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Showing results for tags 'Never event'.
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Content ArticleCase submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above, de
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News Article
Trust warned by regulator after cluster of never events
Patient Safety Learning posted a news article in News
The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months. The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year. In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initi -
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News Article
Multiple whistleblowers flag ‘heartbreaking’ incidents at major trust
Patient Safety Learning posted a news article in News
Clinicians within a major teaching hospital’s cancer services have raised multiple concerns over patient safety, which they believe have resulted from badly planned service changes in response to the covid crisis. HSJ has spoken to several staff members who have worked in the haematology speciality at University Hospitals Birmingham Foundation Trust since last June, when the services underwent significant changes to free up capacity for coronavirus patients. This involved most haematology services at Heartlands Hospital in east Birmingham moving to the trust’s main Queen Elizabeth Ho -
Content ArticleNational guidance for the investigation of any patient safety incidents identified as either a Serious Incident (SI) or No Surprises/Sensitive Issue relating to the provision of digital health care services in Wales
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News ArticleAt least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said. The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening. The errors include examples such as a 62-year-old man having the wrong hip rep
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Content ArticleHSIB has made three safety recommendations as a result of this report - two to NHS England and NHS Improvement, and one to the Centre for Perioperative Care. NHS England and NHS Improvement It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers. It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barrie
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Community PostSubject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deplo
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News ArticleNHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. H
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Content ArticleNasogastric (NG) tubes placed incorrectly, going undetected and delivering food, liquid or medication into the lungs is a well-recognised never event in the NHS. Despite safety alerts and various safety initiatives, the investigation identified that this type of never event continues to happen and that there are not strong ‘systemic’ barriers to prevent NG tubes being accidentally placed into the lungs. Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year. The report acknowledges that measures carried out to tackle
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News Article
Trusts warned they are being ‘complacent’ on A&E over-crowding
Patient Safety Learning posted a news article in News
Emergency medics are writing to hospital chief executives warning them that some trusts are being ‘complacent’ about crowding in A&E, they have told HSJ. The Royal College of Emergency Medicine (RCEM) is sending a letter to trust chiefs today calling on them to urgently plan for how they will stop corridor waits and exit blocking ahead of January and February, typically the busiest months. It says some trusts were not treating emergency department crowding as a “high priority”, despite covid risks and pressures. It is also calling for overcrowding in the emergency department (ED) -
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Patient Safety Authority: Wrong-site surgery
Patient Safety Learning posted an article in Surgery
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NHS England: Never Events data
Patient Safety Learning posted an article in Data and insight
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News Article
Cluster of never events has sparked ‘great deal of soul searching’ says trust CEO
Patient Safety Learning posted a news article in News
An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures. The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient. Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”. Prior to the incidents the trust had gone 13 months without recording a never even -
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News ArticleA trust which had four ‘never events’ where patients were connected to air rather than an oxygen supply could have avoided them if it had been more proactive when a national patient safety alert was sent out several years earlier, a report has found. In one case, a baby being investigated for sepsis had oxygen saturation levels of just 75% before the mistake was realised. In another, a woman with COPD and pneumonia had oxygen saturation at 80% when she was connected to the air outlet. Calderdale and Huddersfield Foundation Trust asked the Royal College of Physicians to carry out an i
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Community PostHi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NH
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News ArticleAn external review has been launched at a leading children’s hospital after a series of “never events”. According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month. Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to nati
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Medical error prevention (5 May 2020)
Sam posted an article in Good practice
Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that: All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments. Effective communication related to medical errors may foster autonomy and ultimately improve patient safety. Error reporting better serves patients and providers by mitigating their effects. Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to -
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News ArticleThere were 21 “wholly preventable” patient safety incidents of the most serious category at private hospitals last year, new data has shown, as NHS bosses prepare to invest up to £10bn in the sector. This is the first time that a comprehensive dataset of 'never events’ within private hospitals has been published in the UK, and comes ahead of plans to outsource both inpatient and outpatient services, routine surgery operations and cancer treatment to private providers. The audit conducted by the Private Healthcare Information Network (PHIN), established in 2014 to bring greater transp
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Misuse of hydrogen peroxide in a theatre environment
Kathy Nabbie posted an article in Good practice
During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution -
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NHS Improvement: Never Events
Patient Safety Learning posted an article in NHS Improvement
