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Content ArticleAs the NHS crisis has deepened in recent weeks, frontline staff have posted vivid, troubling accounts on social media of what has been happening in their workplaces. Many have described the NHS, and often themselves too, as “broken”. They have related the difficulty of providing proper care, the impact of acute understaffing and their fears for the NHS’s future. In this Guardian article, read some of what doctors, nurses and other NHS staff have been saying.
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Content ArticleHospitals are crammed full of patients, the staffing crisis in adult social care continues to escalate, and alarming numbers of junior doctors report that they are planning to quit their NHS posts to work abroad. The multiple problems confronting the UK’s health and care system are interconnected and have been years in the making. While the pandemic exacerbated many of them, hugely increasing pressures on staff, political failures and, above all, a lack of investment are making it impossible for the service to stand still this winter – let alone recover. This Guardian Editorial gives its view on the current state of the NHS.
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News Article
Midlands hospital investigating forceps left inside patient after surgery
Patient Safety Learning posted a news article in News
A hospital is investigating how a pair of metal surgical forceps were left inside a patient after they had been stitched up after abdominal surgery. Worcestershire Acute Hospitals NHS trust has apologised unreservedly and said the incident at Redditch’s Alexandra hospital was “exceptionally rare”. The medical blunder only became apparent after a seven-hour abdominal procedure last month, according to BBC Midlands, when the forceps were reported to be missing. The worst fears of medics were confirmed when the missing 15cm arterial clamp was found by an X-ray while the patient was still under anaesthetic. The surgical instrument could not be immediately removed and the patient was moved to intensive care overnight before another operation was performed the next day to retrieve the clamp. It is understood the trust’s investigation will look at whether the required double-checking of all instruments was conducted before the patient was stitched up after surgery. It will also examine the end of operation signing-out process, which is supposed to ensure such errors do not happen. Read full story Source: The Guardian, 23 December 2022 -
Content ArticleExtravasation is the unintentional leakage of vesicant fluids or medications from the vein into the surrounding tissue. This can cause harm and lead to complications for the patient. This guide, produced by the Royal Children's Hospital Melbourne, includes: Introduction Aim Definition of terms Risk factors Assessment Management Irrigation Procedure Follow-up/Review Special considerations Evidence Table Companion documents References
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News Article
Fury as minister says strikers choosing to harm
Patient Safety Learning posted a news article in News
Ambulance unions have reacted with anger after the health secretary said they had "taken a conscious choice to inflict harm on patients". Steve Barclay said unions had refused to work with the government at a national level on how they would cover emergency calls during strike action. Unison said it was "utterly shocked" by the comments, while the GMB union said they were "insulting". Paramedics are among those striking in England and Wales on Wednesday. Control room staff and support workers who are members of the Unison, GMB and Unite unions are also involved. NHS bosses are warning patient safety cannot be guaranteed during the action, although unions say life-threatening callouts will still be responded to by an ambulance. They also argue patients are already being put at risk due to waiting times and the pressure on the health service, made worse by staff shortages. Read full story Source: BBC News, 21 December 2022 -
News ArticleThe Birmingham MP Preet Gill has called on the UK health secretary to launch a major public inquiry into allegations that a bullying and a toxic culture is risking patient safety at University Hospitals Birmingham (UHB). The MP for Edgbaston, where UHB is based, said she had received complaints from staff alleging elderly patients had been left on beds in corridors outside wards due to mismanagement, and medics were discouraged from speaking out about problems. In a letter to Steve Barclay, seen by the Guardian, Gill said: “I have been inundated by messages from UHB staff, past and present, who have contacted me to share their experience of what has been repeatedly described as a toxic culture that has had an alarming impact on staff and patient care.” After an investigation by BBC Newsnight earlier this month, which found that doctors at the trust were “punished” for raising safety concerns, the Birmingham and Solihull Integrated Care Board (ICB) announced a three-part review into the culture at UHB. The first report is expected at the end of January. But Gill criticised the plans, saying she did not think it would “be sufficient to adequately investigate this scandal”, and instead called for a major independent public inquiry, similar to the 2013 Francis inquiry into the Stafford hospital scandal. “We cannot rely on an ICB investigation to solve this issue. Many of those on the ICB are former members of the senior leadership team from UHB and would not offer the independence required to recommend the changes that are so needed or give confidence to whistleblowers,” she said. Read full story Source: The Guardian, 19 December 2022
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News Article
Avoid any ‘risky activities’ on ambulance strike day, says health minister
Patient Safety Learning posted a news article in News
Health minister Will Quince has warned the public to avoid any “risky activities” on Wednesday as ambulance drivers stage strike action. The NHS is set to be hit by major disruption as ambulance workers including paramedics, control room workers and technicians walk out in England and Wales. During the strike, the military will not drive ambulances on blue lights for the most serious calls but are expected to provide support on other calls. Mr Quince urged the public to avoid anything risky on Wednesday, telling BBC Breakfast: “Where people are planning any risky activity, I would strongly encourage them not to do so because there will be disruption on the day.” The health minister did not offer examples of what might be defined as risky behaviour but told the public that in any emergency calling 999 should still be the first option. Read full story Source: The Independent, 20 December 2022 -
Content Article
Confraternity of Patients Kenya (COFPAK)
Patient Safety Learning posted an article in International patient safety
The Confraternity of Patients Kenya (COFPAK) is a registered non-profit organisation, independent of politics or religion, supporting health and social well-being of the public in Kenya. Their mandate is to advance, represent, safeguard and promote the interests of healthcare services seekers at all levels. COFPAK aims to collaborate with all stakeholders in the health sector to advance access to high quality, safe, accountable, affordable and sustainable healthcare ecosystem in Kenya. It exerts influence on policies and programmes toward the attainment of Universal Health Coverage. -
News ArticleNine ambulance trusts in England and Wales are expected to be affected by industrial action on Wednesday, coordinated by the GMB, Unison and Unite unions. The ambulance strikes will involve paramedics as well as control-room staff and support workers. The threat to patient safety on Wednesday will be exceptional. Under trade union laws, life-preserving care must be provided during the strikes. But there remains a lack of clarity about what will be offered. Even at this late stage, NHS leaders say negotiations are continuing between unions and ambulance services to agree which incidents will be exempt from strike action. All category 1 calls – the most life-threatening cases – will be responded to, while some ambulance trusts have agreed exemptions with unions for specific incidents within category 2 calls. However, in some cases, elderly people who fall during the strikes may not be sent help until they have spent several hours on the floor. Heart attack and stroke patients may get an ambulance only if treatment is deemed “time critical”. There is no doubt that many of those patients making 999 calls on Wednesday will not get the care they need. Some will probably die as a result. NHS leaders believe Wednesday’s strike will present a completely different magnitude of risk. Quite simply, patients not getting emergency treatment quickly enough can mean the difference between life and death. Read full story Source: The Guardian, 19 December 2022
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News Article
Take car in emergency during 999 strike, says cabinet minister
Patient Safety Learning posted a news article in News
Patients should “make their own way to hospital” if they can do so during Wednesday’s strike by ambulance workers, a cabinet minister said yesterday, as the government warned that the industrial action would put lives at risk. Senior government figures said that ambulance unions had still not agreed national criteria for what conditions would be considered life threatening and responded to during the strike. Steve Barclay, the health secretary, is understood to be writing to all striking unions, including nurses, seeking discussions on patient safety. Yesterday Oliver Dowden, the Cabinet Office minister, said people should still call 999 in an emergency but might in less serious cases have to make their own way to hospital. “We are working to ensure that if you have a serious injury, in particular a life-threatening injury, you can continue to rely on the ambulance service, and we would urge people in those circumstances to dial 999,” he told Sunday with Laura Kuenssberg on BBC1. “If it is the case that you have less serious injuries, you should be in touch with 111, and you should seek to make your way to hospital on your own if you are able to do so.” Read full story (paywalled) Source: The Times, 19 December 2022 -
News Article
The mental health patients dying on NHS wards from starvation and neglect
Patient Safety Learning posted a news article in News
Asystemic failure to provide basic physical care on NHS mental health wards is killing patients across the country, despite scores of warnings from coroners over the past decade, The Independent can reveal. An investigation has uncovered at least 50 “prevention of future death” reports – used by coroners to warn health services of widespread failures – since 2012, involving 26 NHS trusts and private healthcare providers. Cases include deaths caused by malnutrition, lack of exercise, and starvation in patients detained in mental health facilities. Experts warn that poor training and a lack of funding are factors in the neglect of vulnerable patients. The Independent investigation uncovered: Staff failing to carrying out basic health checks, such as assessment for risk of blood clots. Cases of nurses and care assistants without adequate CPR training. Doctors unable to carry out emergency response procedures. Patients not treated for side effects of antipsychotic medication. Rapidly deteriorating health going unnoticed and untreated. Coroners have exposed multiple cases of mental health patients receiving inadequate treatment in general hospitals, with their illness being mistaken for a psychiatric problem. Read full story Source: The Independent, 18 December 2022 -
News Article
Ambulance strike cover must be sufficient, says health secretary
Patient Safety Learning posted a news article in News
Unions must ensure there will be "sufficient" staffing during this week's ambulance strike to protect patients, the health secretary says. Workers in England and Wales will walk out on Wednesday in a dispute over pay, but life-threatening emergencies will be responded to. Unions say discussions were still taking place with ambulance trusts to draw up detailed plans for cover. Steve Barclay said there is a lack of clarity about what is being offered. He said it was for the unions to ensure they "meet their obligations" for emergency cover so that people in crisis get the care they need. But Unite leader Sharon Graham, whose union is co-ordinating the ambulance strikes with Unison and GMB, said Mr Barclay will "have to carry the can if patients suffer". The ambulance walkouts will involve paramedics as well as control room staff and support workers. The action by the three main ambulance unions - Unison, GMB and Unite - will affect non-life threatening calls, meaning those who suffer trips, falls or other injuries may not receive treatment. Read full story Source: BBC News, 19 December 2022 -
Content ArticleIn this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
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News Article
Republic of Ireland: 'Unsafe' A&Es criticised as doctors warn of GP crisis
Patient Safety Learning posted a news article in News
Patients are not safe from harm in three out of seven emergency departments, a damning new Hiqa inspection report has revealed. The report was released on the same day as an Oireachtas committee was warned of a growing crisis in primary care, with patients in some parts of the country unable to access basic GP services. Emergency Departments in Cork University Hospital (CUH) and University Hospital Limerick (UHL) were among seven EDs assessed by the health watchdog. In three EDs, including Cork and Limerick, inspectors found failures to ensure “service providers protect service users from the risk of harm.” Inspectors also found patients’ “dignity, privacy and autonomy” was not respected in UHL, while CUH was only partially compliant in this area. The report also highlighted lengthy waiting times, including one patient who spent 116 hours on a trolley at UHL. Read full story Source: The Irish Examiner, 15 December 2022 -
Content ArticleThis 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.
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News Article
ER doctors in the US misdiagnose patients with unusual symptoms
Patient Safety Learning posted a news article in News
As many as 250,000 people die every year because they are misdiagnosed in the emergency room, with doctors failing to identify serious medical conditions like stroke, sepsis and pneumonia, according to a new analysis from the US federal government. The study by the Agency for Healthcare Research and Quality estimates roughly 7.4 million people are inaccurately diagnosed of the 130 million annual visits to hospital emergency departments in the United States. Some 370,000 patients may suffer serious harm as a result. Researchers from Johns Hopkins University analysed data from two decades’ worth of studies to quantify the rate of diagnostic errors in the emergency room and identify serious conditions where doctors are most likely to make a mistake. While these errors remain relatively rare, they are most likely to occur when someone presents with symptoms that are not typical. “This is the elephant in the room no one is paying attention to,” said Dr. David E. Newman-Toker, a neurologist at Johns Hopkins University and director of its Armstrong Institute Center for Diagnostic Excellence, and one of the study’s authors. The findings underscore the need to look harder at where errors are being made and the medical training, technology and support that could help doctors avoid them, Dr. Newman-Toker said. “It’s not about laying the blame on the feet of emergency room physicians,” he said. Read full story Source: New York Times, 15 December 2022 -
Content ArticleFor decades, western Europe’s national healthcare systems have been widely touted as among the best in the world. But an ageing population, more long-term illnesses, a continuing recruitment and retainment crisis plus post-Covid exhaustion have combined, this winter, to create a perfect healthcare storm that is likely to get worse before it gets better, writes Jon Henley (Berlin), Kate Connolly (Berlin), Sam Jones (Madrid) and Angela Giuffrida (Rome) in this Guardian article.
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News Article
No timetable for infected blood victims' compensation
Patient Safety Learning posted a news article in News
There is a "moral case" for compensation to be paid to people affected by the contaminated blood scandal, the government has said. But Paymaster General Jeremy Quin told MPs he could not commit to a timetable. In August, the government announced that 4,000 UK victims would receive interim payments of £100,000. Tens of thousands of people contracted HIV or hepatitis C in the 1970s and 80s after being given infected blood. In September, modelling by a group of academics commissioned by the public inquiry estimated that 26,800 people were infected after being given contaminated transfusions between 1970 and 1991. The study calculated that 1,820 of those died as a result, but that the number could be as high as 3,320. The inquiry, chaired by retired High Court judge Sir Brian Langstaff, began taking evidence in 2018. The interim compensation announcement in August came after Sir Brian argued there was a compelling case to make payments quickly - saying victims were on borrowed time because of their failing health. Payments have been made to those whose health is failing after developing hepatitis C and HIV, and partners of people who have died. But families have complained that many people affected, such as bereaved parents, missed out. Read full story Source: BBC News, 15 December 2022 -
Content ArticleRecording of the Health and Social Care Committee meeting held on Tuesday 13 December 2022. Meeting started at 10.03am, ended 11.45am.
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Content ArticleThe Communication, Apology and Resolution model (CARe) offers healthcare organisations a detailed process for responding to unanticipated adverse outcomes, which includes proactively communicating with patients and families, examining and explaining what happened, avoiding recurrences by improving systems of care and, where appropriate, apologising and offering financial compensation. The model recognises that clinicians and staff will need peer support and training to effectively communicate with patients and families. In June 2022, advocates of the CARe model held an annual forum to highlight the successes of CARe programs in Massachusetts and to look at challenges health care providers face in doing this work consistently across their organisations. This article by the Betsy Lehman Center highlights video recordings shared at the forum including: A family member testimonial by Jane Bugbee, whose healthy daughter, Lindsay, died of Strep A and sepsis shortly after giving birth to her third child in July 2018 A simulation of a resolution conversation with a family A simulation of a conversation with provider after an adverse event.
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Content ArticleThis policy paper, published by the Department of Health and Social Care, provides an update on the UK Government’s progress in implementing the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review, sometimes referred to as the Cumberlege Review.
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Content ArticleThis is an Adjournment Debate from the House of Commons on Wednesday 7 December 2022 on fatalities relating to foetal valproate spectrum disorder.
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Content ArticlePatient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
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News Article
Six NHS workers reported ‘every week’ for sexually harassing patient or colleague
Patient Safety Learning posted a news article in News
Six NHS staff workers are typically reported every week in England for sexually harassing a patient or colleague, the Telegraph can reveal. Nearly a fifth of English trusts have recorded a rise in reports of sexual harassment within their services since 2017, while millions have been spent by the NHS on legal claims specific to sexual abuse over the same time period, according to newly obtained data. Health secretary Steve Barclay described the findings as “worrying” and urged NHS leaders to take “robust action in response to any such incidents in their organisation”. Patient Safety Learning said the Telegraph's “deeply troubling” revelations demonstrated an abuse of the “significant power imbalance” that exists between vulnerable patients and their care providers. “Healthcare professionals need to recognise the power they hold over patients,” said chief executive Helen Hughes. “Inappropriate behaviours undermine trust in healthcare system and the ability to deliver safe care.” “Clinicians, managers and healthcare leaders have both a professional and moral responsibility to patients to ensure that there is a safe culture in healthcare settings and that misconduct is not tolerated," said Ms Hughes. As part of its investigation into sexual harassment within the NHS, the Telegraph uncovered the case of a mentally incapacitated patient who was raped by her healthcare worker and subsequently fell pregnant. The healthcare worker, who is in his 30s, was recently jailed for eight months after pleading guilty to sexual activity with a mentally disordered female. Joe Matchett, an expert lawyer at Irwin Mitchell who has secured settlements for survivors of abuse, said his firm continues to “represent a number of patients subjected to terrible abuse at the hands of hospital staff who have betrayed their position of trust in the worst imaginable way”. Read full story (paywalled) Source: The Telegraph, 11 December 2022 -
News Article
Over 1000 'adverse events' in women and infants' care in Scotland
Patient Safety Learning posted a news article in News
More than 1000 investigations have been launched in Scotland over the past decade into adverse events affecting women and infants' healthcare. Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (Saers) have been initiated by health boards since 2012 following "near misses" or instances of unexpected harm or death in relation to obstetrics, maternity, gynaecology or neonatal services. The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards reported the totals per year as "less than five" to protect patient confidentiality. Saers are internal health board investigations which are carried out following events that could have, or did, result in major harm or death for a patient. Major harm is generally classified as long-term disability or where medical intervention was required to save the patient's life. They are intended as learning exercises to establish what went wrong and whether it could have been avoided. Not all Saers find fault with the patient's care, but the objective is to improve safety. NHS Lanarkshire was only able to provide data from April 2015 onwards, but this revealed a total of 194 Saers - of which 102 related to neonatal or maternity services, and 80 for obstetrics. A Fatal Accident Inquiry involving NHS Lanarkshire has already been ordered into the deaths of three infants - Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021 - because they had died in "circumstances giving rise to serious public concern". Read full story (paywalled) Source: The Herald, 10 December 2022
