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The Communication, Apology and Resolution model (CARe) offers healthcare organisations a detailed process for responding to unanticipated adverse outcomes, which includes proactively communicating with patients and families, examining and explaining what happened, avoiding recurrences by improving systems of care and, where appropriate, apologising and offering financial compensation. The model recognises that clinicians and staff will need peer support and training to effectively communicate with patients and families. In June 2022, advocates of the CARe model held an annual forum to highlight the successes of CARe programs in Massachusetts and to look at challenges health care providers face in doing this work consistently across their organisations. This article by the Betsy Lehman Center highlights video recordings shared at the forum including: A family member testimonial by Jane Bugbee, whose healthy daughter, Lindsay, died of Strep A and sepsis shortly after giving birth to her third child in July 2018 A simulation of a resolution conversation with a family A simulation of a conversation with provider after an adverse event.

Health care providers that encourage patients and parents to be "the eyes and ears" of patient safety gain many insights into opportunities for improvement and risk prevention. However, in the world of quality improvement the voices of patients and their families often go unheard. Dale Micalizzi and Marie Bismark published this article in the journal Pediatric Clinics of North America to share their perspectives as mothers of children who have benefited from and been harmed by paediatric care.

This blog describes the experience of Colonel Steven Coffee, Cofounder of Patients for Patient Safety US, who experienced a series of medical errors following the birth of his son. After a missed diagnosis of galactosemia, his son suffered liver failure and underwent a liver transplant at eight weeks old. Following his operation, the hospital where he was being treated did not have access to the powdered soy milk which was essential for his son's recovery. This experience spurred Colonel Coffee on to become an advocate for patient quality and safety in health care. For the last nine years, he has worked toward improved patient safety as the first community chair of MedStar Health’s Patient and Family Advisory Council for Quality and Safety (PFACQ).

This report is part of a technical series on safer primary care, published by the World Health Organization. The series explores the magnitude and nature of harm in the primary care setting from a number of different angles and provides some possible solutions and practical next steps for improving safety. The patient engagement report examines why it is important to involve people using services in improving safety and how this might best be done.

This Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines. Some drugs, such as those used in anaesthesia and pain management, can cause patients to stop breathing. After administration, these drugs should be flushed through cannulae and extension lines to make sure no residual quantities of the drugs are left. Despite the issuing of multiple safety alerts over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury (where the brain is damaged after a period where it does not get enough oxygen) or death. The investigation was launched after concerns were reported to HSIB by a consultant anaesthetist at a district general hospital where a patient had stopped breathing several hours after undergoing an anaesthetic. It’s thought that a quantity of the drug Suxamethonium - a muscle relaxant - was retained in their cannula after the procedure. The cannula containing the drug was flushed on the ward by a nurse preparing to administer intravenous paracetamol around three hours after the patient had returned from his procedure. The event was witnessed by a doctor who immediately started manual ventilation. The patient began to breathe spontaneously a few minutes later and suffered no physical harm. However, they have been left with a significant psychological impact following their experience of being awake but unable to move or breathe.

In 2021, a multi-professional staff support group was established under the Northern Care Alliance NHS Foundation Trust’s Freedom to Speak Up process which raised new questions and concerns around the probity and clinical standards of a Consultant Spinal Surgeon (“Consultant Spinal Surgeon A”) whilst they were employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) (“the Trust”). As a result, the Trust commissioned the Spinal Patient Safety Look Back Review (“SPSLBR”) and Investigation Group to evaluate these concerns, including obtaining independent expert advice.In January 2022, the Trust commenced the SPSLBR to investigate and manage patient safety concerns raised in respect of Consultant Spinal Surgeon A who was employed at Salford Royal NHS Foundation Trust (now part of the Northern Care Alliance NHS Foundation Trust) between 1991 and January 2015. This report outlines the investigation carried out by the SPSLBR Investigation Group on behalf of the Trust to investigate and manage potential Serious Incidents (“SI”) caused by the errors and omissions attributable to clinics, surgery and/or consultations undertaken by Consultant Spinal Surgeon A within the scope identified in the Terms of Reference. 

Read the latest monthly letters from the Chairman of the Patient Safety Movement Foundation.

David Gilbert is a writer and health activist. He was the first patient director in the healthcare system. He is a mental health service user with 40 years of experience in healthcare, specialising in patient and public engagement and coproduction. He helped pioneer the concept of patient leadership and authored ‘The Patient Revolution - how we can heal the health care system’. He is the founder and director of InHealth Associates, a network of specialists that supports experiential practice and patient leadership. His monthly newsletter, Impatient, is now published on the HSJ website.

Following Jeremy Hunt’s appointment as chancellor, HSJ is now hosting the Patient Safety Watch newsletter, written by Patient Safety Watch trustee James Titcombe.  Read the latest newsletter: Patient Safety Watch: What can be done to improve duty of candour?