Becky T

This report looks at an incident where a neonate suffered an oesophageal perforation following endotracheal and nasogastric tube insertion.

This article looks at the issue of distinguishing between haemofilters and plasma filters, which are used in similar clinical settings, to reduce the risk of mis-selection that could result in patient death.

This report looks at how when face-to-face midwife visits were replaced by virtual appointments during the Covid-19 pandemic, the health of the some babies deteriorated. Guidance has been amended to state that initial visits should be face-to-face.

This report looks at several incidences of pregnant women with Covid-19 symptoms being sent to a maternity unit, when it would have been more appropriate for them to attend A&E. It highlights some confusion amongst health professionals and states that the Coronavirus (Covid-19) Infection in Pregnancy Guidance was updated to make care pathways clearer.

Case study looking at how a Covid patient on a ventilator deteriorated due to their heat and moisture exchanger filter (HMEF) being flooded with secretions. The identified incident highlighted a possible under-recognised patient safety risk of the need to replace such filters.

This report highlights the risk of patient overdose when converting tacrolimus (a medicine used following organ transplantation) from an oral to intravenous route.

Through its core work to review patients safety events, recorded on national systems such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources, the National Patient Safety Team identified a patient safety issue where the antibiotic ceftazidime was infused over 24 hours.

This case study looks at the issue of using ethyl chloride spray during fetal blood sampling procedures, which leaves a plastic residue on the babies scalp.

This case study looks at how plastic cord clamps used in caesarean sections are not visible on x-ray, which could be a patient safety issue.

This article, published in the Enhanced Recovery After Surgery e-book, explores the multimodal approach to improve overall patient recovery after surgery. The idea of implementing specific interventions throughout the perioperative period to improve patient recovery has been proven to be beneficial. Whereas many approaches to enhanced recovery after surgery (ERAS) implementation may seem straightforward, careful advanced planning, multiple stakeholder involvement, and addressing other contextual constraints are needed if there is to be improvement.

This article looks at the issue of oxygen hoses becoming disconnected from transport ventilators when patients are moved between hospitals, which led to a patient death. Following the incident, the National Patient Safety team worked with national partners involved in transfer of patients to ensure a ‘tug test’ is incorporated into local practice.

This article discusses the use of wireless heart monitoring in hospitals - telemetry - and the safety standards that need to be met.

This article, published in the BMJ Quality & Safety, discusses the value of incident reporting systems. Reporting systems, both local and national, are overwhelmed by the volume of reports they receive and fall short in defining recommendations for improving healthcare safety. Focusing incident reporting systems on the local learning process of healthcare providers could mitigate many of the problems that have been attributed to reporting systems.

This study, published in the International Journal for Quality in Health Care, examined the perceived effectiveness of incident reporting in improving safety in mental health and acute hospital settings by asking staff about their perceptions and experiences. It highlighted the complexities involved and the difficulties faced by staff in learning from incident data.

This article, published by the BMJ, discusses mandatory and voluntary medical error reporting programmes and comments that voluntary reporting by practitioners is usually more useful.

Mandatory and voluntary safety reporting policies are an extremely important part of providing guidance for safety reporting in aviation safety management systems (SMS). This blog highlights the purpose of safety reporting policies, how to train employees on voluntary vs mandatory reporting, and how to encourage mandatory and voluntary safety reporting. Although written for the aviation industry, many of the principles can be applied to healthcare.

This article, published on SKYbrary, discusses the importance of correct safety reporting in the aviation industry. Safety occurrence reporting aims to improve safety of aircraft operations by timely detection of operational hazards and system deficiencies; the aviation service provider organisations have a legal responsibility to report to their national authorities all accidents or serious incidents of which they become aware.  Although for the aviation industry, some of the principles can be applied to healthcare.

The 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Recently there has been greater research attention on patient safety in low- and middle-income countries due to the global awareness of the need to improve safety standards for all patients, including in maternal care. In this blog, I highlight the scale of maternal and newborn death in low- and middle-income countries, the contributing factors to this, and the need to improve maternal health and safety. The 17 September marks World Patient Safety Day, and this year the focus is on ‘Safe maternal and newborn care’. Patient Safety Learning has recently published a blog highlighting and summarising this topic.[1] While issues of unsafe care are a global challenge, they disproportionately impact on low- and middle-income countries. 134 million adverse events occur in hospitals every year in such countries, contributing to 2.6 million deaths.[2] Research in patient safety has primarily been associated with high income countries, but more recently there has been greater attention on low- and middle-income countries due to the global awareness of the need to improve patient safety standards for all patients, including maternal care.[3] Worldwide, around 295,000 women died during and following pregnancy and childbirth in 2017.[4] Approximately 810 women and 6,700 newborns die every day from preventable causes related to pregnancy and childbirth.[5] These global statistics are shocking and highlight the attention that is needed to address maternal safety. Of all the global maternal deaths, 94% occur in low- and middle-income countries.[4] This reflects inequalities in access to quality health services and highlights the global gap between rich and poor.[3] Of the many health statistics monitored by the World Health Organization (WHO), the largest gap between rich and poor nations is seen in maternal mortality levels.[7] Sub-Saharan Africa and Southern Asia accounted for approximately 86% of the estimated global maternal deaths in 2017.[4] Adolescent girls are more likely than older women to die due to complications related to pregnancy and childbirth; this is the leading cause of death for adolescent girls in low- and middle-income countries.[8] Infants also suffer greatly – of the approximate 8 million infant deaths each year, around two-thirds occur in the first month of life in low income countries.[6] Moreover, about 2 million babies are stillborn every year, with over 40% occurring during labour.[5] Maternal deaths occur as a result of complications that can transpire during and following pregnancy and childbirth, most of which are preventable or treatable.[4] The major complications that account for nearly 75% of all maternal deaths include severe bleeding after childbirth, infections and pre-eclampsia.[4] Additionally, for every woman who dies, at least 30 others are injured, often in disabling and socially devastating ways.[8] For example, obstetrical fistula is common in poor communities in sub-Saharan Africa and South Asia, where access to maternal health services is limited.[9] Most of neonatal and perinatal deaths are the result of poor maternal health and inadequate care during pregnancy and delivery and the critical immediate postpartum period.[6] The main factors that prevent women from receiving or seeking care during pregnancy and childbirth in low- and middle-income countries are poverty, distance to facilities, lack of information, inadequate and poor-quality services, and cultural beliefs/practices.[4] For instance, 35% of Senegalese women who live in rural areas deliver their children at home, often without a skilled midwife or birth attendant present, which poses dangers to both mother and child.[7] Care by trained staff is vital in preventing maternal deaths in low-income countries, yet only about half of births in such countries occur in health facilities.[9] Poor person-centred maternity care (PCMC) is one of the main factors driving both the low proportions of facility-based deliveries and high maternal mortality.[8] There is also a strong connection between the low societal status of women in low income countries and the risk of maternal illness and death.[6] The reality is that most maternal deaths are preventable, as the healthcare solutions to prevent or manage complications before, during and after childbirth are well recognised. It is particularly important that all births are attended by skilled health professionals because timely management and correct treatment can preserve the life of both mother and baby.[4] To improve maternal health in low- and middle-income countries, barriers that limit access to quality maternal health services must be identified and addressed at both health system and societal levels.[4] While additional resources are essential to patient safety improvement in low-income settings, such resources on their own will not be enough to secure the changes needed.[9] Recognising the scale of this problem, improving maternal health is now one of WHO’s key priorities.[6] Whilst many other health indicators have improved over the last two decades, maternal mortality rates in low- and middle-income countries have remained high and progress in reducing maternal and newborn mortality has been very slow.[8] Unsafe maternal care represents a serious and considerable danger to patients in low income countries – primarily due to scarce resources, weak infrastructure, cultural beliefs and limited skilled professionals – hence it should be a high priority public health problem that needs drastic attention.[10] References Patient Safety Learning. Safe maternal and newborn care: World Patient Safety Day 2021. The G20 Health and Development Partnership and RLDatix. The Overlooked Pandemic: How to transform patient safety and save healthcare systems, 2021. Elmontsri M, Banarsee R, Majeed A. Improving patient safety in developing countries – moving towards an integrated approach. JRSM Open, 2020; 9(11). World Health Organization. Maternal mortality, 2019. World Health Organization. World Patient Safety Day 2021, 2021. Donnay, F. Maternal survival in developing countries: what has been done, what can be achieved in the next decade. Gynecology & Obstetrics, 2000; 70(1). Plan International. What pregnancy looks like in 10 developing countries, 2018. Rosenfield A, Min C, Freedman L. Making Motherhood Safe in Developing Countries. The New England Journal of Medicine, 2007; 356:1395-1397. Aveling E, et al. Why is patient safety so hard in low-income countries? A qualitative study of healthcare workers’ views in two African hospitals. BMC, 2015; 11(6). Wilson R, et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ, 2012; 344.

This article, published in Medical Economics, looks at the Ethical Principles in Health Care (EPiHC), established June 2020. EPiHC serves as a global network of private health care providers, payors and investors committed to ethical conduct. It provides health care organisations with ten clear principles to navigate complex ethical decisions – principles that have never been more critical than in the midst of the COVID-19 pandemic.

This article, published in the BMJ, looks at the declining mental health of staff in ICU during the height of the Covid-19 pandemic, based on research by King's College London in 2020.

This editorial, published in the BMJ, comments on the 2019 paper by Daisy Fancourt examining how receptive arts engagement could have a protective association with longevity in older adults.

This article, published in the BMJ, looks at a study exploring associations between different frequencies of arts engagement and mortality over a 14 year follow-up period. It concludes that receptive arts engagement could have a protective association with longevity in older adults.

This manuscript provides a comprehensive overview of what healthcare worker support models are available in Canada and internationally. It outlines best practice guidelines, tools and resources that policy makers, accreditation bodies, regulators and healthcare leaders can use to assess the support needs of healthcare workers. The Canadian Peer Support Network is intended as a forum for healthcare organisations seeking guidance in the development of their Peer Support Programs to assist providers who have experienced a patient safety incident. These interventions aim to improve the emotional well-being of healthcare workers and allow them to provide the best and safest care to their patients. The components of this manual include: A survey of Canadian healthcare workers Global environmental scan of peer support programs Creating a safe space: Confidentiality and legal privilege for peer support programs Creating a safe space: Best practices for workplace peer support programs in healthcare organisations Creating a safe space: Peer support toolkit.