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Found 1,491 results
  1. News Article
    Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal. Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage. At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died. City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed. An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world." “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.” Read full story Source: Chronicle Live, 22 December 2019
  2. News Article
    A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed. Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder. Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital. He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria. Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS. Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.” Read full story Source: The Telegraph, 21 December 2019
  3. Content Article
    A recent report from the Healthcare Safety Investigations Branch, Investigation into electronic prescribing and medicines administration systems and safe discharge, highlighted the fact that poorly implemented ePMA (electronic prescribing and medicines administration) systems can result in potentially fatal medication errors. The report focused on the death of 75 year-old Mrs Ann Midson, following a medication error.  In this podcast interview, Pharmacy in Practice speaks to Scott Hislop and Helen Jones, two of the investigators, to discuss the series of events that ultimately culminated in the sad passing of Mrs Ann Midson.
  4. Content Article
    The Parliamentary and Health Service Ombudsman (PHSO) were set up by Parliament to provide an independent complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. They share findings from casework to help Parliament scrutinise public service providers. They also share their findings more widely to help drive improvements in public services and complaint handling. Miss K complained to the PSHO about the care and treatment that her son, Baby K, received at the Trust in November 2015. She said that the Trust failed to act following various checks on Baby K, and it failed to escalate his care in line with the seriousness of his condition and he died as a result. Miss K also complained about the Trust’s handling of her complaint.
  5. News Article
    Sick newborns in some areas of the UK are dying at twice the rate of seriously ill babies in other areas, a new report has revealed. The findings raise serious questions about the quality of care in some neonatal units, with experts warning action needs to be taken to tackle the “striking variation”. Across the country neonatal units are also short of at least 600 nurses with four in five failing to meet required safe staffing levels for specialist nurses. The regions with the highest mortality rate at 10 per cent were Staffordshire, Shropshire and the Black Country, where 107 babies died. This compared with a rate of 5 per cent in north central and northeast London. The Shropshire region includes the Shrewsbury and Telford Hospitals Trust, which is at the centre of the largest maternity scandal in the history of the NHS, with hundreds of alleged cases of poor care now under investigation. Dr Sam Oddie, a consultant neonatologist at Bradford Teaching Hospitals Trust and who led the work for the Royal College of Paediatrics and Child Health, said he was “surprised and disappointed” by the differences in death rates between units. “The mortality differences are very striking, with some units having a mortality rate twice that of the lowest. This variation in mortality is a basis for action by neonatal networks to ensure they are doing everything they can to make sure their mortality is as low as possible,” he said. Read full story Read MBBRACE-UK report Source: The Independent, 18 December 2019
  6. Content Article
    This is the sixth annual report produced for the Maternal, Newborn and Infant Clinical Outcome Review Programme, run by the MBRRACE-UK collaboration. The authors analysed 2.3 million pregnancies from 2015-2017 in the UK and Ireland. During that three-year period, 209 women in the UK and Ireland died during their pregnancies or up to six weeks afterwards from pregnancy-related causes. This is equivalent to just over 9 women per 100,000. The leading cause of maternal deaths in the UK is still cardiovascular disease, including heart attacks, heart failure and heart rhythm problems, and there has been no reduction in maternal deaths from heart-related causes for more than 15 years. The full report can be found through the link below, or you can read the lay summary here. 
  7. Content Article
    Since the emergence of the opioid epidemic in the United States at the beginning of the 21st century, more than 400,000 Americans have died as the result of an opioid overdose. As of 2018, the Substance Abuse and Mental Health Services Administration estimates that more two million people have an opioid use disorder. With the rate of opioid-related inpatient stays and the number of opioid-related emergency department visits continuing to rise dramatically in the US, hospitals have the opportunity to make a major impact in reducing morbidity and mortality related to opioid use. This document, produced by the Institute for Healthcare Improvement, provides system-level strategies that hospitals can implement immediately to address the challenges of preventing, identifying, and treating opioid use disorder.
  8. News Article
    An 88-year-old woman with a broken neck died after being transferred three times between two hospitals in the space of just 48 hours, The Independent has reveal. The death of Jean Waghorn, who died after contracting pneumonia in hospital, sparked criticism from a coroner who said the NHS trust had ignored earlier warnings over moving patients between hospitals. Senior coroner Veronica Deeley had issued two official alerts to Brighton and Sussex Hospitals Trust last year after the deaths of frail elderly patients who were wrongly shuttled between hospitals. But despite this, in June this year Ms Waghorn, who broke her neck after falling at home, was repeatedly transferred between the Princess Royal Hospital in Sussex and Brighton’s Royal Sussex County Hospital. She caught pneumonia and died two days later. The hospital, which is rated good by the CQC, has now apologised and said it has learned lessons from the case. A spokesperson said it did take action following the previous warnings and added that work was ongoing to ensure the changes were consistently applied. Read full story Source: The Independent, 17 December 2019
  9. News Article
    A hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed. Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions. The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded. Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days. An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”. Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made. Read full story Source: The Independent, 12 December 2019
  10. News Article
    Patients are more likely to die on wards staffed by a high number of temporary nurses, a study has found. Researchers say the findings, published in the Journal of Nursing Scholarship, are a warning sign that the common practice by many hospitals of relying on agency nurses is not a risk-free option for patients. The University of Southampton study found that risk of death increased by 12 per cent for every day a patient experienced a high level of temporary staffing – defined as 1.5 hours of agency nursing a day per patient. For an average ward, this increased risk could apply when between a third and a half of the staff on each shift are temporary staff, according to Professor Peter Griffiths, one of the study’s authors. He told The Independent: “We know that patients are put at risk of harm when nurse staffing is lower than it should be. “One of the responses to that is to fill the gaps with temporary nursing staff, and that is an absolutely understandable thing to do, but when using a higher number of temporary staff there is an increased risk of harm. “It is not a solution to the problem.” Read full story Source: The Independent, 10 December 2019
  11. Content Article
    This study from Dall'Ora et al., published in the Journal of Nursing Scholarship, explores the association between the levels of temporary nurse staffing and patient mortality. They found that heavy reliance on temporary staff is associated with higher risk for patients dying. The risk of death increased by 12% for every day a patient experienced a high level of temporary staffing – defined as 1.5 hours of agency nursing a day per patient. For an average ward, this increased risk could apply when between a third and a half of the staff on each shift are temporary staff. However, there is no evidence of harm associated with modest use of temporary registered nurses so that required staffing levels can be maintained.
  12. Content Article
    NHS investigators are to meet the family of a young, autistic man - left starving and desperately thirsty in hospital while waiting for a delayed operation. Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years.  These are the harrowing events that came days before the needless, avoidable death of Mark Stuart. Mark was a young man with autism.
  13. News Article
    More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner. Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online. Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet. The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken. The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online. Read full story Source: BBC News, 9 December 2019
  14. Content Article
    In January 2016, a high-profile local inquest examined the death of Jasmine Lapsley, a six year old child who sadly died after choking on a grape. One of Bangors post-ACCS Clinical Fellows (not involved with the case) attended the inquest with the intention of sharing any learning points at a CPD Day for Emergency Medical Service (EMS) colleagues we were due to hold six weeks later.  Upon releasing the CPD Day programme, organisers realised some EMS colleagues were profoundly uncomfortable about this talk, stating concerns such as 'talking publicly about lessons learned might upset the bereaved family'. They decided to ask all delegates at the CPD day what they thought of the inclusion of this item on the conference programme before and after the talk. This poster shows the results. 
  15. News Article
    Half of the unexpected deaths in Belgian hospitals are due to a shortage of nurses, according to a study by the University of Antwerp. Researchers from the University of Antwerp show the link between the number of nurses in hospitals and the death of the patients they care for, based on data from 34,567 patients’ medical records in four Flemish, one Walloon and two Brussels hospitals. The records showed that, on average, three out of every thousand patients in the hospital died ‘unexpectedly’. A death is considered as unexpected when a patient suddenly dies during active treatment, with no care plan for the end of their life having been started. “We know from previous research that part of these unexpected deaths can be avoided, which is always heartbreaking for the family as well as the staff,” said Filip Haegdorens, a researcher at the university. “As a sector, we must do everything we can to prevent this,” he added. The average nurse in Belgium is responsible for 9.7 patients at a time. For 89% of all departments, the number of nurses per hospital department was too low to be able to ensure good quality care. “Compared to, for example, Australian hospitals, where legal minimums exist, our Belgian figures could be improved,” said Haegdorens. The study also shows a link between the training level of nurses and the number of unexpected deaths in the hospital. “In some hospital services, we found that more nurses with a high level of education would reduce the risk of unexpected deaths,” Haegdorens added. Read research paper Read full story Source: The Brussels Times, 4 December 2019
  16. Content Article
    A blog from Dr Linda Dykes. "Bryn was my patient. He died. He may have stood a better chance of survival had I been aware of the risk of small bowel volvulus in an adult.  I produced this reflective learning resource with some colleagues - and with Bryn's widow, whom we call Fiona.  Please read it... it may help you save a life one day."
  17. News Article
    One of the main brands of adrenaline auto-injector pen, which can save lives during serious allergy attacks, is being recalled in the UK after the death of a teenager whose family say the product failed. Shante Turay-Thomas, 18, died in September last year after it is claimed that her adrenaline pen did not work although she tried it twice. She told her mother, “I’m going to die,” as she succumbed to an allergic reaction to hazelnuts. Her death was the subject of an inquest hearing last month, which resumes this week. The Medicines and Healthcare products Regulatory Agency (MHRA) confirmed this weekend that all batches of Emerade auto-injector had been recalled from pharmacies after an error was identified that can cause some pens to fail to activate. Between July and November, the agency said it had been made aware of 16 suspected activation failures. The agency said it was aware of two fatalities of patients reported to have used the pens but the fault had not been confirmed as a contributor to the deaths. Read full story Source: The Times, 8 December 2019
  18. News Article
    Safety incidents at hospital, mental health and ambulance trusts were linked to more than 4,600 patient deaths in the last year, data shows. The types of patient safety issues recorded by the National Reporting & Learning System (NRLS), which compiles NHS data, include problems with medication, the type of care given, staffing and infection control. In total 4,668 deaths were linked to patient safety incidents, of which 530 deaths specifically linked to mental health trusts and 73 to ambulance trusts. Guidance accompanying the data from the NRLS, which was set up in 2003, states deaths are not always “clear-cut” and cannot always be attributed to patient safety incidents. However, under the “degree of harm” section recorded on the system, there were 4,688 cases listed as death. In total, 4,356,277 reports of patient safety incidents were reported between November 2018 and October 2019. They are described as issues where unintended or unexpected incidents which could have – or did – lead to harm of a patient under the care of the NHS. Other safety incidents had links to consent, paperwork, facilities, and in some cases patient abuse by staff or a third party. Read full story Source: The Guardian, 9 December 2019
  19. News Article
    Maternity services at Shrewsbury and Telford Hospitals Trust were 50 midwives short of what was safe, hospital inspectors have said. A new report by the Care Quality Commission, published today, revealed the trust, which is at the centre of the largest maternity scandal in the history of the NHS, had a 26% vacancy of midwives in April this year. An independent investigation has been examining poor maternity care at the hospital since 2017 and the trust was put into special measures and rated inadequate by the CQC in 2018. Read full story Source: The Independent, 6 December 2019
  20. News Article
    Two patients have died as a result of NHS hospitals failing to heed warnings about the use of super-absorbent gel granules, which patients mistakenly eat thinking they are sweets or salt packets. A national patient safety alert has been issued by NHS bosses to all hospitals, ambulance trusts and care homes instructing them to stop using the granules unless in exceptional circumstances. An earlier alert in 2017 warned the granules, which are used to prevent liquid being spilled, had caused the death of one patient who choked to death after eating a sachet left in an empty urine bottle in their room. The 2017 alert warned hospitals there had been a total of 15 similar incidents over a six-year period between 2011 and 2017. The latest warning from NHS England says most hospitals concentrated on “raising awareness” rather than stopping the use of gel granules. Read alert Read full story Source: The Independent, 4 December 2019
  21. Content Article
    Superabsorbent polymer gel granules are used to reduce spillage onto bedding and clothing when patients use urine bottles or vomit bowls, or when staff move fluid-filled containers (eg washbowls or bedpans). If the gel granules are put in the mouth, they expand on contact with saliva risking airway obstruction. This National Patient Safety Alert requires any organisation still using these products to protect patients by introducing strict restrictions on their use. 
  22. News Article
    The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life. Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December. The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate". The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance." At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset". It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient". The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety". Read full story Source: BBC News, 5 December 2019
  23. News Article
    NHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
  24. News Article
    How many people die in California psychiatric facilities has been a difficult question to answer. No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation. In an effort to assess the scope of the problem, The Times submitted more than 100 public record requests to nearly 50 county and state agencies to obtain death certificates, coroner’s reports and hospital inspection records with information about these deaths. The Times review identified nearly 100 preventable deaths over the last decade at California psychiatric facilities. It marks the first public count of deaths at California’s mental health facilities and highlights breakdowns in care at these hospitals as well as the struggles of regulators to reduce the number of deaths. The total includes deaths for which state investigators determined that hospital negligence or malpractice was responsible, as well as all suicides and homicides, which experts say should not occur among patients on a psychiatric ward. It does not include people who died of natural causes or other health problems while admitted for a psychiatric illness. Read full story Source: Los Angeles Times, 1 December 2019
  25. Content Article
    Reducing the burden of harm and instilling better practice requires both systems thinking and committed local ownership. Comparisons of health systems across the world can help visualise best practice, opportunities for learning and potential for diffusion of innovations. Most importantly, depicting the global state of patient safety showcases exemplar safety systems and facilitates exploration of their characteristics and enablers.   This report seeks to stimulate ambitious visions and bold action to significantly reduce harm and improve the lives of millions of patients and their families. 
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