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Found 137 results
  1. Content Article
    In March 2019, NHS England published Saving Babies Lives version 2, which included information for providers and commissioners of maternity care on how to reduce perinatal mortality across England. One element of this recommends the appointment of a fetal monitoring lead with the responsibility of improving the standard of fetal monitoring. The aim of the fetal monitoring lead is to support staff working on the labour ward to provide high quality intrapartum risk assessments and accurate CTG interpretation and should contribute to building and sustaining a safety culture on the labour ward with all staff committed to continuous improvement. The importance of fetal monitoring was highlighted again in the Ockenden Report, published December 2020. The report recommended, as an essential action, that all maternity services must appoint a dedicated lead midwife and lead obstetrician, both with demonstrated expertise, to focus on and champion best practice in fetal monitoring. Monitoring May is a month long learning event based around fetal monitoring, human factors, maternity safety and shared learning. The East Midlands Academic Health Sciences Network has shared the recording of Monitoring May’s discussions and presentations.
  2. Content Article
    Remote digital postoperative wound monitoring provides an opportunity to strengthen postoperative community care and minimise the burden of surgical-site infection (SSI). This study aimed to pilot a remote digital postoperative wound monitoring service and evaluate the readiness for implementation in routine clinical practice. It concluded that remote digital postoperative wound monitoring successfully demonstrated readiness for implementation with regards to the technology, usability, and healthcare process improvement.
  3. News Article
    Hundreds of children who manage their type 2 diabetes by regularly pricking their finger can now monitor their glucose levels using automated sensors, the government’s expert health advisers have announced. Doctors and nurses in England, Wales and Northern Ireland have been advised they can now give glucose monitoring devices to children with type 2 diabetes who currently use the more intrusive finger-prick testing methods, the National Institute for Health and Care Excellence (NICE) said on Thursday. The health minister Helen Whately said that offering children the devices would relieve a burden and “empower them to manage their condition more easily”. She said: “Type 2 diabetes is increasingly being diagnosed in children, many of whom face the constant stress of needing to monitor their blood glucose levels by finger-prick testing – often multiple times a day – just to stay healthy and avoid complications.” The NICE committee that reached the decision heard that children found finger pricking to check their glucose levels several times a day “burdensome”, “tiring” and “stressful”. The devices, which give a continuous stream of real-time information on a smartphone, have already been recommended for children with type 1 diabetes, a less aggressive form of the disease. Read full story Source: The Guardian, 11 May 2023
  4. News Article
    Maternity services at a trust in Staffordshire have been rated as 'requires significant improvement' by the Care Quality Commission (CQC). University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely. It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be. Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services. The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage. Read full story Source: ITV News, 28 April 2023
  5. News Article
    A team from NHS Ayrshire & Arran has successfully created a system to ensure that people with Parkinson’s get their medication on time while they are in hospital. Parkinson’s nurse specialist Nick Bryden, who led the team, explains: “The timely administration of medication is hugely important in helping to control symptoms in people with Parkinson’s. "Guidance states that Parkinson’s medication should be administered within 30 minutes, either side, of the prescribed time which can be challenging within a busy hospital ward environment." Nick, who works out of Biggart Hospital in Prestwick, added: “When we initially worked with our digital pharmacist, Richard Cottrell, it was to develop a system that would alert us to when a Parkinson’s patient was admitted to hospital. "It then became clear that we could take the system a step further and use it to monitor if people are on the right medication and whether or not it is being administered at the right time.” The team worked to develop a further system of clear visual prompts with NHS Digital services, which appear alongside relevant patient details on wards’ electronic whiteboards. Every patient prescribed Parkinson’s medication has a tulip symbol beside their name which changes colour and flashes when it’s close to the time to administer the medication. The system was initially piloted in a couple of wards and, due to its success, has now been rolled out to almost every ward in Ayrshire and Arran. Read full story Source: The Herald, 19 April 2023 Related reading on the hub: Top picks: Seven resources about Parkinson’s Professionals with Parkinson’s tackle time critical patient safety issue: a blog by Sam Freeman Carney
  6. Content Article
    Near misses include conditions with potential for harm, intercepted medical errors, and events requiring monitoring or intervention to prevent harm. Little is reported on near misses or their importance for quality and safety in the emergency department (ED). This is a secondary evaluation of data from a retrospective study of the ED Trigger Tool (EDTT) at an urban, academic ED. It was published in the Journal of Patient Safety. Authors conclude that near-miss events are relatively common (22.7% of their sample, 19.3% in the population) and are associated with an increased risk for an adverse event. Most events were patient care related (77%) involving delays due to crowding and ED boarding followed by medication administration errors. The EDTT is a high-yield approach for detecting important near misses and latent system deficiencies that impact patient safety.
  7. News Article
    Dilshad Sultana was 36 weeks pregnant with her second child in 2019 when she experienced stomach pain and noticed her baby was moving less. Mrs Sultana, from Sutton Coldfield, said she had been due to have a Caesarean section on 8 July but on 20 June she started to feel pain in her abdomen and lower back. She said she was confused but that it did not feel like a contraction and called hospital staff at about 17:00 to say it felt like her baby was moving less. After following advice to rest and take pain relief, she attended hospital at about 22:30 and staff started monitoring Shanto's heart rate. It was not until almost three hours later that Shanto was delivered by emergency C-Section. Shanto suffered severe brain damage and would spent the next 22 days in intensive care, suffering seizures and multiple brain haemorrhages. Shanto now requires around-the-clock care and Mrs Sultana enlisted lawyers to pursue a care of medical negligence against the trust. Birmingham Women's and Children's NHS Foundation Trust has admitted liability and made a voluntary interim payment allowing the family to move to a new home specifically adapted to meet Shanto's extensive care, therapy and equipment needs. Fiona Reynolds, the chief medical officer, said: "We'd like to offer our heartfelt apologies again to the family. "It's clear the standard of care we offered to them fell below those required and expected. For this, we are truly sorry." Now, Mrs Sultana is campaigning for change - she wants to see mothers listened to in maternity care and more attention paid to monitoring babies' heart rates. Read full story Source: BBC News, 27 March 2023
  8. News Article
    More than 100,000 patients, including children, have been treated in so-called virtual wards over the last year, NHS officials have said. Leading medics said that the use of the system to monitor patients at home has been a “real game changer”. Officials say virtual wards can help patients avoid unnecessary hospital trips altogether, or enable them to be sent home from hospital sooner. Using various equipment and technology, clinicians can monitor vital signs such as a patients’ heart rate, oxygen levels and temperature remotely. NHS England’s national medical director, Professor Sir Stephen Powis, said: “The advantages of virtual wards for both staff and patients have been a real game-changer for the way hospital care is delivered and so it is a huge achievement that more than 100,000 patients have been able to benefit in the last year alone, with the number of beds up by nearly two thirds in less than a year. “With up to a fifth of emergency hospital admissions estimated to be avoided through better supporting vulnerable patients at home and in the community, these world-leading programmes are making a real difference not just to the people they directly benefit but also in reducing pressure on wider services.” Read full story Source: The Independent. 11 March 2023
  9. Content Article
    Risk assessment during the maternity pathway relies on healthcare professionals recognising a change in a pregnant woman/person’s circumstances that may increase the level of risk. Risk assessments are undertaken during the numerous contacts pregnant women/people have with a team of healthcare professionals throughout the maternity pathway. This thematic review draws on findings from the Healthcare Safety Investigation Branch's (HSIB's) maternity investigation programme to identify key issues associated with assessing risk during pregnancy, labour and birth (known as the ‘maternity pathway’). It examined all reports undertaken by the HSIB maternity investigation programme from April 2019 to January 2022, with the aim of identifying key learnings about risk assessment. A total of 208 reports that had made findings and recommendations to NHS trusts about risk assessment during the maternity pathway were included. The review identified an overarching theme around the need to facilitate and support individualised risk assessments for pregnant women/people to improve maternity safety. Within this, seven specific ‘risk assessment themes’ within the maternity care pathway were identified as commonly appearing in HSIB reports. These seven themes require a focus from the healthcare system to help mitigate risks and enable NHS trusts and clinicians to deliver safe and effective maternity care to pregnant women/people.
  10. News Article
    The trust at the centre of a maternity scandal has been ordered to report on urgent improvements in services for women and babies, amid ‘significant concerns’ about the risk of harm. The Care Quality Commission (CQC) used its enforcement powers to issue the conditions on East Kent Hospitals University Foundation Trust, after it carried out an unannounced inspection last month. However, the “section 31” warning letter has just been made public, and the first deadline for the trust to report back to the CQC is Monday (20 February). The CQC said some of the problems it found were due to the labour ward environment – but others involved monitoring of women and babies whose conditions deteriorate and the risk of cross-infection due to poor cleanliness standards. “We have significant concerns about the ongoing wider risk of harm to patients and a need for greater recognition by the trust of the steps that can be taken in the interim to ensure safety and an improved quality of care,” Carolyn Jenkinson, CQC’s deputy director of secondary and specialist healthcare, said in a statement today. Read full story (paywalled) Source: HSJ, 17 February 2023
  11. News Article
    A heart failure patient has become the first in the UK to be fitted with an early warning sensor the size of a pen lid which gives off an alert if their condition deteriorates. Consultant cardiologists Dr Andrew Flett and Dr Peter Cowburn have pioneered the procedure to fit the FIRE1 System during trials at University Hospital Southampton (UHS), Hampshire. Dr Flett said: “This innovative new device has the potential to improve patient safety and outcomes in the management of patients with chronic heart failure and we are delighted to be the first site in the UK to implant as part of this ground-breaking study". Read full story Source: The Independent, 12 February 2023
  12. News Article
    East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light. The Care Quality Commission has highlighted: Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup. Read full story (paywalled) Source: HSJ, 6 February 2023
  13. Content Article
    In this video, Leah Coufal’s mother, Lenore Alexander, recounts the tragic story of her 12-year-old daughter’s preventable death in hospital in December 2002. Leah died from opioid-induced respiratory depression due to a lack of continuous postoperative monitoring which could have saved her life. Lenore now campaigns for the legal requirement to monitor patients on opioids after surgery.
  14. Content Article
    This report provides an overview of the findings of Ireland's Health Information and Quality Authority (HIQA)’s monitoring programme against the national standards in emergency departments in 2022.  Throughout 2022, HIQA commenced a new monitoring programme of inspections in healthcare services against the National Standards for Safer Better Healthcare. As part of the initial phase, HIQA’s core assessment in emergency departments focused on key standards relating to governance, leadership and management, workforce, person-centred care and safe and effective care. The report highlights, HIQA has identified key areas for both immediate and longer-term attention to address safety issues in our emergency departments. 
  15. Content Article
    This article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
  16. Content Article
    Vision-based patient monitoring systems (VBPMS) are assistive tools that enable staff to enhance and support patient safety in inpatient services by delivering non-contact measurement of physiological parameters such as pulse and breathing rate, some estimate of patient location, activity or behaviour data and some form of contextual video information (which may be blurred) either in real-time or through subsequent reviews. In some cases, a VBPMS can be classified as a medical device regulated by the Medicines and Healthcare products Regulatory Agency and have specific indications for use. Providers adopting the technology need to ensure users are appropriately trained.
  17. Content Article
    This study in the Annals of Surgery aimed to characterise errors, events and distractions in the operating theatre, and measure the technical skills of surgeons in minimally invasive surgery practice. The authors of the study implemented the use of an operating room (OR) Black Box, a multiport data capture system that identifies intraoperative errors, events and distractions. The study found that the OR Black Box identified frequent intraoperative errors and events, variation in surgeons’ technical skills and a high number of environmental distractions during elective laparoscopic operations.
  18. Content Article
    This blog by Dr Anna Bayes from Altera Digital Health looks at the benefits of closed-loop medication administration (CLMA) in preventing avoidable medication errors. CLMA provides an extra validation at the point of drug administration by using barcode technology to positively identify the patient and validate their prescribed medications against the physical medication product (for example, pills, infusions or creams) at the point of care. Anna also considers CLMA's role in advancing digital maturity.
  19. Content Article
    Martin Anderson, author of the Human Factors 101 blog, looks at the case of US nurse RaDonda Vaught, who was found guilty of criminally negligent homicide and abuse of an impaired adult following a medication error that led to a patient death in 2017. He provides a timeline of the events that occurred in the run up to the criminal trial and highlights concerns that the case will set a precedent in bringing criminal charges against nurses when there is no intent to harm a patient. He then looks at the system factors that may have contributed to the medication error, asking a number of questions about the circumstances under which Vaught made the error. The blog goes on to outline the serious impact the case could have on healthcare professionals' willingness to report errors, take on complex cases and use innovative treatments—it may even put people off taking on a career in the healthcare sector in the first place.
  20. News Article
    Norfolk Community Health and Care it is using a remote monitoring service from Inhealthcare which allows patients to monitor their vital signs at home and relay readings via a choice of communication channels to clinicians who monitor trends and intervene if readings provide any cause for concern. Analysis of the six months before and after introduction showed a significant reduction in hospital bed days, A&E attendances, GP visits and out-of-hours appointments. Lead heart failure nurse at the trust, Rhona Macpherson, spoke to Digital Health News about the impact of the services on patients and nurses. For Macpherson, the service has helped promote self-management. “We give each of the patients a set of scales, blood pressure monitor and pulse oximeter and we get them to do their observations,” she said. “So we’re promoting self-management and looking at things but also it means that we can get accurate information on what’s happening with their observations. “We then set parameters to alert if they go outside of the parameters, and it just means we can intervene much more quickly than we would do, and we can see what’s going on between our visits as well as what’s happening when we’re actually there.” The service has transformed working practices for nurses, increasing efficiency and saving valuable time. Macpherson said: “We’re using the technology to try and make ourselves a little bit more efficient, so it’s saving on the travel time and face to face visits. “We can do a lot more with telephone. We’ve got the option of using video, but telephone is actually quite useful. So it’s less face to face visits, less travel and also, we’re trying to empower the patients to do their own observations and monitor themselves, rather than us just doing it for them.”
  21. Content Article
    This article tells the story of Baby E, who died two hours after delivery following issues with the management of her labour. The maternity unit was short-staffed on the night of Baby E's birth and there were delays in getting her mother to theatre for a caesarean section. Baby E's parents felt that the hospital withheld information from them, failing to inform them of internal investigations that had taken place following Baby E's death. At the inquest, the coroner concluded that errors had been made, including the fact that Baby E's low heart rate had been missed. She also criticised the decision-making process in the management of labour, but concluded that she was unable to say whether this had made a difference to whether or not Baby E lived.
  22. Content Article
    This case study summarises the story of Evadney Dawkins, a 77 year-old living in East London who died on 23 August 2018 as a result of treatment errors and poor care received at Newham University Hospital. Following a fall at home, Evadney was taken to the hospital on 22nd July 2018, where she was initially treated for a chest infection and fast atrial fibrillation (an irregular and abnormally fast heart rate). As she had other co-morbidities that included chronic renal failure, a treatment plan including renal monitoring was agreed, but the hospital failed to monitor her renal function and she sustained a profound acute kidney injury. Following intensive treatment, the acute kidney injury resolved but she sustained a cardiac arrest on 23rd August 2018 and died later that day. This case study outlines how Action Against Medical Accidents (AvMA) helped Evadney's family convince the Coroner to open an inquest. The inquest found that there were ‘gross failures’ in the care provided to Evadney which led to her renal deterioration, including a failure in the frequency of blood tests, a failure in fluid monitoring and a failure to carry out renal ultrasound. The Coroner also criticised Bart's Health NHS Trust's systems of governance for not identifying for two years that Evadney’s case was a serious incident which required investigation.
  23. Content Article
    The purpose of this investigation by the Healthcare Safety Investigation Branch (HSIB) was to consider the management and care of preterm labour and birth of twins. Preterm birth—defined as babies born alive before the completion of 37 weeks of pregnancy—is one of the main causes of death, long-term conditions and disability in under-fives worldwide, and 60% of twin pregnancies result in premature birth. The reference event for this investigation was the case of Sarah, who was pregnant with twins and was overseen by an obstetrician during her pregnancy. Sarah was assessed as having a higher-risk pregnancy as she had had previous medical intervention on her cervix and was pregnant with twins. Shortly after having been discharged from a hospital with a specialist neonatal unit following suspected early labour, she went to her local maternity unit at 29+2 weeks with further episodes of abdominal tightening. Her labour did not progress as expected and a caesarean section was required to deliver the babies at 29+6 weeks. The twin girls were born well, but 23 days after their birth a scan revealed brain injury in both babies. The investigation identified several findings to explain the experience of the mother in the reference event, including the lack of scientific evidence or specific guidelines and the uncertainty associated with the clinical decision making in this scenario. This highlighted the need for further research into preterm labour as a recognised risk factor for twin pregnancies. As part of the investigation, HSIB identified that since 2019 a large volume of national work and research in the area of twin pregnancy and preterm birth has been undertaken. The investigation report sets out the work currently in progress and seeks to understand if it will address gaps in knowledge.
  24. Content Article
    On 3 September 2021 assistant coroner Jonathan Stevens commenced an investigation into the death of Martha Mills, aged 13 years. Martha sustained a handlebar injury whilst cycling on a family holiday in Wales. She was transferred to King’s College Hospital London and died approximately one month later. Her medical cause of death was: 1a refractory shock 1b sepsis 1c pancreatic transection (operated) 1d abdominal trauma.
  25. Content Article
    This guideline covers preventing and managing inadvertent hypothermia in people aged 18 and over having surgery. It offers advice on assessing patients’ risk of hypothermia, measuring and monitoring temperature, and devices for keeping patients warm before, during and after surgery.
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