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Showing results for tags 'Patient harmed'.
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Content Article
In this blog, Patient Safety Learning looks in detail at the results of the NHS Staff Survey 2022, focusing on responses relating to reporting, speaking up and acting on safety concerns. It includes the following key points: It is difficult to imagine other safety critical industries would deem these results acceptable. Nearly half of all respondents did not feel confident their organisation would address their concerns about unsafe clinical practice. It is hugely concerning that over 40% of respondents could not say that they would be treated fairly if involved in a patient safety incident. This could significantly undermine the willingness of staff to raise concerns, with significant consequences for patient safety. There needs to be greater urgency to improve the safety culture in the health service. NHS England needs to recognise the scale of this challenge and provide clarity on how it will work with organisations to tackle this. NHS England, working in partnership with the National Guardian and the Care Quality Commission, should bring forward as a matter of urgency robust and specific commitments to drive forward the work of improving the safety culture in the NHS. -
Content ArticleThis editorial commentary, published in the Journal of the Royal College of Physicians of Edinburgh, looks at the College's response to the Mid Staffordshire inquiry.
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Content ArticleNiche Health and Social Care Consulting (Niche) were commissioned by NHS England in November 2019 to undertake an independent investigation into the governance at West Lane Hospital (WLH), Middlesbrough between 2017 up to the hospital closure in 2019. WLH was provided by Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) and delivered Tier 4 child and adolescent mental health services (CAMHS) inpatient services. This review initially incorporated the care and treatment review findings of two index case events for Christie and Nadia who both died following catastrophic self-ligature at the unit. The Trust subsequently agreed to include the findings of the care and treatment review of Emily which related directly to her time at West Lane Hospital, even though Emily did not die at this site. This is to ensure that optimal learning could be achieved from this review.
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Content ArticleThe National Patient Safety Board (NPSB) is a proposed independent federal agency modelled in part after the National Transportation Safety Board (NTSB) and Commercial Aviation Safety Team (CAST) that would identify and anticipate significant harm in health care; provide expertise to study the context and causes of harm and solutions; and create solutions to prevent patient safety events from occurring. Watch this video from the Pittsburgh Regional Health Initiative.
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Content ArticleSome medical mistakes have been stubbornly hard to eliminate. Now, hospitals hope technology can make a difference. This Washington Post article highlights are some of the biggest problems that caregivers are trying to address with technology.
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Content ArticleECRI’s Top 10 Patient Safety Concerns 2023 list identifies potential sources of danger for patients and staff. ECRI believe these risks require the greatest focus for the coming year and offer actionable recommendations for reducing these risks. ECRI conducts independent medical device evaluations, annually compiles scientific literature and patient safety events, concerns reported to or investigated by the organization, and other data sources to create its top 10 list.
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Content Article
Patient Safety 5th Global Ministerial Summit 2023
Patient Safety Learning posted an article in WHO
The World Health Organization's 5th Global Ministerial Summit took place on the 23 and 24 February and was an opportunity for experts from across the world to send clear messages to ministers globally, and for ministers to respond with their pledges about what they were going to do to improve patient safety. Watch the opening and read the outcomes and documents from the Summit, -
Content Article
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Patient Safety Learning recently interviewed Keith Conradi, former HSIB chief executive, on why healthcare needs to operate as a safety management system. In this interview, we speak to Jono Broad, part of the South West Integrated Personalised Care team at NHS England, to hear his response to this, how patients, families and relatives can get involved, and why we need to really embed patient safety in a management culture and a healthcare management system.- Posted
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Content ArticleStatement from Maria Caulfield, Parliamentary Under Secretary of State (Minister for Mental Health and Women's Health Strategy) on the Government’s initial response to the report of the independent review into the maternity and neonatal services at East Kent University NHS Foundation Trust that was published on the 19 October 2022. NHS England commissioned Dr Bill Kirkup to undertake this review following concerns about the quality and outcomes of care.
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Content ArticleDysphagia (swallowing problems) occurs in all care settings and although the true incidence and prevalence are unknown, it is estimated the condition can occur in up to 30% of people aged over 65 years of age. Stroke, neurodegenerative diseases and learning disabilities can be the cause of some cases of dysphagia, and may also result in cognitive or intellectual impairment, as well as visual impairment, NHS England received details of an incident where a care home resident died following the accidental ingestion of the thickening powder that had been left within their reach. Whilst it is important that products remain accessible, all relevant staff need to be aware of potential risks to patient safety. Appropriate storage and administration of thickening powder needs to be embedded within the wider context of protocols, bedside documentation, training programmes and access to expert advice required to safely manage all aspects of the care of individuals with dysphagia. Individualised risk assessment and care planning is required to ensure that vulnerable people are identified and protected.
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Content Article
Infiltration is when fluid or intravenous drugs administered to a patient (which are given to patients into a vein through a cannula or other device) inadvertently leak into the tissue surrounding a vein by mistake. Extravasation is when infiltration occurs but the drugs involved are called vesicants which can damage the tissue and cause serious harm to the patient. The National Infusion and Vascular Access Society (NIVAS) are leading a campaign to improve awareness of infiltration and extravasation and reduce avoidable harm. In this interview Andrew Barton, Chair of NIVAS, explains why this is such an important issue and what needs to happen to improve patient safety. -
Content ArticleIn this article, John Tingle, Assistant Professor at the University of Birmingham Law School, discusses recent developments in patient safety in the context of possible reform of the clinical negligence system in the UK.
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Content ArticleIt's now a decade since the Francis Report, which outlined the causes of serious failures in care at Mid Staffordshire NHS Foundation Trust. The report and prior media coverage exposed a wide set of issues surrounding the culture and transparency of health care, and these topics remain of major concern today. In this article for the Nuffield Trust, Shaun Lintern has interviewed Sir Robert Francis KC about the weight of those patient stories and treatment of the NHS's staff, then and now.
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Content Article
In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries. In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign. -
Content ArticleThe Harmed Patients Alliance (HPA) was founded to highlight and promote restorative approaches to healthcare harm. To support their campaign for action, HPA carried out a survey of 44 people asking how those harmed by their contact with healthcare felt about the response, and what impacts this had on them. They were also asked what could have been done differently.
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Content ArticleMidurethral tapes (MUTs) were the most common surgical treatment for stress urinary incontinence (SUI) between 2008 and 2017. Transobturator tapes were introduced as a novel way to insert MUTs. Some women have experienced life-changing complications, and opt to undergo a total excision of transobturator tape (TETOT). This study, published in Neurourology and Urodynamics, aims to report clinical outcomes of all women who underwent TETOT in a specialist mesh centre.
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Content Article
In this opinion piece, Kath Sansom, founder of Sling the Mesh, looks at why an audit of pelvic mesh outcomes due to be published in April 2023 has again failed to capture the true extent of the harm caused by the procedure. She outlines why the approach taken by the Government and NHS Digital was flawed and why it is so important to understand both the proportion of women who have experienced harm as a result of the procedure, and the nature of their injuries and side effects.- Posted
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) have published a third interim report for this investigation which focuses on staff wellbeing across the urgent and emergency care systems and the impact that this has on patient safety.
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Content ArticleThis report looks into the circumstances surrounding the deaths of three young adults; Joanna, Jon and Ben. They each had learning disabilities, were patients at Cawston Park Hospital and died within a 27 month period (April 2018 to July 2020). It highlights multiple significant failures in care, including excessive use of restraint and seclusion, overmedication of patients, lack of record keeping and the physical assault of patients. The report also makes a series of recommendations for critical system and strategic change, both at a local and national level.
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Content Article
MDU: Cautionary tales - Real member stories
Patient Safety Learning posted an article in Legal matters
These case studies, based on MDU members' real-life experiences, provide a valuable opportunity for shared learning across a wide range of specialties and situations. MDU is a UK medical defence organisation. -
Content ArticleElectronic prescribing (ePrescribing) systems allow healthcare professionals to enter prescriptions and manage medicines using a computer. Sheikh and colleagues set out to find out how these ePrescribing systems are chosen, set up and used in English hospitals. Given that these systems are designed to improve medication safety, we looked at whether or not these systems affected the number of prescribing errors made (mistakes such as ordering the wrong dose of medication). They also tried to see whether or not the systems were good value for money (or more cost-effective). Finally, they made recommendations to help hospitals choose, set up and use ePrescribing systems.
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Content ArticleThe Patient Safety Authority has developed a series of decision trees to determine whether a patient safety event is a serious event or incident in a range of different situations.
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News Article
USA: House Bill establishes Federal Agency dedicated to patient safety
Patient Safety Learning posted a news article in News
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 -
News Article
Overcrowding at Forth Valley Royal Infirmary ‘risked harming patients’
Patient Safety Learning posted a news article in News
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 -
News Article
Prolific surgeon ‘harmed more than 100 patients’
Patient Safety Learning posted a news article in News
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
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