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Patient Safety Learning

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  1. Event
    DECON UK is back for 2023, providing valuable insights into decontamination and infection prevention it is a free event for healthcare professionals. The Royal Wolverhampton NHS Trust, Wallsall Healthcare NHS Trust and University Hospitals Birmingham NHS Foundation Trust jointly brings you DECON UK 2023. This event is expected to host over 150 healthcare professionals from various fields within the decontamination sector. We aim to provide a high quality of educational content to our delegates with a comprehensive programme covering water, air and sustainability. Register
  2. Event
    Energy-based devices, lasers and diathermy are some of the most commonly used pieces of equipment in operating theatres today. Dangerous emissions can be produced that affect the respiratory systems of everyone in the operating theatre. This study day will look at the occupational hazards of exposure to surgical plume in the operating theatre, as well as the associated risks to the surgical team, patients and visitors. It will also highlight how to assess risk and mitigate against the dangers of surgical plume and how to implement changes. Topics Include: Electrosurgery/diathermy/laser. Anaesthetic airway fires. Laparoscopic surgery aerosolisation. Health and Safety and risk assessment. Surgical plume. Register
  3. Event
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    Free online congress, in Santiago de Chile. Welcome to all of you. Please find attached the programme. FINAL FLYER OFICIAL 2 (1).pdf
  4. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety by supporting healthcare staff in the safe use of central venous catheters to access a patient’s blood supply. Specifically, it looks into the use of tunnelled haemodialysis central venous catheters, which are a type of central line. The reference event involved Joan, who had a cardiac arrest caused by an air embolus after her haemodialysis catheter was uncapped, unclamped, and left open to air. This took place during a procedure to take blood culture samples to test for a possible line infection (where bacteria or viruses enter the bloodstream). This investigation’s findings, safety recommendations and safety observations aim to prevent the future occurrence of an air embolus following uncapped and unclamped haemodialysis catheters, and to improve care for patients across the NHS.
  5. News Article
    NHS Highland has been reprimanded for a data breach which revealed the personal email addresses of people invited to use HIV services. The health board used CC (carbon copy) instead of BCC (blind carbon copy) to send an email to 37 people. The Information Commissioner's Office (ICO) said the error amounted to a "serious breach of trust". It called for improvements to be made to data protection safeguards for HIV service providers. The mistake meant all recipients of the email could see the personal addresses of the others receiving it. One person said they recognised four other individuals, one of whom was a previous sexual partner. Read full story Source: BBC News, 30 March 2023
  6. News Article
    New restrictions are being introduced for autism assessments, with some areas now only accepting referrals for patients in crisis, HSJ has learned. Commissioners in North Yorkshire and York have become the latest to introduce new criteria for autism and attention deficit hyperactivity disorder referrals. Getting a diagnosis is key to unlocking care packages such as speech and language therapy, counselling, or special educational needs. They said the changes are due to “unprecedented demand that has exceeded supply, resulting in unacceptable wait times and the need to prioritise resources towards children and most at-risk adults”. Read full story (paywalled) Source: HSJ, 30 March 2023
  7. News Article
    A review of the whistleblowing framework – the laws that support workers who blow the whistle on wrongdoing in the workplace – has been launched by the Government. The review will seek views and evidence from whistleblowers, key charities, employers and regulators. Whistleblowing refers to when a worker makes a disclosure of information which they reasonably believe shows wrongdoing or someone covering up wrongdoing. Workers who blow the whistle are entitled to protections, which were introduced through the Public Interest Disclosure Act 1998 (PIDA). Successive governments have taken steps to strengthen whistleblowing policy and practice. It provides a route for employees to report unsafe working conditions and wrongdoing across all sectors. This was keenly felt during the height of the Covid-19 Pandemic, when the Care Quality Commission and Health and Safety Executive recorded sharp increases in the number of whistleblowing disclosures they received. The review will gather evidence on the effectiveness of the current regime in enabling workers to speak up about wrongdoing and protect those who do so. The evidence gathering stage of the review will conclude in Autumn 2023. Read full press release Source: Gov.UK, 27 March 2023
  8. News Article
    A rise in the use of slimming jabs could lead to an increase in unsafe treatment for tummy tucks and surgery to remove excess skin, UK surgeons have warned. Drugs such as semaglutide and liraglutide are approved for use on the NHS for certain groups of people with obesity, and could help people reduce their weight by more than 10%. Surgeons have warned that people using the jabs may not realise they could be left with excess skin. “Whilst the newly introduced weight-loss drugs are not likely to produce comparable weight loss to bariatric surgery there is always the possibility that accompanying weight loss, a patient might be left with a degree of deflation and redundant skin,” said Marc Pacifico, the president of the British Association of Aesthetic Plastic Surgeons. However, access to surgery on the NHS to remove excess skin is limited because the NHS do not fund post-weight loss plastic surgery any more, so it has to be undertaken in the private sector. That costs about £4,500 to £6,000 in the UK, so Mr Pacifico warned patients might seek cheaper procedures abroad.. “I would strongly warn against this as there might not be the safeguards and assurances that the drugs being used are of the same quality and provenance as those being prescribed in the UK,” he said. He also warned that there are risks associated with having weight-loss plastic surgery abroad, such as the inability to undertake proper research on a surgeon, as well as the risks associated with flying straight after significant surgery – such as blood clots, as well as a lack of accessible follow-up with the surgeon and clinic to treat post-operative wound infections. Read full story Source: The Independent, 29 March 2023
  9. News Article
    The Care Quality Commission’s follow-up of whistleblowing concerns from health and care staff has been poor and inconsistent, and there is a “widespread lack of competence and confidence” on dealing with race and racism at the organisation, two reviews have found. A “Listening, learning, responding to concerns” review was published by the Care Quality Commission, alongside a linked independent review into how the regulator failed Shyam Kumar, a consultant orthopaedic surgeon in the North West, who was also a CQC specialist professional adviser. The wider review looked at a range of issues including how the CQC deals with racism; how well it listens to whistleblowers in providers; and how it deals with its own staff, including as part of a recent restructure, and its internal “Freedom to Speak Up” process. It followed concerns bring raised, in addition to Mr Kumar’s case, about these issues. Scott Durairaj, a CQC director who joined it last year and led the review work along with a panel of advisers, reported there was “clear evidence, during the scoping, design phase and throughout the review, of a widespread lack of competence and confidence within CQC in understanding, identifying and writing about race and racism”. Read full story (paywalled) Source: HSJ, 29 March 2023
  10. Content Article
    On 24 August 2022, the Employment Tribunal found that Mr Shyam Kumar, a consultant orthopaedic surgeon employed at University Hospitals of Morecambe Bay NHS Foundation Trust (UHMB), had been disengaged from his role as a Specialist Advisor within the Care Quality Commission (CQC) on account of having made “protected disclosures” to the CQC. This means he had raised concerns with CQC about the health of patients and other important issues and had done so in the public interest. The Employment Tribunal found that the fact that he had raised these various concerns with CQC had materially influenced its decision to disengage him. It awarded him £23,000 in damages for injury to feelings, on account of what it described as “the inevitable impact” of CQC’s actions upon Mr Kumar’s reputation among his peers and the shock, confusion and concern it caused to him. The CQC has accepted these findings and apologised to Mr Kumar. CQC’s Chief Executive, Ian Trenholm, issued a public statement on 6 September 2022 about what occurred, including a recognition of the importance of the concerns Mr Kumar raised, the importance of the information raised by staff and the public generally, and the “vital role” played by Specialist Advisors in CQC’s inspections. Following this, Zoe Leventhal KC was appointed by CQC’s Executive Board to carry out an independent review into whether CQC took appropriate action as a regulator in response to the protected disclosures that Mr Kumar made, and whether it dealt appropriately with a sample of other instances where concerns have been raised with CQC.
  11. Content Article
    A shortage of nurses across the world, including in countries that provide nurses for international recruitment, has created a global health emergency, according to the latest report from the International Council of Nurses. The report, Recover to Rebuild: Investing in the Nursing Workforce for Health System Effectiveness, lays out the devastating impact that the Covid-19 pandemic has had on nurses around the world. It urges that investment in a well-supported global nursing workforce is needed if health systems around the world are to recover and be rebuilt effectively. It also warned against reliance on the “quick fix” of international recruitment instead of investing in nursing education, as this was contributing to staff shortages even in countries with a long tradition of educating nurses to work in higher income countries. The report, co-authored by the organisation's chief executive, Howard Catton, and nursing workforce policy expert Professor James Buchan, includes the findings of workforce surveys from more than 25 countries, including the UK, as well as other research.
  12. Content Article
    The concerns that health and care workers and the public share with the Care Quality Commission (CQC) about health and care services are critical to its work. It is also vital that CQC listens to its own staff. This review explores whether there are areas of culture or process within CQC that need to be improved in relation to listening, learning, and responding to concerns. The review focused on these key areas: Organisational findings Reviewing how well we listen to whistleblowing concerns. Reviewing our Freedom to Speak Up policy. Learning from the tribunal case. Reviewing how we listen to our staff. Reviewing the expectations and experiences of people who raise concerns with us.
  13. Content Article
    Patient Safety Awareness Week is an annual recognition event intended to encourage everyone to learn more about health care safety. During this week, the Institute for Healthcare Improvement (IHI) seeks to advance important discussions locally and globally, and inspire action to improve the safety of the health care system — for patients and the workforce. During Patient Safety Awareness Week, IHI held three webinars. Watch the webinars from the links below.
  14. Event
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    Cardiovascular disease (CVD) is one of the leading causes of morbidity, disability and mortality in England and a significant driver of health inequalities. It disproportionately affects people in deprived and ethnic minority communities and accounts for one-fifth of the gap in life expectancy between most and least deprived areas. The King’s Fund report, Cardiovascular disease in England, highlights the need to prevent and manage CVD. CVD accounts for one in four of all deaths in England. The yearly health care costs related to CVD are estimated at £7.4 billion with an annual cost to the wider economy of £15.8 billion. At a time when the NHS and social care workforce and finances are facing unprecedented and rising pressures, urgent comprehensive action across the public health, health and care sectors is needed to significantly reduce the adverse health impacts of CVD and associated workloads and costs. Leaders and experts from across the NHS and its partners will gather to discuss how best to prioritise and deliver services to reduce the prevalence of CVD and its risk factors across the population, and to improve early detection, management and treatment of CVD and its risk factors. Register
  15. News Article
    The leaders of University Hospitals Birmingham (UHB) must acknowledge and seek to tackle the organisation’s pervasive bullying culture, and those who cannot may need to leave, the lead author of its patient safety review has warned. In an interview with HSJ, Mike Bewick said humility is required to address major cultural issues identified through conversations he had with senior medics and former employees. Professor Bewick’s overall view was that UHB was a “safe” place to receive care, but his team had been “disturbed” by consistent reporting of a bullying culture. Professor Bewick wrote in his report that even during his six-week review, initial goodwill from the trust had “dissipated”, adding his team has seen an organisation that is “culturally very reluctant to accept criticism”. Speaking to HSJ, he acknowledged there were people within UHB who do not accept cultural problems, adding: “I would hope they see the right thing to do is to accept [they] didn’t get everything right, to do a bit of mea culpa, have some humility, and move on. Because I don’t think there’s necessarily a place for people who can’t move on.” Read full story (paywalled) Source: HSJ, 28 March 2023
  16. Content Article
    Oxford Health NHS Foundation Trust want your feedback.
  17. News Article
    An inquest report into the death of a young boy who died at home in his sleep has called for health bodies to take action to prevent further deaths. Louis Rogers' death was initially categorised as Sudden Unexplained Death in Childhood (SUDC) but the report recorded febrile seizures contributed. The recommendations include: A greater emphasis on medical education, research and public information for sudden unexpected deaths associated with febrile seizures Referrals for assessment of febrile seizures should be undertaken earlier to exclude more severe underlying illnesses The NHS website and pamphlet given to parents and guardians following a child's febrile seizure should be updated to help assist them in picking up potential early indicators of a more severe illness "Robust national guidance" and education should be given to GPs so that timely referrals could be made A checklist should be provided for health practitioners so that a child was not given a misdiagnosis of a febrile seizure Records of all contact with health practitioners - including GPs and paramedics - should be available for all The recommendations were made to six health authorities: Royal College of Paediatricians, Joint Royal Colleges Ambulance Liaison Committee, National Institute for Health and Care Excellence (NICE), Royal College of General Practice, Royal College of Emergency Medicine and NHS England. Read full story Source: BBC News, 29 March 2023
  18. News Article
    People dying in the UK face “uncontrollable” pain and “unbearable suffering”, which palliative care alone cannot fix, according to the first evidence to a major new parliamentary inquiry asking if assisted dying should finally be legalised. In a shocking submission in favour of a law change, Molly Meacher told the Commons health and social care committee that the reality of end of life could include vomiting faeces, endless nausea and decaying tumours that smelled so bad they drove people out of hospital wards. People “are existing, they’re not living”, the crossbench peer and chair of the charity Dignity in Dying told the committee inquiry, which comes eight years after the House of Commons last considered changing legislation in 2015. Arguing strongly against any law change, Ilora Finlay, a crossbench peer and palliative care physician warned of the risk of “elder abuse” being worsened by a law change and said wider availability of palliative care, which remains patchy in the UK, must instead be a priority. Charles Falconer, a Labour peer and former Lord Chancellor, described the current situation, where dying people sometimes withdraw their own treatment rather than taking drugs to end their life, as “a mess”. He proposed that assisted dying should be available only to terminally ill people and not those facing “unbearable suffering”, as others have suggested. A diagnosis would be needed from two doctors plus approval from high court judge. “The bills that have been proposed [previously but defeated] say the person who decides to have an assisted death must have the capacity to make that decision,” he said. Read full story Source: The Guardian, 28 March 2023
  19. News Article
    Mothers and babies are being put at risk because maternity services are still providing unsafe care, despite a series of scandals that have cost lives, the NHS ombudsman has warned. More tragedies will occur unless the health service takes decisive action to put an end to repeated and deeply ingrained problems which lead to “the same mistakes over and over again”, he said. Rob Behrens, the NHS ombudsman for England, voiced his concerns when he launched a report on Tuesday which details the failings several women experienced while giving birth. It also sets out the lessons the NHS needs to learn, but Behrens claimed that too many trusts were not doing so. Behrens voiced alarm that, although efforts have been made to improve the care mothers and their children receive, progress is too slow – and that means patients remain in danger. His report says that: “We recognise that people working in maternity services want to provide high-quality care. Culture, systems and processes can get in the way of achieving that goal. “But improvements are not happening quickly enough, and we have not seen sustainable change. We must do more to make services safer for everyone.” Read full story Source: The Guardian, 28 March 2023 Further reading on the hub: Patient Safety Learning - Mind the implementation gap: The persistence of avoidable harm in the NHS
  20. Content Article
    Women should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs. That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk. This Parliamentary and Health Service Ombudsman (PHSO) report looks at themes from maternity complaints families have brought to us, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help families complain and help NHS organisations understand the issues.
  21. Content Article
    This NatSSIPs 8 flow chart illustrates the sequential standards in the National Safety Standards for Invasive Procedures 2 combined with the World Health Organization (WHO) surgical safety checklist.
  22. Content Article
    A number of serious concerns have been raised about the University Hospitals Birmingham NHS Foundation Trust, relating to patient safety, governance processes and organisational culture. The Trust has been under review by the Birmingham and Solihull Integrated Care Board (ICB), following a junior doctor at the trust, Dr Vaishnavi Kumar, taking her own life in June 2022. In response to these concerns, a series of rapid independently-led reviews have been commissioned at the Trust. This report outlines the outcomes of the first of these reviews, which is focused on clinical safety. It identified a number of issues which require attention, setting out 17 recommendations for further action.
  23. News Article
    More than three quarters of NHS workers are seriously considering leaving their jobs amid the ongoing strain on the health service. According to research from the worker-led network Organise – which surveyed 2,546 NHS staff in March – 78.5% are thinking about packing it all in. Only a fifth (21.5%) said they had no plan to give up their NHS job any time soon. And the survey shows this sentiment is shared across a range of professions within the health service – with nurses, healthcare assistants, paramedics, doctors, health visitors and more all struggling with their jobs right now. This comes after years of public concerns about the longevity of the health service, amid funding cuts, staff shortages and burnout – not to mention the additional strain from the Covid pandemic. The findings also show that in the last three years: 79% of respondents experienced stress 62% reported anxiety 55% reported burnout. More than half (55%) of respondents said they needed to take time off from their jobs as a result, with a quarter saying this meant a month or more away from work. Read full story Source: Huffington Post, 29 March 2023
  24. News Article
    A scandal-hit children’s mental health hospital will close months after an investigation by The Independent uncovered claims of poor care and systemic abuse. Taplow Manor hospital, in Maidenhead, was threatened with closure by the NHS safety watchdog, the Care Quality Commission, only last week if it failed to make improvements following a damning report. Active Care Group, which runs the hospital, confirmed it would close by the end of May, saying a decision by the NHS to stop admitting patients had rendered its “service untenable”. The move comes after an investigation by The Independent and Sky News heard from more than 50 patients who alleged “systemic abuse” by the provider, while Taplow Manor is facing two police probes – one into a patient death and a second into the alleged rape of a child involving staff. Read full story Source: The Independent, 29 March 2023
  25. News Article
    Repeated cases of bullying and a toxic environment at one of England's largest NHS trusts have been found in a review. The Bewick report was ordered after a BBC Newsnight investigation heard from staff at University Hospitals Birmingham (UHB) saying a climate of fear had put patients at risk. A first phase of the rapid review, headed by independent consultants IQ4U and led by Prof Mike Bewick, was published Tuesday. It is one of three major reviews into the trust, commissioned following a series of reports by Newsnight and BBC West Midlands in which current and former staff raised concerns. Summarising the findings, Prof Bewick, a former NHS England deputy medical director, said: "Our overall view is that the trust is a safe place to receive care. "But any continuance of a culture that is corrosively affecting morale and in particular threatens long-term staff recruitment and retention will put at risk the care of patients across the organisation - particularly in the current nationwide NHS staffing crisis. "Because these concerns cover such a wide range of issues, from management organisation through to leadership and confidence, we believe there is much more work to be done in the next phases of review to assist the trust on its journey to recovery." The West Midlands trust said it fully accepted the report's recommendations. Read full story Source: BBC News, 28 March 2023
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