctor’s suicide, a petition is calling for the GMC to take responsibility for the wellbeing of those under its investigation. Read full story (paywalled) Source: Pulse, 25 February 2020
  17. Content Article
    While approximately one in ten Americans suffers from a rare disease, only 5% of rare diseases have a U.S. Food and Drug Administration (FDA) approved treatment. Congressional and regulatory efforts to stimulate the development of rare-disease treatments, while laudable, have not resolved the fundamental issues surrounding rare-disease treatment development. Indeed, small patient populations, incomplete scientific understanding of rare diseases, and high development costs continually limit the availability of rare-disease treatments. To illustrate the struggle of developing and approving safe rare-disease treatments, this article from While approximately one in ten Americans suffers from a rare disease, only 5 percent of rare diseases have a U.S. Food and Drug Administration (FDA) approved treatment. Congressional and regulatory efforts to stimulate the development of rare-disease treatments, while laudable, have not resolved the fundamental issues surrounding rare-disease treatment development. Indeed, small patient populations, incomplete scientific understanding of rare diseases, and high development costs continually limit the availability of rare-disease treatments. To illustrate the struggle of developing and approving safe rare-disease treatments, this article from Julien B Bannister begins by discussing the approval of Eteplirsen, the first drug approved for treating a rare disease called Duchenne muscular dystrophy. After exploring the current drug regulation system and how this impacts the availability of rare-disease treatments, he examines the 21st Century Cures Act's patient experience data provisions and the pending Trickett Wendler Right to Try Act. Ultimately, the unmet therapeutic needs of rare-disease patients can be met while protecting patient safety. Bannister reasons that, if carefully implemented, the 21st Century Cures Act and the Trickett Wendler Right to Try Act could work in tandem to safely facilitate patient access to rare-disease treatments.
  18. News Article
    More than 70 children and young people have been put at risk by long delays in treatment by mental health services in Kent and Medway, HSJ has learned. According to a response to a Freedom of Information request submitted by HSJ, 205 harm reviews have been carried out for patients waiting for treatment following a referral to the North East London Foundation Trust, which runs the child and adolescent mental health services in Kent and Medway. Of those, 76 patients, who had all waited longer than the 18 week target time for treatment, were found to be at risk of harm. One patient had to be seen immediately as they were judged to be at “severe” risk. Seven were found to be at “moderate” risk and 68 at “low” risk. The trust said “risk” meant a risk of harm to themselves or others. But it said none of the 76 patients had come to actual harm. Read full story (paywalled) Source: HSJ, 25 February 2020
  19. News Article
    Prisoners in Britain frequently have hospital appointments cancelled and receive less healthcare than the general public, a new study has found. As many as 4 in 10 hospital appointments made for a prisoner were cancelled or missed in 2017–18, with missed appointments costing the NHS £2 million. The in-depth analysis of prison healthcare by the Nuffield Trust think tank examined 110,000 hospital records from 112 prisons in England. It revealed 56 prisoners gave birth during their prison stay, with six prisoners giving birth either in prison or on their way to hospital. The Nuffield Trust said its findings raised concerns about how prisoners are able to access hospital care after a cut in the number of frontline prison staff and a rising prison population. Lead author Dr Miranda Davies, a senior fellow at the Nuffield Trust, said: “The punishment of being in prison should not extend to curbing people’s rights to healthcare. Yet our analysis suggests that prisoners are missing out on potentially vital treatment and are experiencing many more cancelled appointments than non-prisoners.” Read full story Source: The Independent, 26 February 2020
  20. News Article
    Tests for coronavirus are being increased to include people displaying flu-like symptoms at 11 hospitals and 100 GP surgeries across the UK. The tests will provide an "early warning" if the virus is spreading, Public Health England Medical Director Prof Paul Cosford said. Up to now, people were tested only if they displayed symptoms having recently returned from one of the countries where there has been an outbreak, including China, South Korea and northern Italy. However, Prof Cosford said Public Health England was now working with hospitals and GP surgeries to conduct "random" tests. These will target some patients with coughs, fevers or shortness of breath, regardless of whether they have travelled to a place where the virus is spreading. "If we do get to the position of a more widespread infection across the country, then it will give us early warning that's happening," said Prof Cosford. Read full story Source: BBC News, 26 February 2020
  21. News Article
    A&E units are so overcrowded that growing numbers of patients have to be looked after in hospital corridors, warn nurses and doctors. There are rising concerns that the “shameful” trend means people stuck in corridors are not getting the care they need, or they may be even coming to harm. A&E health professionals say “corridor nursing” is becoming increasingly widespread as emergency departments become too full to look after the sheer number of people seeking treatment. In a survey of 1,174 A&E nurses in the Royal College of Nursing’s (RCN) Emergency Care Association, 73% of those polled said they looked after patients in a “non-designated area” such as corridors every day and another 16% said they did so at least once a week, while 90% said they feared patient safety was being put at risk by those needing care having to spend time in areas of hospitals which did not have medical equipment or call bells. Staff have had difficulty administering urgent doses of intravenous antibiotics to such patients, some of whom have been denied privacy and found it harder to use a toilet or been left in distress, nurses said. Read full story Source: The Guardian, 26 February 2020
  22. News Article
    The British Medical Association (BMA) should not allow itself to become a campaign tool for vested interest groups seeking a dangerous change in the law, writes Dr Matthew Davis in the Guardian. "Doctors have a responsibility to first do no harm... Even when it may feel uncomfortable, doctors must continue to exercise their Hippocratic duty", says Dr Davies. "The BMA must remain opposed to assisted suicide if the medical profession it claims to represent is to have any credibility in safe, caring and trustworthy expertise. It must not allow itself to become a campaign tool for vested interest groups seeking an extreme and dangerous change in the law that has, even very recently, been rejected by parliament." Read full story Source: The Guardian, 25 February 2020
  23. Content Article
    Avoidable unsafe care kills and harms thousands of people in the UK each year. When a person dies as a result of a preventable error it is vital that we learn from these tragic events and take action to ensure that this does not reoccur. Coroners' Prevention of Future Deaths (PFD reports) are a crucial resource for this and should be used to make healthcare safer. Are we utilising these to their full extent to improve our safety practice and to achieve their aim, to prevent future deaths?
  24. Content Article
    It is widely known that prisons in England and Wales are crowded and facing severe difficulties, but the health and health care use of the prisoners within has received little attention. Drawing on over 110,000 patient hospital records for prisoners at 112 prisons, this study from the Nuffield Trust provides the most in-depth look to date at how prisoners’ health needs are being met in hospital.
  25. Content Article
    The National Organization for Rare Disorders (NORD)’s Rare Disease Database provides brief introductions for patients and caregivers to specific rare diseases. 
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