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Content ArticleThe latest ECRI and the Institute for Safe Medication Practices PSO Deep Dive explores one of the areas that accounts for a large portion of healthcare volume: surgical care. Annually, surgery accounts for 7 million inpatient hospital stays and 36 million procedures in the outpatient setting. Although surgical safety has been the subject of guidelines, patient safety and quality improvement projects, and attention in the literature, adverse events continue to occur with relative frequency, putting patients at risk.
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Content ArticleIn this blog, Patient Safety Learning considers the need for global action to improve patient safety and sets out its response to the WHO’s consultation on the draft Global Patient Safety Action Plan 2021-2030.
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News ArticleAn NHS trust has offered an unreserved apology to an elderly patient and his family after they accused hospital staff of restraining him 19 times in order to forcibly administer treatment. East Kent Hospitals University NHS Foundation Trust admitted that care for the man, who has dementia, “fell far short” of what patients should expect. The 77-year-old had been admitted to the William Harvey Hospital last November for urinary retention problems, according to a recent BBC investigation. In February, The Independent revealed that a police investigation had been launched into an alleged assault against an elderly man at the hospital after nurses and carers were filmed by hospital security staff holding the man’s arms, legs and face down while they inserted a catheter. A whistleblower told The Independent that the incident was being covered up by the trust and staff were told: “Don’t discuss it, don’t refer to it at all.” On Wednesday, the trust said its investigation had found a failure to alert senior medics to the difficulties being experienced in caring for the patient. Changes to dementia care including ward reorganisation, training and recruitment are underway, said a spokesperson, who added: “We apologise unreservedly to the patient and his family for the failings in his care, this fell far short of what patients should expect.” Read full story Source: The Independent, 14 October 2020
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Content ArticleIn this study, Avery et al. estimated the incidence of avoidable significant harm in primary care in England, and describe and classify the associated patient safety incidents and generate suggestions to mitigate risks of ameliorable factors contributing to the incidents. The study found there is likely to be a substantial burden of avoidable significant harm attributable to primary care in England with diagnostic error accounting for most harms. Based on the contributory factors we found, improvements could be made through more effective implementation of existing information technology, enhanced team coordination and communication, and greater personal and informational continuity of care.
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News ArticleThe announcement on Friday by the Care Quality Commission (CQC) that it will bring criminal charges against an NHS trust for failing to provide safe care to a patient is a hugely significant milestone in efforts to bring about greater accountability and safer care in the health service. The CQC has had the power to bring such prosecutions against hospitals since April 2015 when it was given a suite of new legal powers to hold hospitals to account on the care they give to their patients. Bringing in the new laws, the so-called fundamental standards of care, was one of the most significant actions taken after the care disaster at the Mid Staffordshire NHS Trust, where hundreds of patients suffered shocking neglect, with some dying as a result. Prosecuting East Kent Hospitals University Trust over the tragic 2017 death of baby Harry Richford is a big step for the CQC and a consequence of the long-forgotten battles of many patients and families in Stafford who were told they were wrong in their complaints against the hospital. It will almost certainly lead to more calls for criminal charges against hospitals from families who have been failed. There are countless examples of NHS trusts not acting on safety warnings and patients coming to harm as a result. Just this week an inquest into the case of baby Wynter Andrews at Nottingham University Trust revealed fears over safety had been highlighted to the trust board 10 months before her death. At Shrewsbury and Telford Hospitals Trust there are hundreds of families asking the same questions as more evidence emerges of long-standing failures to learn from its mistakes. CQC's chief executive, Ian Trenholm, has provoked anger among NHS leaders and clinicians when he advocated taking a tougher line when trusts break the law. But it is unlikely the CQC will launch a slew of prosecutions. It has said it will bring cases only where it sees patterns of behaviour and systemic failings. That is the correct approach as healthcare is complex and single errors will sadly happen despite everyone doing their best. Read full story Source: The Independent, 10 October 2020
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News Article
NHS compensation payouts have doubled in six years, figures show
Patient Safety Learning posted a news article in News
NHS Payouts linked to medication blunders have doubled in six years, fuelling record spending, official figures show. The NHS figures show that in 2019/20, the health service spent £24.3 million on negligence claims relating to medication errors - up from £12.8 million in 2013/14. The statistics show that in the past 15 years, almost £220 million has been spent on claims relating to the blunders. Previous research has suggested that medication errors may be killing up to 22,000 patients in England every year. Errors occur when patients are given the wrong drugs, doses which are too high or low, or medicines which cause dangerous reactions. In some cases, patients have been given medication which was intended for another person entirely, sometimes with fatal consequences. Other studies suggest that 1 in 12 prescriptions dispensed by the NHS involve a mistake in medication, dose or length of course. In some cases, patients have died after being given a dose of morphine ten times that which should have been administered, with other fatalities involving fatal reactions. Confusion often occurs when drugs are not labelled clearly, or when packaging of different medications looks similar. Jeremy Hunt, now chairman of the Commons Health and Social Care Committee, said the NHS needed to make far more progress preventing harms, instead of seeing an ever increasing negligence bill. He said: “It is nothing short of immoral that we often spend more cleaning up the mess of numerous tragedies in the courts, than we actually do on the doctors and nurses who could prevent them." Read full story (paywalled) Source: The Telegraph, 3 October 2020 -
Content ArticleIn this guest blog for mumsnet, Nadine Montgomery talks about her journey to the Supreme Court to cement patients’ right to make an informed decision. Nadine highlights the lack of information she was given around potential birth risks as a diabetic pregnant women and how, if better informed, she would have made different choices which could have prevented her baby from suffering harm.
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News ArticleThe NHS 111 service has permanently stopped nurses and other healthcare professionals in a clinical division handling calls with people suspected of having COVID-19 after an audit of recorded calls found more than 60% were not safe. The audit was triggered in July after many of the medical professionals recruited to work in that clinical division of the 111 service sounded the alarm, saying they did not feel “properly skilled and competent” to fulfil such a critical role. An investigation was launched into several individual cases after the initial review found that assurances could not be given “in regard to the safety of these calls”, according to an email, seen by the Guardian, from the clinical assurance director of the National Covid-19 Pandemic Response Service. In a further email on 14 August, she told staff that after listening to a “significant number” of calls “so far over 60% … have not passed the criteria demonstrating a safe call”. A number of “clinical incidents” were being investigated, she said, because some calls “may have resulted in harm”. One case had been “escalated as a serious untoward incident with potential harm to the patient”. NHS England declined to answer questions about any aspect of these apparent safety failings, saying it was the responsibility of the South Central ambulance service (SCAS), which set up a section of NHS 111 called the Covid-19 Clinical Assessment Service (CCAS). Read full story Source: The Guardian, 1 October 2020
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News ArticleThe surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent. Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital. It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act. According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery. It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes. Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient. The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise. Read full story Source: The Independent, 30 September 2020
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Content ArticleThis is a video recording of a formal meeting (oral evidence session) of the Health and Social Care Select Committee on Tuesday 29 September 2020, as part of their inquiry looking at the Safety of maternity services in England.
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News ArticleToo many English hospitals risk repeating maternity scandals involving avoidable baby deaths and brain injury because staff are too frightened to raise concerns, the chief inspector of hospitals has warned. Speaking at the opening session of an inquiry into the safety of maternity units by the health select committee, Prof Ted Baker, chief inspector of hospitals for the Care Quality Commission, said: “There are too many cases when tragedy strikes because services are not not doing their job well enough.” Baker admitted that 38% of such services were deemed to require improvement for patient safety and some could get even worse. “There is a significant number of services that are not achieving the level of safety they should,” he said. He said many NHS maternity units were in danger of repeating fatal mistakes made at what became the University Hospitals of Morecambe Bay NHS foundation trust (UHMBT), despite a high profile 2015 report finding that a “lethal mix” of failings at almost every level led to the unnecessary deaths of one mother and 11 babies. “Five years on from Morecombe Bay we have still not learned all the lessons,” Baker said. “[The] Morecombe Bay [report] did talk about about dysfunctional teams and midwives and obstetricians not working effectively together, and poor investigations without learning taking place. And I think those elements are what we are still finding in other services.” Baker urged hospital managers to encourage staff to whistleblow about problems without fear of recrimination. He said: “The reason why people are frightened to raise concerns is because of the culture in the units in which they work. A healthy culture would mean that people routinely raise concerns. But raising concerns is regarded as being a difficult member of the team.” Read full story Source: The Guardian, 29 September 2020
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Content ArticleInfographic from the Patient Safety Movement on what is needed when a patient is harmed and why we need to involve patients and families throughout the process.
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News ArticleAt least 18 serious cases are being investigated by NHS bosses after GP and dermatology services were stripped from private medical company. The Kent and Medway Clinical Commissioning Group (CCG) confirmed on Monday an independent review was taking place. It will see if delays to treatment for thousands of patients using DMC Healthcare services "caused harm". The NHS removed contracts worth £4.1m a year from the private firm in July. DMC was responsible for nearly 60,000 patients at nine surgeries in Medway, and skin condition services in other parts of Kent, the Local Democracy Reporting Service said. In north Kent, there were 1,855 patients needing urgent treatment and a further 7,500 on the dermatology service waiting list. Of those, 700 had been waiting more than a year. Nikki Teesdale, from Kent and Medway's CCG, said it was "too early" to reach definitive conclusions around the 18 serious cases. Speaking to Kent and Medway's joint health scrutiny committee on Monday she said of the 18, five had been waiting "significant periods of time" for cancer services. "Until we have got those patients through those treatment programmes, we are not able to determine what the level of harm has been," she added. Read full story Source: BBC News, 29 September 2020
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Community Post
Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear
Patient Safety Learning posted a topic in Medication including labelling
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See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.
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Content ArticleThis was an Adjournment Debate from the House of Commons on the 24 September 2020 on NHS Hysteroscopy Treatment tabled by Lyn Brown MP.
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Content ArticleInsight into medical device and system failure and the teachings of Henry Petroski, a professor of civil engineering at Duke University, who wrote about failure analysis and design theory.
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Content Article
Nigeria: World Patient Safety Day 2020
Patient Safety Learning posted an article in Staff safety
Nigeria joined the rest of the world to celebrate World Patient Safety Day on 17 September 2020. This event was jointly organised this year in Nigeria by the Occupational Health and Safety Managers (OHSM), Medical and Health Workers Union of Nigeria (MHWUN), OSHAfrica, International Trade Union Congress (ITUC-Africa), Nigeria Labour Congress (NLC), Patient Safety Movement Foundation (PSMF) and the World Health Organization (WHO). -
News ArticleAccidents on maternity wards cost the NHS nearly £1 billion last year, Jeremy Hunt, the chairman of the Commons health committee, has revealed. The former health secretary said the bill for maternity legal action was nearly twice the amount spent on maternity doctors in England. It was part of the NHS’s £2.4 billion total legal fees and compensation bill, up £137 million on the previous year. Mr Hunt has also told the Daily Mail there is evidence that hospitals are failing to provide details of avoidable deaths despite being ordered to do so three years ago as he highlighted “appalling high” figures which showed that up to 150 lives are being lost needlessly every week in public hospitals. Responding to the figures, Mr Hunt said: "Something has gone badly wrong." In 2017, he told trusts to publish data on the number of avoidable deaths among patients in their care. But freedom of information responses from 59 hospital trusts, about half the total, found less than a quarter gave meaningful data on avoidable deaths. Mr Hunt cited “major cultural challenges” which he blamed for preventing doctors and nurses from accepting any blame. He blamed lawyers who get involved “almost immediately” once something goes wrong with a patient’s care. “Doctors, nurses and midwives worry they could lose their licence if they are found to have made a mistake. Hospital managers worry about the reputation of their organisation,” he added. Mr Hunt said: “We have appallingly high levels of avoidable harm and death in our healthcare system. We seem to just accept it as inevitable.” An NHS spokesman said: “Delivering the safest possible health service for patients is a priority, and the national policy on learning from deaths is clear that hospitals must publish this information every three months, as well as an annual summary, so that they are clear about any problems that have been identified and how they are being addressed. Read full story Source: The Telegraph, 18 September 2020
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Content ArticleRecognising the scale of avoidable harm linked with unsafe medication practices and medication errors, WHO launched its third Global Patient Safety Challenge: Medication Without Harm in March 2017, with the goal of reducing severe, avoidable medication-related harm by 50% over the next five years, globally. This report, 'Medication safety in high-risk situations', outlines the problem, current situation and key strategies to reduce medication-related harm in high-risk situation.
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Content ArticleIn the aftermath of an adverse event, an apology can bring comfort to the patient, forgiveness to the health practitioner, and help restore trust to their relationship. According to the Health and Disability Commissioner: "The way a practitioner handles the situation at the outset can influence a patient's decision about what further action to take, and an appropriate apology may prevent the problem escalating into a complaint to HDC". Yet, for many health practitioners saying "I'm sorry" remains a difficult and uncomfortable thing to do. We can help to bring down this wall of silence by developing a clear understanding of the importance of apologies to patients and health practitioners; appreciating the difference between expressing empathy and accepting legal responsibility for an adverse outcome; knowing the key elements of a full apology and when they should be used; and supporting those who have the honesty and courage to say "I'm sorry" to patients who have been harmed while receiving healthcare.
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News ArticleA damning report into Devon’s NHS 111 and out of hours GP service has revealed shocking stories of patients who have either had their health put at risk or tragically died due to the service being in need of urgent improvement. Devon Doctors Limited, which provides an Urgent Integrated Care Service (UICS) across Devon and Somerset, was inspected by independent health and social care regulator the Care Quality Commission (CQC) in July, after concerns were raised about the service. They included the care and treatment of patients, deaths and serious incidents, call waits, staff shortages, and low morale. Inspectors found 'deep rooted issues'. The CQC concluded it was not assured that patients were being treated promptly enough and, in some cases, they had not received safe care or treatment. It is calling for the service to make urgent improvements which will be closely monitored. Since August 2019, the report stated Devon Doctors had received 179 complaints. Nine had been identified by the service as incidents of high risk of harm and six had been identified by the service as incidents of moderate risk of harm. These had been recorded on the service’s significant event log. However, on review, the CQC identified an additional 30 events from the complaints log which could also have been classed as either moderate or high risk of harm. Read full story Source: Devon Live, 15 September 2020
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Content ArticleDo patients’ and families’ experiences with communication-and-resolution programmes suggest aspects of institutional responses to injury that could better promote reconciliation after medical injuries? This interview study of 40 patients, family members, and hospital staff in Australia found that patients have a strong need to be heard after medical injury that is often unmet. Although 18 of 30 patient and family participants (60%) reported positive experiences with communication-and-resolution programmes overall and continued to receive care at the hospital, they reported that hospitals rarely communicated information about efforts to prevent recurrences. Opportunities are available to provide institutional responses to medical injuries that are more patient centred.
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Content ArticleThis was a debate from the Scottish Parliament on the 8 September 2020 concerning the recommendations in the recently published First Do No Harm report by the Independent Medicines and Medical Devices Safety Review, chaired by Baroness Cumberlege (also known as the Cumberlege Review). The debate centred on a motion put forward by Jeane Freeman MSP, Cabinet Secretary for Health and Sport, which read as follows: That the Parliament welcomes the recommendations made by Baroness Cumberlege in her report on the independent medicines and medical devices safety review; acknowledges the Scottish Government's apology to women and families affected by Primodos, sodium valproate and transvaginal mesh; welcomes the Scottish Government’s commitment to establish a Patient Safety Commissioner, and notes the actions taken by the Scottish Government to offer improved services for women who have suffered complications as a result of transvaginal mesh.
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Content ArticleAs patients and families impacted by harm, we imagine progressive approaches in responding to patient safety incidents – focused on restoring health and repairing trust. We can change how we respond to healthcare harm by shifting the focus away from what happened, towards who has been affected and in what way. This is your opportunity to hear about innovative approaches in Canada, New Zealand, and the United States that appreciate these human impacts. This interactive webinar was hosted by Patients for Patient Safety Canada, the patient-led program of the Canadian Patient Safety Institute and the Canadian arm of the World Health Organization Patients for Patient Safety Global Network. View the webinar on demand and download the slides.
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Content Article
Eric Kutscher: First, do no harm—but did I?
Patient Safety Learning posted an article in Blogs
The cost of providing care during a pandemic is seeing firsthand the evolution of medical knowledge, and wishing current data could have guided past decisions, says Eric Kutscher in this BMJ Opinion article.
