Mark Hughes
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Everything posted by Mark Hughes
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Content Article
Due to the scale of the pandemic, despite being in a healthcare setting, patients in hospital and other in-patient settings faced an increased risk of nosocomial (hospital-acquired) Covid-19 infections. This report presents the outcomes of a programme of investigation work into cases of hospital-acquired Covid-19 in Wales. Expanding on the themes identified in the Interim Learning Report, published in March 2023, this report highlights further national learning in relation to communication with families and carers, clinical record keeping, staffing and resource, discharge planning and the impact of hospital environments. -
Content ArticleFollowing the conviction of Valdo Calocane in January 2024 for the killings of Ian Coates, Grace O’Malley-Kumar and Barnaby Webber, the Secretary of State for Health and Social Care commissioned the Care Quality Commission (CQC) to carry out a rapid review of Nottinghamshire Healthcare NHS Foundation Trust (NHFT) under section 48 of the Health and Social Care Act 2008. The first part of this review, published in March 2024, set out the CQC’s findings of their assessment of patient safety and quality of care provide by NHFT, and progress made at Rampton Hospital since their last inspection in July 2023. This second report provides a rapid review of available evidence related to the care of Valdo Calocane.
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Content ArticleOn the 3 July 2023, Susan Pollitt was admitted to the Royal Oldham Hospital following a collapse at her home. She was treated for a number of medical issues including acute kidney injury. During her admission, she developed ascites—a condition in which fluid collects in spaces within the abdomen. The Consultants involved in her care decided an ascitic drain was not required at that time. Subsequently on the 11 July, a junior doctor reviewed Mrs Pollitt and decided that an ascitic drain should be placed. The Physician Associate who undertook the procedure was not aware of the local guidance on the insertion of ascitic drains or that the drain should remain in place for no longer than six hours. Mrs Pollitt’s drain remained in place for 21 hours before being removed. She subsequently developed bacterial peritonitis and died on 16 July.
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Content ArticleThis report examines waiting times, access to assessments, treatment, and post-diagnostic support for people with dementia in memory assessment services. This is drawn from data collection carried out in Memory Assessment services at the end of 2023, relating to patients who had appointments for assessment from the beginning of the year, plus information about how the service is provided. The results indicate that there is still a great deal of variation between services in key results such as average waiting time for patients, the proportion of patients diagnosed with dementia, and the provision of post diagnostic support and therapy.
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Content ArticleThe Centers for Medicare and Medicaid Services (CMS) this month have confirmed they will add seven new measures to their hospital inpatient quality reporting programme starting from 2025. In this short blog, Patient Safety Learning comments on the inclusion of a new Patient Safety Structural Measure (PSSM) as part of this.
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Content ArticleMahamoud Hussain Ali fell in the street and was taken by ambulance to Homerton University Hospital. He discharged himself but was later readmitted after another fall on the same day. Subsequently, he was detained under section 2 of the Mental Health Act 1983 and transferred to Lea Ward, Mile End Mental Health Hospital. He was placed in isolation and assigned to be under observation every 15 minutes. On the 21 August 2020 at around 18:00 he was found unresponsive on the floor of his room. Following this he was taken to Royal London Hospital and died on 26 August 2020 at the Royal London Hospital. Looking into this case, the Coroner has stated that staff at East London Foundation Trust had falsified observation records. The report also notes that investigations commissioned by Trust following Mr Ali’s death uncovered 11 further “fatal incidents” where records may have been fabricated.
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In this episode Dr Paul Grime, Chairman of the Safer Healthcare Biosafety Network, speaks to Paul Leach, National Ambulance Lead, NHS England Net Zero Travel and Transport Team. Having contributed to the recently published NHS Net Zero Travel and Transport Strategy, Paul leads on the transition of the NHS emergency fleet to zero emission vehicles. Safety Talks is a podcast series as part of the Safety for All Campaign, launched to shine a light on the symbiotic relationship and benefits of integrating the approach to deliver healthcare worker safety and patient safety. -
Content ArticleResearchers have traditionally focused diagnostic safety efforts on identifying errors and their causes with the goal of reducing diagnostic error rates. More recently, complementary approaches to diagnostic errors have focused on improving diagnostic performance drawn from the safety sciences. These approaches have been called Safety-II and Safety-III, which apply resilience engineering and system safety principles, respectively. This review explores the safety science paradigms and their implications for analysing diagnostic errors, highlighting their distinct yet complementary perspectives.
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Electronic patient record (EPR) systems have the potential to improve patient treatment, increase efficiency and reduce the costs of healthcare. However, it has become increasingly evident that introducing EPR systems comes with serious patient safety risks. In a new report, Electronic patient record systems: Putting patient safety at the heart of implementation, Patient Safety Learning looks at this in depth. Drawing on a recent roundtable event, we consider how patient safety can, and must, be put firmly at the heart of the design, development and rollout of EPR systems. This blog gives a summary of the report and the 10 principles it sets out for safe EPR system implementations. -
Content ArticleThis investigation by the Health Services Safety Investigations Body (HSSIB) explores the patient safety risks associated with the use of online consultation tools in general practice. The investigation focussed on the use of these tools for ‘asynchronous’ consultation where the patient and healthcare professional are not in the same room, and the patient does not receive a response in real time.
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Content ArticleIn this report, the National Guardian’s Office analyses questions relating to speaking up that were asked in the 2023 NHS Staff Survey. It highlights that while workers’ confidence in speaking up about anything which concerns them showed signs of improvement, the survey revealed a five-year low in the number of respondents who feel secure raising concerns about unsafe clinical practice.
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Content ArticleThe role of the Patient Safety Commissioner for England is to promote patient safety in relation to medicines and medical devices and to promote patients’ voices. This annual report summarises the work of the Patient Safety Commissioner, their strategy and plans for 2024/25.
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Content ArticleIn May 2024, National Institute for Health and Care Research (NIHR) Evidence held a webinar on care for adults in mental health crisis. The webinar shared research findings on what works in community crisis care, how acute day units compare to crisis resolution teams and whether peer-supported self-management can reduce acute readmissions. This Collection summarises the 3 research projects presented at the webinar. It includes video clips from the speakers and incorporates quotes from the day. The information will be useful for anyone involved in commissioning or delivering mental health crisis services.
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Content Article
Radiation safety culture in health care encompasses every action taken to improve the protection and safety of patients and personnel involved in medical exposure. This report provides a framework to establish, maintain and enhance radiation safety culture in health care. It highlights patterns of organisational and individual thinking and behaviours which define a positive safety culture and provides a set of tools to assess the existing level and quality of radiation safety culture and good practice examples. The publication was developed by the World Health Organization (WHO) jointly with the International Atomic Energy Agency (IAEA), the International Organization for Medical Physics (IOMP) and the International Radiation Protection Association (IRPA). -
Content ArticleThe National Guardian’s Office (NGO) leads, trains and supports a network of Freedom to Speak Up (FTSU) Guardians in England. It also conducts speaking up reviews to identify learning and support improvement of the speaking up culture of the healthcare sector. This is their updated strategy to support cultural change in healthcare to improve worker experience and patient safety.
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Listening to the voices of workers is essential for a safe and effective healthcare for workers, patients and the public. Freedom to Speak Up Guardians provide an opportunity for organisations to learn from these voices which may not otherwise be heard. Freedom to Speak Up Guardians are required to report non-identifiable information on the cases they receive both locally to their boards and senior leadership and to the National Guardian’s Office. This report summarises the data shared by Guardians about the speaking up cases they received between 1 April 2023 and 31 March 2024. -
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Safety is a core dimension of health care quality, and measurement of patient safety culture in Organisation for Economic Co-operation and Development (OECD) countries is increasingly conducted as part of efforts to monitor patient safety and to contribute to health system performance assessment. This Health Working Paper looks at the findings of the second OECD pilot on patient safety culture. This occurred in 2022-2023 and in total took data from 648,209 health care providers from 14 countries. -
Content ArticleOn the 30 May 2024, the World Health Organization published the its Global Patient Safety Report 2024. In this blog, Assistant Professor John Tingle from Birmingham Law School at the University of Birmingham, reflects on the findings of this report, in particular considering progress made in nurturing patient safety cultures in different healthcare systems.
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Content Article
This is the recording of a webinar on hosted by the Safety for All Campaign to present findings from a survey on violence and aggression sustained by nursing and midwifery students in a UK university. The findings were presented by Dr Kevin Hambridge, Lecturer in Adult Nursing (Education), Francis Thompson, Associate Professor in Mental Health Nursing (Education) and Dr Matt Carey, Associate Professor in Child Health Nursing – Acute Care, all from the University of Plymouth. The results highlighted worrying trends of verbal violence or aggression, physical violence and sexual violence towards students. The responses also highlighted a culture of acceptance among students who have been programmed to see violence at work as part of the job. There was a detailed question and answer session following the presentation in which webinar attendees asked questions about prevention, protection and collaboration. -
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Taking place on Tuesday 10th December 2024 at the Royal College of Physicians in London, the third annual Safety For All conference provides an opportunity to hear from the nation’s leading voices in healthcare worker safety and patient safety and to network with frontline healthcare workers, unions, key decision makers in public and private healthcare, and patients. This event is hosted by the Safer Healthcare and Biosafety Network and Patient Safety Learning as part of the Safety For All campaign. Launched in 2021, the Safety For All campaign is focused on driving improvements in and between healthcare worker safety and patient safety, highlighting how poor staff safety standards and practice impact adversely on patient safety and vice versa. It is championing the need for a systematic and integrated approach to improve safety practice for staff and patients across health and social care so that the sum is greater than the parts. The conference will be hosted by Dr Rob Galloway, A&E Consultant at Brighton and Sussex Hospital NHS Trust, and regular columnist in the Daily Mail, and with keynote speakers including the CEO of the Royal College of Nursing, and Professor Charlotte McArdle, Deputy Chief Nursing Officer for Patient Safety and Improvement, NHS England. Sessions include; Sustainability Mental health Violence at work Antimicrobial resistance Implementing the Patient Safety Incident Response Framework (PSIRF) Register here. -
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Clinical communications and data sharing should focus both on the needs of patients and staff and safety to turn insights into better patient care. With the demands of patients greater than ever before, the demands placed on clinical staff have only increased in all areas of healthcare. Care teams need to work smarter with a quick and coordinated response to patient incidents by communicating critical notifications and other clinical and operational systems to the right care team members, enhance communication and simplify workflow throughout the process. This Safety For All webinar will delve into the transformative journey undertaken by South Eastern Health & Social Care Trust and the Royal National Orthopaedic Hospital to enhance clinical communications. Attendees will learn about the strategies and innovations implemented by these institutions to improve the clinical workflows, efficiency, effectiveness, and improving clinical quality using their clinical communication system. The session will cover key lessons learned, best practices, and the tangible benefits achieved through their efforts. Join us to gain valuable insights into how these leading healthcare organisations have successfully navigated their path to excellence in clinical communications. Register here. -
Content ArticleIn its manifesto ahead of the 2024 UK general election, the NHS Race & Health Observatory calls for a unification of efforts towards eradicating racial and ethnic health disparities in the nation’s healthcare system.
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The first ever World Health Organization (WHO) global report on patient safety aims to provide a foundational understanding of the current state of patient safety across the world, aligned with the Global Patient Safety Action Plan 2021-2030. It contains insights and information beneficial to health care professionals, policy-makers, patients and patient safety advocates, researchers – essentially anyone involved or interested in the improvement of health care and patient safety globally. -
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In this joint statement, National Voices, The Richmond Group of Charities and 68 other health and social care organisations are calling on the Department of Health and Social Care to pause or extend the consultation process for the 10-year review of the NHS Constitution, ensuring that everyone is able to respond. Patient Safety Learning is one of the signatories of this statement. -
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An investigation published by BBC News has revealed that Electronic patient record (EPR) system failures have been linked to the death of three patients and more than 100 instances of serious harm at NHS hospitals trusts in England. In this short blog, Patient Safety Learning reflects of these issues and the importance of patient safety being at the heart of the development and implementation of EPRs.
