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Found 1,334 results
  1. News Article
    A hospital trust has apologised to a woman for failing to admit a surgeon had been responsible for a massive haemorrhage that almost killed her after a Caesarean section. For seven years, East Kent Hospitals Trust maintained the size of Louise Dempster's baby was to blame. "It was just continuous lies," the 34-year-old told BBC News. East Kent Hospitals chief executive Tracy Fletcher promised "to ensure lessons are learned". Louise Dempster gave birth in May 2015 but the surgeon's error only emerged during an inquiry into poor maternity care at East Kent Hospitals Trust which reported this year. Read full story Source: BBC News, 9 December 2022
  2. News Article
    Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board (NPSB) as a non-punitive, collaborative, independent agency to address safety in healthcare. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions. Prior to the COVID-19 pandemic, medical error was the third leading cause of death in the United States, with conservative estimates of more than 250,000 patients dying annually from preventable medical harm and costs of more than $17 billion to the U.S. healthcare system. Recent data from the Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention indicate that patient safety worsened during the pandemic. The NPSB’s solutions would focus on problems like medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in transition from acute to long-term care. By leveraging interdisciplinary teams of researchers and new technology, including automated systems with AI algorithms, the NPSB’s solutions would help relieve the burden of data collection at the frontline, while also detecting precursors to harm. A coalition of leaders in health care, technology, business, academia, and other industries has united to call for the establishment of an NPSB. “We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have relied on the frontline workforce to do the work or take extraordinary precautions,” said Karen Wolk Feinstein, PhD, president and CEO of the Pittsburgh Regional Health Initiative and spokesperson for the NPSB Advocacy Coalition. “The pandemic has now made things worse as weary, frustrated, and stressed nurses, doctors, and technicians leave clinical care, resulting in a cycle where harm becomes more prevalent. Many organizations have united to advance a national home for patient safety to promote substantive solutions, including those that deploy modern technologies to make safety as autonomous as possible.” Read full story Source: Business Wire, 8 December 2022
  3. 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.
  4. Content Article
    This investigation by the Healthcare Safety Investigation Branch (HSIB) explores the issues associated with the assessment of risk factors for venous thrombosis in pregnancy and the first six weeks after birth. Venous thrombosis occurs when a blood clot forms and causes a blockage in a person’s vein. This can lead to venous thromboembolism (VTE), when part of the clot breaks off and travels through the bloodstream, blocking a blood vessel elsewhere in the body. Pregnant women and pregnant people are at greater risk of developing a venous thrombosis than those who are of the same age and not pregnant. Because of the increased risk, healthcare staff assess a pregnant woman’s risk factors for VTE at key stages before and after the birth, so that they can be given preventative treatment if necessary. While rare, in the UK venous thrombosis and VTE is the leading direct cause of death of pregnant women during pregnancy or up to six weeks after the end of pregnancy. Reference event The reference event for this investigation was the case of Alice, who was 26 years old and was pregnant with her second child. A VTE risk assessment was completed for Alice at her first antenatal appointment, when she was admitted to hospital for the birth of her child, and 24 hours after admission. Her score was zero each time, meaning no risk factors were identified for VTE. During her pregnancy Alice reported experiencing some pain in her calf; she was examined by a doctor who referred her for a scan. This ruled out a deep vein thrombosis (DVT). After giving birth by caesarean section, Alice's risk assessment was repeated, and as it indicated that medication was required, a preventative dose of low-molecular-weight heparin was prescribed and Alice was discharged. Eleven days after the birth of her baby, Alice was taken by ambulance to the emergency department with chest pain, shortness of breath and leg cramps. She was diagnosed with a pulmonary embolism (PE) and was started on a treatment dose of blood-thinning injections. Following investigation, it was found that Alice may not have received an appropriate preventative dose of low-molecular-weight heparin to help prevent the VTE.
  5. News Article
    NHS managers will be held accountable for failings at an overcrowded hospital where patients were put at risk of “serious harm” and some were left waiting up to 25 hours for a bed, ministers have warned. Forth Valley Royal Infirmary’s A&E was operating at two and a half times capacity during a visit by Healthcare Improvement Scotland (HIS) in September. Inspectors said that patients were at risk because of poor handling of medicines and unsafe working conditions at the hospital, which was placed in special measures by the Scottish government last month. The Times reported last month that the hospital had been declared “unsafe” by staff after five consultants resigned following severe criticism of the hospital’s leadership. They described it as a “war zone” and told of fire-fighting to cope with patient numbers while working in a “toxic” environment. Read full story (paywalled) Source: The Times, 6 December 2022
  6. News Article
    A consultant orthopaedic surgeon who carried out double the average number of knee and hip operations over a three year-period is facing a tribunal over alleged misconduct and more than 100 legal cases lodged by former patients, HSJ has been told. Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, is currently appearing before a misconduct hearing. The tribunal is investigating allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It has also been alleged that Mr Parker performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest. The trauma and orthopaedic surgeon is also facing allegations that he added pre-typed operation notes to approximately 14 patients’ records ahead of an invited review into his clinical practice by the Royal College of Surgeons, without indicating they had been made retrospectively. Read full story (paywalled) Source: HSJ, 5 December 2022
  7. Content Article
    An expert review of the clinical records of 44 deceased patients who had been under the care of neurologist Dr Michael Watt has found there were “significant failures” in their treatment and care. Dr Watt, a former Belfast Health and Social Care Trust consultant neurologist, was at the centre of Northern Ireland’s largest ever recall of patients, which began in 2018, after concerns were raised about his clinical work. More than 4,000 of his former patients attended recall appointments. At the direction of the Department of Health, in August 2021, the Regulation and Quality Improvement Authority (RQIA) commissioned the Royal College of Physicians to undertake an expert review of the clinical records of certain deceased patients who had been under the care of Dr Watt, with the intention to understand his clinical practice, to ensure learning for others and to help make care better and safer in the future.
  8. News Article
    More than 11,000 ambulances a week are caught in queues of at least an hour outside A&E units in England, a BBC News analysis shows. The total - the highest since records began, in 2010 - means one in seven crews faced delays on this scale by late November. Paramedics warned the problems were causing patients severe harm. One family told BBC News an 85-year-old woman with a broken hip had waited 40 hours before a hospital admission. She waited an "agonising" 14 hours for the ambulance to arrive and then 26 in the ambulance outside hospital. When finally admitted, to the Royal Cornwall Hospital, which has apologised for her care, she had surgery. Both ambulance response times and A&E waits have hit their worst levels on record in all parts of the UK in recent months. In Cornwall, patients facing emergencies such as heart attacks and strokes are now waiting more than two hours on average for an ambulance. The target is 18 minutes. They are thought to be among the worst delays in the country but none of England's ambulance services is close to the target, while Wales, Scotland and Northern Ireland are all missing their targets. Read full story Source: BBC News, 1 December 2022
  9. Content Article
    Extravasation is the accidental leakage of any liquid from a vein into the surrounding tissues, which can cause serious harm to the patient (NHS England, 2017). From 1 April 2011 until 31 March 2021 the NHS paid £15.6 million in damages relating to extravasation. This leaflet, published by NHS Resolution, aims to share learning from those claims.
  10. News Article
    The NHS could be facing its largest maternity scandal to date as the review into services in Nottingham is now expected to exceed 1,500 cases, The Independent has learned. The probe began in 2021 after this newspaper revealed dozens of babies had died or been left with serious injuries or brain damage as a result of care at NUH, which runs Nottingham’s City Hospital and Queen’s Medical Centre (QMC). But the scope of the investigation has more than doubled, with Nottingham University Hospitals NHS Trust sending more than 1,000 letters to families to contact the independent inquiry, after 700 families previously came forward with their concerns. Of these, the number of families expected to be covered by the probe is more than 1,500 – surpassing the 1,486 examined during the UK’s current largest maternity scandal in Shrewsbury. Read full story Source: The Independent, 30 November 2022
  11. Content Article
    A recently published report highlights the shortcomings in care provided by the NHS. Peter Walsh, Joanne Hughes and James Titcombe emphasise how millions could be saved if people were empowered early on to have their needs met without the need to turn to litigation
  12. Content Article
    This open letter from patient safety campaigner Richard von Abendorff calls for patients, their families and safety campaigners to help improve patient investigation and patient inclusive systems. Richard highlights a new role coming up at the new Health Services Safety Investigations Body (HSSIB).
  13. News Article
    Patients who underwent brain operations at a West Midlands NHS trust suffered unnecessarily because of poor surgical outcomes, a report has found. More than 150 deep brain stimulation surgery cases at University Hospitals Birmingham (UHB) trust are now being investigated and surgery is suspended. There were unacceptable delays responding to patient concerns, the independent review also said. The investigation recommended indefinitely suspending the service at the NHS trust until it is safer. Deep brain stimulation (DBS) for movement disorders is used on patients with conditions including Parkinson's disease and dystonia, where medication is becoming less effective. The independent review, carried out by medics from King's College Hospital, was ordered by UHB after a serious incident investigation of a patient who underwent DBS for Parkinson's disease. One of those 21 people, Keith Bastable, 74, from Brierley Hill, had DBS in May 2019 for his Parkinson's disease and the review found his probes were placed too far away to be acceptable. Due to the misplacement, one was never switched on and the other probe had to be switched off as he suffered slurred speech and other side effects. They were removed and new ones recently reinserted in Oxford after he was referred to a hospital trust there. Mr Bastable said he had felt abandoned in the time it had taken to get resolved. Read full story Source: BBC News, 29 November 2022
  14. Content Article
    Keeping patients safe during their care and treatment should be at the heart of any health system, including the NHS. Yet avoidable harm still occurs every day, around the world. There have been major efforts to prioritise patient safety in England, but the pandemic has shone a light on areas of care where progress has stalled, or safety has deteriorated. This report by Imperial College London's Institute of Global Health Innovation, commissioned by Patient Safety Watch, brings together publicly available data to present a national picture of patient safety in England. 
  15. News Article
    Some of the country’s GP are advising patients requiring urgent hospital care to “get an Uber” or use a relative’s car because of the worst ever delays in the ambulance service in England. Patients with breathing difficulties and other potentially serious conditions are being told in some cases that they are likely to be transferred more quickly from a general practice to accident and emergency if they travel by cab or private vehicle. NHS England data shows that October’s average ambulance response times for category 1 to 3 emergencies, which cover all urgent conditions, appear to be the highest since the categories were introduced nationally in 2017. Some patients who require emergency treatment may have to wait several hours for an ambulance to arrive. Dr Selvaseelan Selvarajah, a GP partner in east London, said: “If somebody is not having a heart attack or a stroke, my default advice is ‘have you got someone who can drive you or do you want to get an Uber?’ “These are patients who may have breathing difficulty or are suffering severe abdominal pain, but their life is not in immediate danger.” He said such patients would have previously been transferred by ambulance. Read full story Source: The Guardian, 27 November 2022
  16. News Article
    Bosses at Nottingham's crisis-hit maternity units are set to miss a deadline for clearing a backlog of incomplete "serious incident" investigations. Nottingham University Hospitals Trust (NUH) has 53 outstanding maternity incidents yet to be investigated. The trust had said it aimed to complete investigations by December 23. But director of midwifery Sharon Wallis says they have not progressed as quickly as she had hoped. The Local Democracy Reporting Service said the trust has managed to clear a number of those incidents - but it declared another nine in September and October. An independent review team, led by senior midwife Donna Ockenden, is examining dozens of baby deaths at the trust. Read full story Source: BBC News, 25 November 2022
  17. Content Article
    When medical errors result in adverse patient outcomes, many healthcare professionals are concerned about malpractice litigation. Fear of malpractice has been associated with excessive health care use through defensive medicine, which involves doctors ordering additional testing or making extra referrals to protect themselves from malpractice accusations. The authors of this study in JAMA Network Open aimed to examine the perspectives of doctors on patient harm and malpractice litigation. They conducted an online survey targeting all emergency department attending physicians and advanced practice clinicians (APCs) in acute care hospitals across Massachusetts from January to September 2020. The results showed that although clinicians feared legal action, they feared harming patients to a greater degree regardless of specialty, experience or sex.
  18. News Article
    A report by the Scottish Public Services Ombudsman (SPSO) said the health board's own investigation into the patient's complaint was of "poor quality" and "failed to acknowledge the significant and unreasonable delays" suffered. The delays led 'Patient C' to develop a severe hernia which left them unable to work, reliant on welfare benefits, and requiring riskier and more complex surgery than originally planned. The watchdog criticised NHS bosses for blaming Covid for the delays when the patient had been ready for surgery since December 2018, and said there had been "no sense of urgency" despite "the gravity of C's situation". The report said: "It is of significant concern that the Board has failed to fully acknowledge the consequences of the delays and the adverse effects upon C's physical and mental health as a result. "The consequences for C of these delays cannot and should not be underestimated." Read full story Source: The Herald, 24 November 2022
  19. Content Article
    A complaint from a patient was made to the Scottish Public Services Ombudsman (SPSO) about the care and treatment provided during the period January 2018 to September 2021. In January 2018 the patient underwent emergency surgery for a perforated sigmoid diverticulum (a complication of diverticulitis, an infection or inflammation of pouches that can form in the intestines). An emergency Hartmann's procedure (a surgical procedure for the removal of a section of the bowel and the formation of a stoma - an opening in the bowel) was performed. In April 2018, the patient was seen in an outpatient clinic and informed it would be possible to have a stoma reversal. The patient complained that the Board had continually delayed the stoma reversal surgery which they required, which as of September 2021 had not taken place. The patient also complained that Covid-19 could not account for the delays between the Board informing patient they were ready for surgery around December 2018 and the start of the pandemic in March 2020. The patient noted that as a consequence they had developed significant complications: a large hernia. The patient added that this had severely impacted their personal life and self-esteem, and left them unable to work and reliant on welfare benefits.
  20. News Article
    Ministers are considering the use of body cameras within mental health units as part of the government’s response to NHS abuse scandals, The Independent has learned. Senior sources with knowledge of the conversation between the Department for Health and Social Care and the NHS have raised concerns about the plans. There are fears that using the technology in mental health units could have implications for human rights and patient confidentiality. One senior figure criticised the proposals and said: “The DHSC are all talking about body-worn cameras, closed circuit TV, etc... The whole thing is fraught with huge difficulties regarding human rights, about confidentiality. They are thinking about it [cameras] and it is ridiculous.” The DHSC’s mental health minister Maria Caulfield said in parliament earlier this month that she and health secretary Steve Barclay were due to meet with NHS officials to discuss what response was needed to recent exposes of abuse within mental health services. It comes after a string of reports from The Independent, BBC Panorama and Dispatches revealing abuse of inpatients. The Panorama and Dispatches reports included video evidence of abuse captured by hidden cameras. Following a scathing independent review into the deaths of three young women, Tees, Esk and Wear Valleys NHS Trust said it is piloting the use of body-worn cameras across 10 inpatient wards “to support post incident reviews for staff and patients.” Read full story Source: The Independent, 23 November 2022
  21. Content Article
    In this BMJ opinion piece, Iona Heath reviews a new book by Penelope Campling, who worked as an NHS psychiatrist and psychotherapist for 40 years. Don't Turn Away tells the story of "an increasingly brutal turning away from the most abused and damaged people who struggle to survive within our complacent society." The article argues that over the past few decades, our society has failed to listen to and support the most vulnerable people, with mental health systems focusing on exclusion criteria and keeping people out of the system.
  22. News Article
    Greater Manchester’s mental health trust has been placed into the ‘equivalent of special measures’, the Manchester Evening News can reveal. The crisis measures enforced by the NHS come after allegations that patients were abused at a mental health unit run by the beleaguered trust. The Edenfield Centre is a mental health care facility in the grounds of the former Prestwich Hospital and was the subject of a BBC Panorama programme that claims patients were abused. Since the episode aired, 30 staff are facing disciplinary action and a dozen have already been sacked, the Manchester Evening News understands. The chair of the trust, Rupert Nichols, resigned last week after 'inexcusable behaviour and examples of unacceptable care' were 'exposed' at a mental health unit, he said. Now, NHS England is placing the Recovery Support Programme, the 'equivalent to the former special measures', multiple senior NHS sources say. Greater Manchester Mental Health NHS Foundation Trust (GMMH) is now under the highest level of NHS England intervention, the M.E.N. can confirm. Every trust is part of the NHS' Oversight Framework, those placed into its highest level are identified as experiencing the most significant and complex challenges in achieving financial sustainability and/or high-quality care receive intensive mandatory support. Read full story Source: 23 November 2022, Manchester Evening News
  23. News Article
    Attending physicians and advanced practice clinicians in US emergency departments are more concerned about medical errors resulting in patient harm than in malpractice litigation, according to a study published JAMA Network Open. The findings are based on an online survey of 1,222 ED clinicians across acute care hospitals in Massachusetts from January to September 2020. Respondents used a Likert scale of 1 (strongly disagree) to 6 (strongly agree) to indicate their degree of agreement with statements on how fearful they are of making a mistake that leads to a patient harm in their day-to-day practice, and how fearful they are of an error that results in being sued. The mean score was greater for fear of harm (4.40) than fear of being sued (3.40), the findings showed. Researchers said the mean scores for both fear of harm and fear of suit were similar regardless of whether the survey was completed before or after onset of the COVID-19 pandemic. Although previous studies have associated clinicians' fear of legal concerns with "excessive healthcare use through defensive medicine," the role fear of patient harm may play in clinical decision-making is less documented, researchers said. "Although the study did not delineate the association between this concern and potential overuse of testing, it suggested that fear of harm should be considered with, and may be more consequential, than fear of suit in medical decision-making," researchers said. Read full story Source: Becker's Hospital Review, 21 November 2022
  24. News Article
    A young mother lost both her feet and all 10 fingers to sepsis after a significant delay in treatment, an investigation has found. Sadie Kemp has been left permanently disabled from the “dangerous condition”, whilst an NHS hospital probe found a 3.5 hour delay in starting her care. Sadie is now calling for lessons to be learned after the internal report found numerous concerns in her treatment that ultimately led to her needing multiple amputations. The 35-year-old mother-of-two first attended A&E with agonising back pain caused by a kidney stone on Christmas night 2021. She was given pain relief at Hinchingbrooke Hospital, Cambridgeshire, and sent home to return the following morning for a kidney scan. She returned the same night at 4am as her pain endured. An assessment at 5.40am found she may have also been suffering from sepsis, but the step-by-step guide to chart and treat the illness was not found in her notes as being done at the time. The investigation found not only should the sepsis have been discovered and treated sooner, but the “lack of effective treatment” of the sepsis prior to the surgery meant she needed prolonged critical care. Read full story Source: The Independent, 22 November 2022
  25. Content Article
    Radar Healthcare has published its 'Incident Reporting in Secondary Care' whitepaper – an in-depth analysis of reporting within secondary care and its effects on patient safety. It has taken a look into the current state of incident reporting: the good work being done, the concerns across the sector, and how we can all aim to improve the situation. The report was conducted using a panel provided by SERMO from its database of UK Nurses and includes the views from 100 nursing staff members working in hospital wards across the UK. Those surveyed work with hospital in-patients daily and are responsible for reporting safety and regulatory incidents involving patients to senior colleagues.
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