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Content ArticleHow many of you know the full history of duty of candour in healthcare in the UK? It was Will Powell who, after the tragic death of his son Robbie, brought to light that there was none. Even today we only have an institutional duty of candour in place, leaving clinicians with the right to lie as no specific law exists to prevent this.
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News ArticleA new study shows a quarter of mothers say their choices were not respected during childbirth, with some left with life-changing injuries as a result, despite Britain’s highest judges establishing women should be the primary decision makers during labour five years ago. A poll of 1,145 women, carried out by leading pregnancy charity Birthrights and shared exclusively with The Independent, also found that a third said healthcare professionals did not even seek their own opinions on the childbirth process, while 14& said their choices were overruled. One woman told The Independent she had been forced to give up her career as a lawyer following what she described as a “violent delivery”, while her baby daughter also sustained serious injuries to her face which can still be seen now – 12 years after she gave birth. Birthrights, which campaigns for respectful pregnancy care for women, pointed to the fact half a decade has passed since Nadine Montgomery’s Supreme Court case proved mothers-to-be are the primary decision-makers in their own care yet this is still not the reality for the majority of women. Read full story Source: The Independent, 3 September 2020
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Content ArticleDr Abdulelah Alhawsawi, Abdominal Organs Transplant and Hepato-biliary Surgeon, and Director General of the Saudi Patient Safety Center, discusses why hospitals are falling short of safe care levels. He believes healthcare continues to be structurally weak when it comes to the safety conditions and suggests that there is an urgent need for a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. In his essay, Dr Alhawsawi proposes four practical solutions.
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Content Article
Patient Safety Authority: Bed safety
Patient Safety Learning posted an article in Patient safety in health and care
In the past, healthcare workers considered bed rails a useful device to prevent patient falls from bed. While bed rails have their benefits, their use or misuse may also place patients at significant risk, resulting in death or serious injury. Entrapment is an occurrence involving a patient who is caught, trapped, or entangled in the hospital bed system, which includes the spaces in or around the bed rail, hospital bed mattress, or hospital bed frame. Entrapped body parts associated with risk for severe injury include the head, neck, and chest. Awareness of this risk must be heightened across the healthcare continuum. The Patient Safety Authority has collated guidelines, resources and educational tools on bed safety. -
Content ArticleThe COVID-19 pandemic will impact the health of many people in England and unfortunately many people will lose their lives. This paper from the Department of Health and Social Care, Office for National Statistics, Government Actuary’s Department and Home Office, provides a summary of research and analysis, discussing and estimating the health impacts (both excess deaths and morbidity) from the pandemic.
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Content ArticleThis Heathcare Huddle video focuses on key themes that came out of the First Do No Harm report. You can watch it in two parts or as one full video. PART ONE (with Darren Thorne, Managing Director of Facere Melius) - Theme 1: ‘No-one is listening’ – The patient voice dismissed - Theme 2: ‘I’ll never forgive myself’ – Parents living with guilt - Theme 3: ‘I was never told’ – the failure of informed consent PART 2 - Theme 4: Redress – ‘We want justice’ - Theme 5: ‘We do not know who to complain to’ – Complaints - Theme 6: Duty of Candour – ‘preventing future errors’ - Theme 7: Conflicts of interest – ‘we deserve to know’.
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News ArticleTheresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects. The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use. In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”. A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”. “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said. The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh. An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people. Read full story Source: The Independent, 28 August 2020
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Content Article
Hazardous Hospitals: research project
PatientSafetyLearning Team posted an article in Research
Hazardous Hospitals aims to elicit a wide range of viewpoints and experiences about the historical development of safety in NHS hospitals. They are interested to hear from anyone with direct experience of encountering health and safety risks in hospitals, promoting safety, or exposing shortcomings in healthcare quality. Follow the link below to find out more and how to participate. -
Content ArticleHazardous Hospitals is a Wellcome Trust Research Fellowship, exploring the history of safety in the British National Health Service.
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Content ArticleThe dangers of health care in Britain have been long understood. Systematic data collection of the hazards of health care can be traced back at least to the time of Florence Nightingale's publications in the 1860s. This short paper from Susan Burnett and Charles Vincent, outlines the evolution of patient safety and trace its development and progress over the last 10 years in Britain, where a nationalised health service and sustained commitment from Chief Medical Officer Sir Liam Donaldson and other senior figures have brought patient safety to considerable prominence.
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Content ArticleThis overview considers how the NHS has performed over the current parliament in relation to patient safety. It looks at data relating to reported incidents and harm, episodes of care free of certain types of harm, and patient and staff perceptions of safety.
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News Article
Inspectors criticise poor nursing and leadership in latest damning report
Patient Safety Learning posted a news article in News
A damning new report has exposed numerous lapses in nursing care on wards at Shrewsbury and Telford Hospital Trust amid a culture which left patients at risk of “unsafe and uncaring” treatment, the care watchdog has said. Inspectors from the Care Quality Commission (CQC) cited multiple examples of nurses at the scandal-hit trust lacking the knowledge to look after patients safely and failing to record key information needed to keep patients safe during an inspection of medical wards in June this year. The inspectors found poorly completed nursing records, equipment unavailable and nurses not following procedures. This meant some patients developed pressure sores, fell from their beds and were injured or suffered pain at the end of their life. Other patients were at risk of suffering similar harm. Inspectors ruled the trust, which was rated inadequate and put into special measures in 2018, was unsafe and criticised the hospital leadership for what it said was a “collective failure” that was perpetuating the problems at the hospital. Read full story Source: The Independent, 14 August 2020 -
News Article
Cosmetic surgeon struck off after botched ops
Patient Safety Learning posted a news article in News
A cosmetic surgeon who did not have adequate insurance for operations that went wrong has been struck off. Dr Arnaldo Paganelli worked privately for The Hospital Group in Birmingham. The Medical Practitioners' Tribunal Service ruled his actions constituted misconduct. Four women took their case to the body and the tribunal heard evidence about his time at Birmingham's Dolan Park Hospital where he made regular trips from Italy to work. Lead campaigner Dawn Knight, from Stanley, County Durham, said too much skin was removed from her eyes during an eyelift in 2012 and they became "constantly sore". She told BBC Radio 4's You and Yours programme she felt relieved Dr Paganelli "cannot injure anyone else on UK soil" and called for the government to tighten regulation around cosmetic procedures to protect the public. "The process has been long, emotional and exhausting. This situation must never be repeated. After all, when are you more vulnerable than when under aesthetic at the hands of a surgeon who has no insurance?" Read full story Source: BBC News, 12 August 2020 -
Content ArticleThis month, the Institute of Public Policy Research (IPPR) published their new Injury Prevention Policy, Better Than Cure.[1] In this report they call on the Government to make injury prevention a public health priority and to take further action to prevent the transmission of Covid-19 in the workplace. Patient Safety Learning welcomes the publication of this report and its recognition of the importance of improving patient safety. We concur with its identification of unsafe care as being driven by a range of underlying systems issues, such as the culture of fear, barriers to resource sharing and insufficient focus on patient safety training and skills. These closely relate to the six foundations of safer care we have set out in A Blueprint for Action.[2] We also agree about the importance of two core areas which they highlight for action in this respect: 1) The Government should commit to long-term safe staffing This is particularly an important issue as we return to more normal levels of care following the peak of the Covid-19 pandemic, with the need to ensure that organisations and staff transition to this safely.[3] We consider that system wide (health and social care) workforce modelling is needed to inform resourcing and ensuring safe staffing. 2) The NHS should use patient safety networks to share best practice We strongly agree about the importance of sharing learning for patient safety. We need people and organisations to share learning when they respond to incidents of harm, and when they develop good practice for making care safer. This is why we have created the hub, a patient safety learning platform. Designed with input from patient safety professionals, clinicians and patients, the hub provides a community for people to share learning about patient safety problems, experiences, and solutions. References 1. IPPR. Better Than Cure: Injury Prevention Policy, August 2020. 2. Patient Safety Learning. The Patient-Safe Future: A Blueprint For Action, 2019. 3. Patient Safety Learning. Patient Safety Learning’s response to the Health and Social Care Select Committee Inquiry: Delivering Core NHS and Care Services during the Pandemic and Beyond, June 2020.
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News ArticleLike most women affected by incontinence, 43-year-old Luce Brett has her horror stories. As a 30-year-old first time mum she recalls wetting herself and bursting into tears in the “Mothercare aisle of shame”, where maternity pads and adult nappies sit alongside the baby nappies, wipes and potties. But, she adds, these isolated anecdotes don’t really do justice to what living with incontinence is really like. “It’s every day, it’s all day. People talk about leaking when you sneeze or when you laugh, but for me it was also when I stood up, or walked upstairs. It was always having two different outfits every time I left the house to go to the shops. Incontinence robbed me of my thirties; it made me suicidally depressed,” Luce explains. “Everyone kept telling me it was normal to be leaky after a vaginal birth. It took quite a long time for me to find the courage or the words to stop them and say: ‘Everybody in my NCT (National Childbirth Trust) class can walk around with a sling on, and I can’t do that without wetting myself constantly’,” she adds. Read full article here.
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News ArticleA survey of members of the Royal College of Physicians (RCP) has found that almost two thirds (60%) of doctors worry that patients in their care have suffered harm or complications following diagnosis or treatment delays during the pandemic, while almost all doctors (94%) are concerned about the general indirect impact of COVID-19 on their patients. This is also compounded by the difficulty doctors are finding in accessing diagnostic testing for their patients. Only 29% of doctors report experiencing no delays in accessing endoscopy testing (one of the main diagnostic tests used by doctors) for inpatients, decreasing to just 8% for outpatients. Only 5% of doctors feel that their organisations are fully prepared for a potential second wave of COVID-19 infection, and almost two thirds (64%) say they haven’t been involved in any discussions about preparations for a second wave of the virus. While the government’s promise to roll out flu vaccines to millions more people is welcome, the RCP recently set several more priorities to help prepare the health service for future waves of COVID-19, including the need to ensure the NHS estate is fully able to cope. Only 5% say they wanted an antibody test for COVID-19 but were unable to access one. Of those tested, a quarter (25%) were positive, with little or no difference when it came to gender, between white and BAME doctors, trainees and consultants or between London and the rest of England. Professor Andrew Goddard, president of the Royal College of Physicians, said: “Delays to treatment are so often a major issue for the NHS but as a result of the COVID-19 pandemic, it’s fair to say we’ve reached crisis point. Doctors are, understandably, gravely concerned that their patients’ health will have deteriorated to the point where they will need much more extensive treatment than previously, at a time when NHS resources are already incredibly depleted." “We also cannot underestimate the need to prepare for a second wave of COVID-19 infection, which threatens to compound the situation. Without careful and rigorous preparation, a second wave coupled with the winter flu season, could overwhelm the NHS.” Source: Royal College of Physicians, 5 August 2020
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Content ArticleConcerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analysing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and the therapies often have narrow therapeutic windows. Thus, many of the processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviours that can result in substantial patient harm. To improve safety at the University of North Carolina, Chera et al. have applied the concepts of NAT to their practice to better understand their systems’ behaviour and adopted strategies to reduce complexity and coupling. Furthermore, recognising that you cannot eliminate all risks, they have stressed safety mindfulness among their staff to further promote safety. Many specific examples are provided herein. The lessons from NAT are translatable to clinical oncology and may help to promote safety.
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News ArticleThe mother of a former patient at a north Wales mental health unit has said she "couldn't let" her daughter "go back there" as new details about people being "neglected" there have emerged. ITV News has seen a leaked copy of the Robin Holden report from 2014. It was commissioned by Betsi Cadwaladr Health Board after staff on the Hergest mental health unit, which is situated within Ysbyty Gwynedd in Bangor, blew the whistle over management and patient safety concerns. It reveals details never before made public, about how staff struggled to care for patients. The document, which the health board has fought for six years to keep out of public view, gives an account of the death of a patient while no doctor was available because of rota gaps, another of a patient who tried to take their own life, again when no doctor was available, and inadequate staffing affecting patient care. Read full story Source: ITN News, 31 August 2020
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Content Article
Keeping patients safe from falls
Claire Cox posted an article in International patient safety
Tens of thousands of patients fall in health care facilities every year and many of these falls result in moderate to severe injuries. Find out how the participants in the Center for Transforming Healthcare’s seventh project are working to keep patients safe from falls. -
Content ArticleSince the release of the report Hearing and Responding to the Stories of Survivors of Surgical Mesh in December 2019, the New Zealand Ministry of Health, in collaboration with other health sector agencies, has been working to progress the agreed actions and support those who have been affected and minimise future harm. An update on each of the actions is detailed in the report is provided below.
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Content ArticleChaired by Baroness Julia Cumberlege, the Independent Medicines and Medical Devices Safety Review, First Do No Harm, examines how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. In this blog, Patient Safety Learning reflects on one of the key patient safety themes featured in the Review – patient complaints.
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Content ArticleRestorative justice is an approach that aims to replace hurt by healing in the understanding that the perpetrators of pain are also victims of the incident themselves. In 2016, Mersey Care, an NHS community and mental health trust in the Liverpool region, implemented restorative justice (or what it termed a 'Just and Learning Culture') to fundamentally change its responses to incidents, patient harm, and complaints against staff. This study highlights the qualitative benefits from this implementation and also identifies the economic effects of restorative justice.
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Content ArticleIn this article, published by Refinery 29, author Sarah Graham talks about gender bias in healthcare and the risk to patient safety.
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Content ArticleIn our final 2-minute Tuesday session of July 2020, Patient Safety Learning's Chief Executive, Helen discusses Baroness Cumberlege’s report ‘First Do No Harm’. She focuses on how the report amplifies the voices of women, identifying the scale and severity of harm going back decades to thousands of women. She adds: "This has been a problem hidden in plain sight that is now being exposed." Helen asks listeners whether they agree that transformational change is needed in the health and social care system to address these issues. Read more on our thoughts and the actions in response to the Cumberlege Review.
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News Article
Falls team on the up thanks to North Wales volunteers
Clive Flashman posted a news article in News
A dedicated team of 32 volunteers are hitting the roads across North Wales assisting the Welsh Ambulance Service in dealing with fallers. Based out of the Ambulance headquarters in St Asaph, the Community First Responder Falls Team was launched on 30 April this year and has already assisted almost 250 people. The team was created to use the talents and experience of the familiar Community First Responders (CFRs) who had to be stood down from their normal duties at the start of the Covid-19 pandemic. Read the full article here.
