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News ArticleOversight failures, a fearful workplace culture and lax quality standards for years at a Veterans Affairs hospital in Arkansas, USA, allowed a pathologist who was routinely drunk on the job to misdiagnose thousands of veterans — sometimes with dire or deadly consequences, a new investigation has found. Hospital leaders “failed to promote a culture of accountability” that would have led more of the doctor’s colleagues to come forward with accounts that his behavior was putting patients at risk, according to the report released Wednesday by VA’s Office of Inspector General. But the staff members at the Veterans Health Care System of the Ozarks in Fayetteville feared that reporting their concerns would lead to retaliation from their bosses. “Any one of these breakdowns could cause harmful results,” Inspector General Michael Missal’s staff wrote in an 86-page report about the failures to stop the pathologist, Robert Morris Levy. “Together and over an extended period of time, the consequences were devastating, tragic, and deadly.” Read full story Source: The Washington Post, 2 June 2021
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News Article
Sisters with sickle cell had devastating, and preventable, strokes
Patient Safety Learning posted a news article in News
It was 4am on a Sunday in San Antonio, US, when Dana Jones heard an ominous sound, barely audible over the whirring of box fans, like someone struggling to breathe. She ran down the hall and found her daughter Kyra, age 12, lying on her back, gasping for air. Terrified, she called 911. A police officer, the first to arrive, dashed into Kyra’s bedroom, threw the slender girl over his shoulder and laid her on a leather sofa in the living room. He asked her mother, an oral surgery technician, to give her CPR. Kyra’s lips were ice-cold. An ambulance whisked the girl to Methodist Children’s Hospital, where staff members swarmed her and put her into a medically induced coma. Kyra, who has sickle cell, had suffered a devastating stroke — her second — a common complication of this inherited disease, which afflicts 100,000 Americans, most of them Black. She most likely would never have had the strokes if she had been given an annual screening test and treatment proven more than two decades earlier to prevent 9 out of 10 strokes in children with the disease and recommended by the National Institutes of Health. But like countless other children with sickle cell, she was never screened. Read full story Source: New York Times, 23 May 2021 -
News Article“Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital. The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures. The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period. It was recognised during a routine wound dressing change, about 48 hours postoperatively. “A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said. “We would also like to affirm that we will be doing everything to unravel the case, to investigate all internal processes and critically analyze them. Any necessary steps will immediately be taken.” Read full story Source: Lansing Injury Law News, 24 May 2021
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News Article
NHS warned multiple times that imaging shortages may kill
Patient Safety Learning posted a news article in News
Coroners have warned the NHS nearly a dozen times in recent years that a lack of imaging capacity could lead to more deaths, HSJ can reveal. Five of these warnings followed deaths at a single site, Tameside General Hospital in Greater Manchester. The most recent case concerned a patient that died after developing covid during a prolonged wait for an MRI scan. Sir Mike Richards last year warned in a major report for NHS England about the lack of imaging equipment, and the Royal College of Radiologists has highlighted national shortages of radiology staff on numerous occasions in recent years. HSJ combed through more than 100 prevention of future death reports and responses published between 2018 and 2021 in an effort to quantify harm linked to these shortages. Of dozens of reports mentioning imaging issues, including software problems, poor note-taking and incorrect interpretation of results, HSJ identified 11 cases where coroners specifically warned either the trust or system concerned, and/or NHS England or the Department for Health and Social Care, that capacity issues could lead to future deaths. In some of the cases, coroners concluded that shortages likely contributed to a patient’s death. Read full story (paywalled) Source: HSJ, 20 May 2021 -
News Article
Breast implant victims to receive compensation
Patient Safety Learning posted a news article in News
More than 2,500 women who were victims of the PIP breast implant scandal should receive compensation, a French appeal court has decided. It also upheld an earlier judgement finding German company TUV Rheinland, which awarded safety certificates for the faulty implants, negligent. The case in Paris involved 540 British women, who said they suffered long-term health effects. The results could have far-reaching implications for other victims. Jan Spivey is one of the women in the case. She was given PIP implants after she had a mastectomy due to breast cancer. She developed sore and aching joints, chest and back pain, fatigue, severe headaches and anxiety. Once removed it was clear her implants had been leaking silicone into her body. She says the implants have had a massive impact on her mental health. "My PIP implants from 20 years ago are still impacting on my life and my health and my wellbeing, even today." Read full story Source: BBC News, 19 May 2021 -
News Article
Alarm raised years before hospital’s ‘inadequate’ rating
Patient Safety Learning posted a news article in News
Multiple concerns were being raised about an inpatient hospital for several years before it was rated ‘inadequate’ by the Care Quality Commission (CQC), HSJ has learned. Huntercombe Hospital in Maidenhead, which provides NHS-funded mental healthcare for children, was put into special measures in February after an inspection raised serious concerns over the apparent over-use of medication to sedate patients, among other issues. It has since received a further warning notice. The unit, which predominantly treats female patients, had previously been rated “good” by the CQC in 2016 and 2019. Five former patients and four parents have now told HSJ of poor care and practices at the unit between 2016 and 2020. Two of the families raised concerns directly to Huntercombe, as well as NHS England, local authorities and the local community provider, Berkshire Healthcare FT. Read full story (paywalled) Source: HSJ, 18 May 2021 -
EventNever Events and serious Incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commision (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified and errors attributed to processes and individual staff. In this webinar, we welcome representatives from the CQC and the National Orthopaedic Alliance (NOA) to discuss learning from never events and serious incidents. Register
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EventThere are a number of circumstances that compromise a clinician’s ability to provide safe care, such as unfollowable policies, malfunctioning equipment, or a culture of blame when something goes wrong. In some cases, these system-based factors force clinicians to step outside of the standard of care. Panelists will discuss how to apply the Just Culture framework to inform improvements when the standard of care is not followed and will describe the data that can identify system failures before harm occurs. Register
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Event
First Do No Harm APPG: Virtual public meeting on redress
Sam posted an event in Community Calendar
untilOn Wednesday 26th January from 10:30-12:00, the All-Party Parliamentary Group for First Do No Harm (APPG FDNH) will hold a virtual public meeting on the topic of redress schemes for those who have suffered avoidable harm linked to pelvic mesh, sodium valproate and Primodos. This meeting will be an opportunity to hear from representatives of various patient groups about what victims need and what they are missing from current support mechanisms. Officers and members of the APPG FDNH will also provide an update on the Health and Care Bill, which will have passed through Committee in the House of Lords earlier that month. The meeting will be Chaired by Baroness Cumberlege (Co-Chair, APPG FDNH), who will be joined on a virtual panel by representatives of the following patient groups, as well as Officers and members of the APPG FDNH: Sling the Mesh Organisation for Anti-Convulsant Syndrome (OACS) Association for Children Damaged by Hormone Pregnancy Tests (ACDHPT) Independent Fetal Anti-Convulsant Trust (IN-FACT) Attendees will have the opportunity to put forward questions during the meeting and are invited to follow the event on social media by using #Redress and #FirstDoNoHarm. Those interested in attending are welcome to express their interest by emailing the APPG FDNH Secretariat via fdnh@luther.co.uk. -
EventuntilPatient safety is a critical global public health issue and is essential if health systems are to advance and achieve universal health coverage (UHC). Every year, an inadmissible number of patients are harmed or die because of unsafe and poor-quality healthcare, exerting a very high global burden especially in low- and middle-income countries (LMICs). Even before the pandemic, 1 in 10 patients in high-income countries were harmed from safety lapses during their hospital care. This number is greater in LMICs where adverse events in healthcare contribute to around 2.6 million hospital deaths each year. With the unprecedented COVID-19 pandemic, patient safety has become an even more crucial area for international cooperation. The United Kingdom of Great Britain and Northern Ireland invites you to join a high-level event on patient safety, co-sponsored by the World Health Organization, to: Illustrate the scale and significant burden of avoidable harm in healthcare globally and its impact on patients, families, healthcare workers, health system finances, communities and societies. Advocate a vision for eliminating avoidable harm in healthcare and demonstrate the need to prioritise patient safety as a global health priority, including by supporting strategic patient safety initiatives. Advocate for all countries to designate patient safety officers responsible for the coordination of patient safety implementation at national and facility levels. Register
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EventThis webinar will focus on how to harness the vast experience of the voluntary sector and advocate locally appropriate strategies to improve patient safety, through a network of Ambassadors. Who should attend? Patient safety can only be achieved by collaboration between the professionals, patients, families, community members and stake holders. So, whatever your background you are most welcome. Objectives To raise awareness about the burden of unsafe health care. To bring together the voluntary sector with a stake in health improvement programmes, to adopt a charter for patient safety and integrate safety strategies into their programmes. Speakers Neelam Dhingra, Unit Head, WHO Patient Safety Flagship/A Decade of Patient Safety 2020-2030, World Health Organization, Geneva Dr. Abdulelah Alhawsawi, Global Ambassador, The G20 Health and Development Partnership; Former Director General, Saudi Patient Safety Centre Dr. Zakiuddin Ahmed Founder, Riphah Institute of Healthcare Improvement & Safety and Healthcare Quality & Safety Association of Pakistan Ms Regina N. M Kamoga, Executive Director, CHAIN Uganda Register
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EventJoin the Patient Safety Movement for a unique opportunity to view the award-winning HBO hit film Bleed Out and talk with the filmmaker, Steve Burrows afterwards. Bleed Out is the harrowing HBO feature documentary film that explores how an American family deals with the effects of medical malpractice. After Judie Burrows goes in for a routine partial hip replacement and comes out in a coma with permanent brain damage, her son, Steve Burrows, sets out to investigate the truth about what really happened. The documentary film takes place in real time over a span of ten years. Tickets
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EventThis conference focuses on reducing medication errors and resulting harm in line with the WHO Medication without Harm Programme goal to reduce the level of severe, avoidable harm related to medications by 50% over the next five years. The conference focuses on prioritising high risk medications and high risk patient groups to enable your interventions to have the highest impact on patient care and reduction in patient harm. The conference which aims to bring together clinicians and pharmacists, managers, and medication safety officers and leads will reflect on medication safety issues that have arisen as a result of the COVID-19 pandemic, understand current national developments, and to debate and discuss key issues and areas they are facing in improving and monitoring medication safety, and reducing medication errors and harm in hospitals. There will also be a focus on prescribing error following the recent HSIB investigation and the January 2021 investigation into prescribing error in children. Further information and registration or email: kerry@hc-uk.org.uk hub members receive 10% discount. Email: info@pslhub.org Follow the conversation on Twitter #MedicationErrors
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EventuntilThere are many sources of variation in healthcare that can affect the flow of patients through care systems. Reducing and managing variation enables systems to become more predictable and easier to manage so allowing improvement of quality and safety. To effect successful service improvements, you need to understand the source of variation and use a range of tools to reduce and manage it. This pandemic has provoked the best of human compassion and solidarity, but those who manage our health systems still face extraordinary challenges responding to COVID-19. Looking beyond the crisis, our collective learning about the effects of the large falls in healthcare use can help inform and intensify efforts to reduce unnecessary care. The aim of this webinar from GovConnect is to build a culture of collaborative working across the healthcare workforce and reduce variation to prevent avoidable harm to patients, enhance healthcare equity, and improve the sustainability of health systems everywhere. Register
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EventuntilHarmed Patients Alliance we will be hosting an online webinar focusing on restorative healing after healthcare harm. This online webinar will explore the issue of second harm in healthcare with a range of patient, academic and clinical expert members of our advisory group. Each panel member will give a presentation sharing their experience and perspective, followed by an interactive panel discussion chaired by Shaun Lintern, Health Correspondent for the Independent. Register
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Content ArticleSome patients are unable to tolerate imaging procedures such as MRIs due to pain or anxiety. In these cases, a variety of medications are routinely used prior to imaging to allow the procedure to be carried out successfully. Varying levels of sedation before imaging can be appropriate given the need for patients to remain still during the imaging process, but the minimal amount of sedation should be used to mitigate unwanted side effects and reduce the risk of adverse events. This article examines two cases that highlight the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required and when monitoring is limited or inadequate.
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Content Article
Vaginal mesh: The forgotten women (4 July 2022)
Patient Safety Learning posted an article in Women's health
Mesh survivors Katherine Cousins and Mary McLaughlin talk about their ongoing fight for justice for women suffering due to vaginal mesh. -
Content ArticleDiscussion on issues relating to vaginal mesh implants from 29 Jun 2022.
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Content ArticleComplications of surgical mesh procedures have led to legal cases against manufacturers worldwide and to national inquiries about their safety. The aim of this study from Keltie K et al. was to investigate the rate of adverse events of these procedures for stress urinary incontinence in England over 8 years.
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Content ArticleIn this presentation Paula Goss, the founding member of Rectopexy Mesh Victims and Support, shares her experience of having a mesh implant. She describes the absence of informed consent during the procedure and the pain and complications she experienced following her surgery. This was shared at a Bristol Biomedical Research Centre workshop aimed at improving shared decision making for surgical innovation.
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Content ArticleIn this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.
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Content ArticleThis is the annual report of the National Diabetes Inpatient Audit–Harms (NaDIA-Harms) programme, which aims to monitor and reduce instances of key life-threatening diabetes specific inpatient events. The programme covers hypoglycaemic rescue, diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state (HHS) and diabetic foot ulcer. Overall 4,605 inpatient harms were submitted to the NaDIA-Harms audit between May 2018 and October 2020; the majority of which related to hypoglycaemic rescue (69%). This report also covers: the number of submissions of each inpatient harm. the impact of the Covid-19 pandemic on inpatient harms. patient profiles of people that experience each inpatient harm. These include demographics, diabetes characteristics, treatment targets, care processes, admission characteristics and comorbidities.
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Content Article
Two years after Baroness Cumberlege shared her damning report, 'First Do No Harm', which highlighted serious failures in response to reports about harmful side effects from medicines and medical devices, too many mesh injured women still continue to be let down by the healthcare system. Women who have been harmed by pelvic mesh surgery have shared a series of appalling accounts of how they have been treated by their doctors while desperately seeking help for their injuries and complications. In this blog, we examine how these comments reveal an underlying misogyny held by many doctors, and a failure to take women’s concerns seriously. -
Content Article
Safe care for people with diabetes in hospital (January 2020)
Patient-Safety-Learning posted an article in Diabetes
This article in the journal Clinical Medicine looks at the safety of people with diabetes when they are admitted to hospital as an inpatient. Having diabetes in hospital is associated with increased harm. Although the National Diabetes Inpatient Audit has shown that inpatient care for people with diabetes has slowly improved over the last few years, there are still challenges in terms of providing appropriate staffing and education. Progress is still needed to ensure the safety of people with diabetes in hospital. The authors look at some of the key areas of concern for people with diabetes in hospital, including increased risk of hypoglycaemia, hyperglycaemia (including diabetic ketoacidosis (DKA) and hyperosmolar hyperglycaemia state), medication errors, hospital acquired foot ulcers, increased length of stay and overall increase in death. -
Content Article
In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents.
