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Found 110 results
  1. News Article
    The chief executive of a hospital has said the building is not in a condition "we should expect any of our nearest and dearest to receive care" in. Kettering General Hospital chief executive Simon Weldon described the site as "a big hotchpotch of things, some things that are new, about 10 years old, to things that are 100 years old, and everything in between". He added: "Those are not conditions a modern hospital should be proud of, those are not conditions we should ask any staff to work in, they are not the conditions we should expect any of our nearest and dearest to receive care." The initial £46m the hospital was award in 2019 was to replace the temporary "power plant". Mr Weldon said he would submit a business case to get money "to fix the vital infrastructure work that will keep this site safe". But he said the hospital really needed to be rebuilt, and that "fixing the hospital would be bad value for taxpayers". Read full story Source: BBC News, 7 July 2022
  2. Content Article
    Tracey Cammish, Patient safety, Clinical Intelligence and Partnership Lead, explains why patient safety is central to everything NHS Supply Chain does, and why clinical and end-user experience is so important.
  3. News Article
    A hospital and one of its managers are facing a criminal investigation into the death of a vulnerable man who absconded by climbing a fence. An inquest concluded failings amounting to neglect contributed to the death of Matthew Caseby in 2020, after he fled from Birmingham's Priory Hospital Woodbourne and was hit by a train. The investigation will be carried out by the Care Quality Commission (CQC). Priory said it would co-operate fully "if enquiries are raised by the CQC". Mr Caseby, 23, climbed over a 2.3m-high (7ft 6in) courtyard fence on 7 September 2020. He was found dead the following day after being hit by a train near Birmingham's University station. The inquest in April heard other patients had previously climbed the fence and, despite concerns by members of staff, no action was taken to improve security in and around the courtyard until another patient absconded two months after Mr Caseby's death. Following the inquest, coroner Louise Hunt said she was concerned the fence and courtyard area may still not be safe and urged health chiefs to consider imposing minimum standards for perimeter fences at mental health units. She also criticised record-keeping and how risk assessments were carried out. Read full story Source: BBC News, 23 June 2022
  4. Content Article
    Government must seize the post-pandemic opportunity to mandate long-term improvements to infection control in commercial, public and residential buildings to reduce the transmission of future waves of COVID-19, new pandemics, seasonal influenza and other infectious diseases, according to a report published by the National Engineering Policy Centre (NEPC). Infection control must also be coordinated with efforts to improve energy efficiency and fire safety, to support the three goals of safe, healthy and sustainable buildings. Commissioned in 2021 by the Government Chief Scientific Adviser Sir Patrick Vallance FRS FMedSci, the NEPC research, led by the Royal Academy of Engineering and the Chartered Institution of Building Services Engineers (CIBSE), set out to identify the measures needed in the UK’s built environment and transport systems to reduce transmission of infectious diseases. Ensuring that buildings and transport systems are designed, operated, managed and regulated for infection control is critical to minimise transmission, states the report.
  5. News Article
    NHS patients are being put in danger and waiting lists are getting even longer due to a £9bn maintenance backlog and a major lack of capital funding that has left some parts of hospitals “extremely dilapidated” and unfit for patients, health leaders have warned. Boris Johnson promised in 2019 to “build and fund 40 new hospitals”. But the Infrastructure and Projects Authority (IPA), the government watchdog, later gave the project an “amber/red” ranking, meaning its delivery “is in doubt with major risks or issues apparent in a number of key areas”. At the same time, the NHS in England is facing a £9bn maintenance backlog. Half of that sum, which is up from £6.5bn just three years ago, is required to tackle failings classed as posing either a “high” or “significant” risk to patients and staff. Now health leaders are warning that without an urgent injection of capital funding, patient safety is at risk and the waiting list for care – worsened by the pandemic – “will grow even larger”. Speaking to the Guardian, Matthew Taylor, the chief executive of the NHS Confederation, which represents the whole healthcare system in England, Wales and Northern Ireland, said the crisis had become extremely serious. Patient safety as well as the ability of the NHS to tackle record waiting lists is being “severely hampered”, Taylor warned, because the UK has been “plagued” by one of the worst records for capital investment in healthcare across all OECD countries over the past decade. One NHS trust chair in London told a survey, carried out this month, that “cramped” space means the trust is not “building up our capacity to deal with waiting lists”, and conditions for patients in some wards were “not fit for purpose”. Read full story Source: The Guardian, 14 June 2022
  6. Content Article
    This report from the Chartered Institution of Building Services Engineers allows users to assess the variety of air cleaning devices currently marketed for the removal of SARS-CoV-2, and to discover which air cleaner, if any, will effectively reduce transmission risk in a given space.  This guidance will be of use to lay-readers, and also to those requiring a detailed background of air flow performance metrics, pollutant and viral decay, and tools assessing the performance of air cleaners in context.  
  7. News Article
    The death of a retired police officer who got his head trapped in a hospital bed was an avoidable accident, an inquest has concluded. Max Dingle, 83, of Newtown, Powys, died after he became stuck between the rails and mattress at the Royal Shrewsbury Hospital on 3 May 2020. The initial post-mortem test gave the cause of death as heart disease. But a second examination, commissioned by Mr Dingle's son, found entrapment and asphyxiation to be the cause. After comparing and discussing their findings, both pathologists then agreed "entrapment did play a significant part in the cause of death", the senior coroner for Shropshire John Ellery said. The inquest was told Mr Dingle's son Phil had asked for the second post-mortem test because "did not accept" the initial findings and had sought the opinion of a pathologist in Australia, where he lives. Max Dingle, who had been admitted to the hospital with shortness of breath, died 15 minutes after he was found to be trapped, the hearing was told. Concluding the inquest, Mr Ellery said: "Based on all the evidence, the conclusions of this inquest are Mr Dingle's death was an avoidable accident." Read full story Source: BBC News, 1 June 2022
  8. Content Article
    This Healthcare Safety Investigation Branch (HSIB) investigation aims to improve patient safety in relation to the decontamination of surgical instruments. It focuses on the work of sterile services departments (SSDs) in hospitals, where reusable medical equipment is cleaned, disinfected and sterilised to make it safe before it is used again. The investigation looked at the regulatory framework which SSDs work within, and their use of assurance models, which provide evidence that a service is running according to the relevant policies and procedures. These mechanisms are designed to keep patients safe and enable NHS trusts to manage risk within their organisations. For its reference case, the investigation used the case of a 56 year-old woman who underwent surgery to remove a kidney stone in her right kidney. During the procedure, 'black stuff' came out of one of the instruments being used, which was later analysed and found to be dried blood. The surgeon stopped the surgery immediately and proceeded with an alternative procedure to remove the kidney stone, for which the patient had already consented. The patient was tested for blood-borne viruses as she had been exposed to another person's dried blood, but tests did not show any evidence that she had contracted any.
  9. News Article
    Patients’ lives are at risk because NHS hospitals have been allowed to crumble into disrepair, with ceilings collapsing and power cuts disrupting surgery. The number of clinical incidents linked to the failure to repair old buildings and faulty equipment has tripled in the past five years, an investigation by The Times found. Hundreds of vital NHS operations and appointments are being cancelled as a result of outdated infrastructure, undermining attempts by doctors to tackle record waiting lists. Recent incidents include an unconscious patient on a ventilator being trapped in a broken lift for 35 minutes and power running out as a patient lay in an operating theatre. On Saturday, April 23, a five-hour power cut at the Royal London Hospital in east London led to the cancellation of operations including two lifesaving kidney transplants, and meant women giving birth had to be transferred to different maternity units in the backs of taxis. Hospitals have also recorded hundreds of rat and pest infestations, and some rooms containing patients have been left “overflowing with raw sewage”. Read full story (paywalled) Source: The Times, 2 May 2022
  10. News Article
    Authorities were aware of discrepancies in Covid test results across England one month before the lab responsible was ordered to shut down its operations, legal papers show. An estimated 43,000 incorrect false negative tests were processed for the NHS by the Immensa laboratory in Wolverhampton between 8 September and 12 October. UK Health Security Agency became aware of an “unusual spike” in suspicious test results on 14 September, with large numbers of people testing positive on lateral flow devices but negative via PCR. It took a month before the UKHSA determined that the “likely cause was a technical issue at the Immensa laboratory”, according to court papers filed by the government in response to a lawsuit. The Independent also revealed in October how machines at the Wolverhampton lab were poorly maintained, concerns over quality control dismissed and untrained staff regularly “left to their own devices”. Samples at the site were wrongly processed or cross-contaminated, leading to incorrect test results, while faulty air conditioning and fluctuating humidity levels within the lab also led to spoiled tests, whistleblowers said. Read full story Source: The Independent, 22 December 2021
  11. Content Article
    In this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. The authors also examine the impact that learning projects based on incident reporting can have on clinicians involved in the initial incidents, highlighting that revisiting errors may prevent individuals from moving on from them.
  12. Content Article
    This study in The British Journal of General Practice aimed to quantify the time GPs spend on different activities during clinical sessions, to identify the number of operational failures they encounter and to define the nature of operational failures and their impact for GPs.
  13. Content Article
    Despite decades of research into patient falls, there is a dearth of evidence about how the design of patient rooms influences falls. This multi-year study aims to better understand how patient room design can increase stability during ambulation, serving as a fall protection strategy for frail and/or elderly patients.
  14. Content Article
    OzSAGE has created this infographic for creating safer indoor air for workspaces. It should be used with masks as a complete strategy. OzSAGE is a multi-disciplinary network of Australian experts from a broad range of sectors relevant to the well-being of the Australian population during and after the COVID-19 pandemic.
  15. News Article
    The increase in estates-related problems disrupting clinical services comes despite the government handing out £600m to trusts last year to modernise their facilities, and at a time when the NHS is struggling to bring down elective waiting lists and handle high emergency demand. Annual figures published by NHS Digital yesterday show nearly 7,000 “clinical service incidents caused by estates and infrastructure failure” in 2020-21. This marks a 15% increase on the previous year, although it is less than the level of growth in 2017-18 (25 per cent) and 2018-19 (22%). The incidents are defined as infrastructure failures which cause delays, cancellations or other interference with clinical services. This includes issues like power outages, building defects, and even a lack of estates and facilities staff such as porters. High-risk estate is defined as needing “urgent priority” to prevent “catastrophic failure, major disruption to clinical services, or deficiencies” in safety which are “liable to cause serious injury and/or prosecution”. Read full story (paywalled) Source: HSJ, 15 December 2021
  16. Content Article
    Nuffield Trust analysis of data to look at how the cost of the maintenance backlog in the English NHS has changed over the years, with the latest rise in the costs of necessary repairs and maintenance in the health service making it an even more pressing factor in calculations ahead of the Spending Review.
  17. News Article
    Police have launched a criminal investigation into a number of deaths at a Glasgow hospital, including that of 10-year-old Milly Main. It comes as a separate public inquiry into the building of several Scottish hospitals is being held. Milly's mother recently told the inquiry her child's death was "murder". A review in May found an infection which contributed to Milly's death was probably caused by the Queen Elizabeth University Hospital environment. The Crown Office and Procurator Fiscal Service has now instructed police to investigate the deaths of Milly, two other children and 73-year-old Gail Armstrong at the Glasgow campus. It is understood the probe could lead to criminal charges or a fatal accident inquiry. A spokesperson said: "The investigation into the deaths is ongoing and the families will continue to be kept updated in relation to any significant developments." The Crown Office added that it was committed to supporting the Scottish Hospitals Inquiry and "contributing positively" to its work. Read full story Source: BBC News, 26 September 2021
  18. News Article
    An inquiry will begin hearing evidence on Monday into problems at two flagship Scottish hospitals that contributed to the death of two children. The Scottish Hospitals Inquiry is investigating the construction of the Queen Elizabeth University Hospital (QEUH) campus in Glasgow and the Royal Hospital for Children and Young People and Department of Clinical Neurosciences in Edinburgh. The inquiry was ordered after patients at the Glasgow site died from infections linked to pigeon droppings and the water supply, and the opening of the Edinburgh site was delayed due to concerns over the ventilation system. Earlier this year, an independent review found the death of two children at the QEUH were at least in part the result of infections linked to the hospital environment. The review investigated 118 episodes of serious bacterial infection in 84 children and young people who received treatment for blood disease, cancer or related conditions at the Royal Hospital for Children at the campus. It found a third of these infections were “most likely” to have been linked to the hospital environment. The inquiry will aim to determine how issues at the two hospitals relating to ventilation, water contamination and other matters impacted on patient safety and care and whether this could have been prevented. Read full story Source: The Herald, 20 September 2021
  19. Content Article
    The Queen Elizabeth University Hospital Review was prompted by public and political concern following reports of the deaths of three patients between December 2018 and February 2019. The deaths had been linked to rare microorganisms and concern was growing that these organisms were in turn linked to the built environment at the Queen Elizabeth University Hospital (QEUH) and Royal Hospital for Children (RHC). The Review's remit was: “To establish whether the design, build, commissioning and maintenance of the Queen Elizabeth University Hospital and Royal Hospital for Children has had an adverse impact on the risk of Healthcare Associated Infection and whether there is wider learning for NHS Scotland”.
  20. News Article
    The first new hospital cleaning standards for 14 years have been outlined by regulators, including confirmation of new food hygiene-style star ratings. Wards and theatres will be given ratings from one to five stars – based on audits which score the cleanliness of areas against safe standards – and these ratings will be made visible to patients. The plans for the new star ratings, which are expected to be easier for patients to understand than the current cleanliness percentage scores, were first revealed by HSJ in 2019. The ratings are also designed to encourage a more collaborative approach, by reflecting the cleanliness score for whole areas, as opposed to the performance of individual parties responsible for cleaning certain elements. Areas rated one to three stars would require improvement plans and be automatically placed under review, with “immediate action” being required in one-star rated areas. Read full story (paywalled) Source: HSJ, 6 May 2021
  21. News Article
    Raw sewage flooding wards, power failures, and rat infestations were just some of more than 1,200 critical incidents at NHS trusts in the past year caused by ageing equipment and crumbling infrastructure. NHS leaders have said more investment is needed to reverse a backlog in buildings maintenance across the health service which has now reached an unprecedented £9bn. The situation is getting worse, with the backlog costs rising by 60 per cent in four years. In some hospitals the problems have become so severe they are affecting patient care leading to wards being closed, operations delayed and in some cases posing genuine risks to safety. Hampshire Hospitals was forced to suspend some services because of an uncontrollable rat infestation, while at East Cheshire NHS trust a power failure led to a back-up generator causing a fire triggering a second blackout. Patients had to be transferred to neighbouring hospitals and given blankets while others were given blankets to keep them warm. In another incident at Great Western Hospitals Trust, a patient having a hip operation was left under anaesthetic “open and exposed” while staff struggled to find a vital part needed for the operation which was in a storeroom that couldn’t be opened. Read full story Source: The Independent, 20 April 2021
  22. Content Article
    Telemetry monitoring of heart rates and rhythms was introduced in intensive care units in the 1960s, and since then it has expanded into patient rooms and units in noncritical care settings. It allows healthcare workers to watch the condition of many patients all at once and intervene quickly when their condition changes; however, if the technology is not used appropriately or the equipment malfunctions, relying on telemetry monitoring also risks patient harm. This study from Kukielka et al. looked at real-life cases of breakdowns in the processes and procedures regarding telemetry monitoring, such as user errors and miscommunication, and equipment failures, including broken transmitters and dead batteries. The lessons learned can help improve training and best practices to improve the safety of patients being monitored.
  23. News Article
    Thirteen trusts are facing billions of pounds of maintenance — in some cases, making it more cost-effective to rebuild the hospital — over ‘significant safety issues’ stemming from outdated construction methods. Reinforced autoclaved aerated concrete planks were used when constructing public sector buildings in the 1960s, 70s and 80s, including a group of prefabricated hospitals under the government’s “Best Buy” building programme. However, RAAC planks used in buildings constructed prior to 1980 have now exceeded their shelf life, meaning affected trusts need to carry out frequent inspections and expensive maintenance. For at least three of the affected trusts — Mid Cheshire Hospitals FT, Airedale FT and The Queen Elizabeth Hospital King’s Lynn FT — it would be more cost-effective to build new hospitals than replace the planks in their existing facilities. Victoria Pickles, director of corporate affairs at Airedale FT, told HSJ 85% of the trust’s buildings’ floors, roofs and walls comprised RAAC planks, with one ward closing due to the risk. Read full story (paywalled) Source: HSJ, 3 December 2020
  24. Content Article
    In 2002 the UK Department of Health and the Design Council jointly commissioned a scoping study to deliver ideas and practical recommendations for a design approach to reduce the risk of medical error and improve patient safety across the National Health Service (NHS). The research was undertaken by the Engineering Design Centre at the University of Cambridge, the Robens Institute for Health Ergonomics at the University of Surrey and the Helen Hamlyn Research Centre at the Royal College of Art. The research team employed diverse methods to gather evidence from literature, key stakeholders, and experts from within healthcare and other safety-critical industries in order to ascertain how the design of systems—equipment and other physical artefacts, working practices and information—could contribute to patient safety. Despite the multiplicity of activities and methodologies employed, what emerged from the research was a very consistent picture. This convergence pointed to the need to better understand the healthcare system, including the users of that system, as the context into which specific design solutions must be delivered. Without that broader understanding there can be no certainty that any single design will contribute to reducing medical error and the consequential cost thereof.
  25. Content Article
    There is a lack of awareness regarding the pervasive influence of the built environment on caregiving activities, and how its design could reduce risks for patients and providers. This article from Joseph et al. presents a narrative review summarising key findings that link health care facility design to key targeted safety outcomes: health care–associated infections, falls, and medication errors. It describes how facility design should be considered in conjunction with quality improvement legislation; projects under way in health systems; and the work of guideline-setting organizations, funding agencies, industry, and educational institutions. The article also charts a path forward that consolidates existing challenges and suggests what can be done about them to create safe and high-quality healthcare environments.
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