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Found 140 results
  1. Content Article
    This article describes how the Care Quality Commission has charged The Dudley Group Foundation Trust with the deaths of Kaysie-Jane Robinson (14) and Natalie Billingham (33) who were found to have died as a result of safety failures. The Dudley Group Foundation Trust pleaded guilty to the charges in court on 2 July 2021, however, only the death of Ms Robinson was accepted by the trust as a result of their care failures.
  2. Content Article
    National Guardian news discussing current events, annual reports, and guidance.
  3. Content Article
    The study aims to describe patients' experiences of acquiring a deep SSI and it's negative impact. The authors propose that as many safety measures should be taken as possible to avoid and prevent infection.
  4. Content Article
    After Rosie Bartel went for knee replacement surgery, she was told she had contracted the MRSA infection. In this video, Mrs. Bartel describes how she is now in a wheelchair after three years and 11 surgeries.
  5. Content Article
    Six news stories relating to studies on surgical site infections and reducing their incidence. Free registration is required to view this content.
  6. Community Post
    As someone who works with NHS and actually as a Mental Health and Physical Health patient I've experienced discrimination and out right assault by the police whilst in hospital and ended up under S136 for no valid reason. Although I was assaulted with handcuffs being thrown over the bed rail, breaking my wrist I think. Still not had my mangled wrist xrayed 2 months on. Nothing worse than being in a vulnerable situation and bullies absolutely thrive on people in vulnerable positions. Their bosses think they're wonderful and so kind but they are in a position of power so of course the bully treats them differently or act differently when seniors are around. I recently put in a formal complaint to CEO I knew very well but instead of replying (after I told her I had recordings) she completely blanked me and now retired. Instead of "this is very serious Dominic, please send any evidence etc" I get told "how wonderful" my bully is! Interim CEO took over so I must inform him of Duty of Candour (Robbies Law) too. They don't seem to like that being pointed out but I shall do it anyway in hope we get a decent CEO who isn't just a pencil pusher waiting for band 9 pension. If as a volunteer I've experienced what I have, I dread to think what goes on as full members of staff. What struck me was the impunity these bullies operate with once in band 8 or above roles. You'd be very shocked if you heard what myself and four other service users went through. At the time my bullies refused to apologise (even though she received "disaplinary action") For me bulling and cronyism are both rotting the NHS from the inside out and needs sorting ASAP Please don't get me wrong, I support 99% of NHS staff but I cannot ignore the bullying, certainly at directorate or managerial level. The small percentage who do bullies seem to have no self awareness and those under them seem to think bullying behaviour is just "Leadership" Well no leader worth any salt will abuse you or tell you who you can and cannot speak too. Seeing service users slowly driven out by a particular bullie was extremely hard and not one manager wanted to know (bar one kind soul). Leadership means you MUST act whenever you even sniff the types of behaviours that signal a bully, however things are that bad that management cannot or won't recognise the controlling and mean behaviours Thanks for reading my first post
  7. Community Post
    Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh yesh@scalpel.ai
  8. Community Post
    It's #SpeakUpMonth in the #NHS so why isn't the National Guardian Office using the word whistleblowing? After all it was the Francis Review into whistleblowing that led to the recommendation for Speak Up Guardians. I believe that if we don't talk about it openly and use the word 'WHISTLEBLOWING' we will be unable to learn and change. Whistleblowing isn’t a problem to be solved or managed, it’s an opportunity to learn and improve. So many genuine healthcare whistleblowers seem to be excluded from contributing to the debate, and yes not all those who claim to be whistleblowers are genuine. The more we move away for labelling and stereotyping, and look at what's happening from all angles, the more we will learn. Regardless of our position, role or perceived status, we all need to address this much more openly and explicitly, in a spirit of truth and with a genuine desire to learn and change.
  9. Content Article
    When many people think about NHS services they often think about clinical staff, such as doctors or nurses, and how they deliver care and interact with patients and families. However, in the context of patient safety, there is often more to see ‘behind-the-scenes’ in non-patient facing services. These services may be less visible, but they play a vital part in ensuring patient safety. Understanding the importance of these services, and how they are crucial to the ability of the NHS to operate effectively, is often underestimated. In this blog for the Healthcare Safety Investigation Branch (HSIB), National Investigators Russ Evans and Craig Hadley highlight how 'behind-the-scenes' services are crucial to help the NHS operate effectively and safely.
  10. Community Post
    I met at a recent conference a newly appointed Patient Safety Manager. She’d been working in a supporting role in another organisation and was delighted with her obviously well deserved promotion to a more senior role of patient safety manager in another Trust. But 6 days in, she’s had no induction, there is no patient safety strategy or plan in the Trust, there isn’t any guidance as how she should do her job other than just ‘get on with doing RCAs. ‘ She doesn’t know who she can turn to for advice or support either in her Trust or elsewhere. Are there networks of PSMs she can turn to? Surely there is a model framework for patient safety that is produced as a guide? How can we help her and other PSMs?
  11. News Article
    Police raised concerns to the Care Quality Commission over the care at a private hospital, run by Cygnet Health Care, after being called eight times by a patient, a report has revealed. The CQC has now placed the hospital, which provides care for female patients with learning difficulties, in special measures and rated it inadequate. The CQC report, published today, said: “Staff we spoke with said they were trained in how to use de-escalation techniques. However, two told us they were anxious as a team about using restraint. As a result, police were being regularly called to respond to incidents at the hospital by both staff and patients.” Read full story (paywalled). Source: HSJ, 02 September 2021
  12. News Article
    A private ambulance company, KFA Medical, which provided patient transport services for the NHS has been deregistered by the Care Quality Commission over concerns for patient safety. Concerns included lack of basic training and Disclosure and Barring Service checks on employees were not up to date or had not been carried out and when looking at four staff files none had current basic life support training. Sarah Dronsfield, the CQC’s head of hospital inspection, said: “We have been working with the provider since their suspension in January, however when we carried out this inspection, we found the provider had been unable to implement and sustain the necessary improvements to assure us that people were receiving safe care. This action should send a very clear message to all providers of independent health and care services that while taking enforcement action of this nature is not something we take lightly, we will always take action where appropriate to protect the health and safety of patients,” Read full story (paywalled). Source: 03 September 2021
  13. News Article
    Doctors have warned GPs are having to make difficult choices about which patients get blood tests because of the ongoing shortage of test tubes, describing it as a "perilous" situation. Due to the shortages, the NHS in England and Wales have told surgeries and hospitals to temporarily stop some blood testing, which includes tests for fertility, allergies and pre-diabetes. One woman, Alison Webb, has said she cannot have her yearly thyroid and cholesterol checked due to the shortages - and her tests are already overdue by four months. A Department of Health and Social Care spokesperson said, "The health and care system continues to work flat out with the supplier and stakeholders to put mitigations in place, and restore normal supply, and there continues to be stock in place." Read full story. Source: BBC News, 30 August 2021
  14. News Article
    According to reports, senior managers at an NHS trust knew up to 30 cancers may have gone undetected two years before an official probe into a backlog of thousands of X-rays. Although the Care Quality Commission (CQC) and Healthwatch made investigations in 2016, neither one were told of potential harm to patients. The backlog was publicly exposed by Ken Hall, who approached the Care Quality Commission in 2016, where it then identified 11,000 X-rays had not been processed, but was subsequently struck off after allegations of fraud. "These go through a rigorous quality assurance process and the Care Quality Commission would not publish any statement in an inspection report that it did not believe to be true." Said the CQC when asked about its findings of no harm after being shown the 2014 trust management committee reports, the CQC also told the BBC it could find no record of inspectors having had sight of them. Read full story. Source: BBC News, 27 August 2021
  15. News Article
    New data from NHS Digital on the latest vacancy statistics shows as of June 2021 there were 38,952 registered nurse vacancies across the health service, with the Royal College of Nursing saying news of worsening nurse shortages should “stun” ministers into taking action. RCN England director, Patricia Marquis, has said: “As health and care services head into what will be a very difficult winter, this should stun ministers to address the rising number of nursing vacancies and prevent further risk to patient care. After the pressures from the last 18 months we also know that many experienced nurses are considering leaving the profession. These are skills that cannot be replaced quickly. Unless there is an urgent investment in the nursing workforce, starting with an increase in pay that reflects their skill and professionalism, and there is accountability for workforce planning at ministerial level, we will be dealing with the fallout for years to come.” Read full story. Source: Nursing Times, 26 August 2021
  16. News Article
    According to Elizabeth Cotton, of Cardiff Metropolitan University, an expert in mental health at work, more than four in 10 – 41 per cent – of therapists working for the NHS’s talking treatments programme had been asked to manipulate data about patients’ progress. This was done in order to to improve the scheme’s apparent achievement rates, although NHS chiefs insist patients’ views are recorded when therapists are not present. Read full story. Source: The Independent, 26 August 2021
  17. News Article
    On 10 August NHS England issued guidance for healthcare workers, including medical directors and GPs, in the light of global shortages of blood tube products, now, doctors have raised concerns about the effects that a shortage of blood tubes in England will have on patient care and the NHS, which already faces backlogs. Read full story (paywalled). Source: BMJ, 24 August 2021
  18. News Article
    The authors of a new study in Australia, published in the Emergency Medicine Journal, have said moving emergency care patients to other hospital departments by wheelchair or trolley is prone to a high rate of mishaps, with nearly 40% leading to incidents. The study, which took place at Austin Hospital, a teaching hospital in the Melbourne suburb of Heidelberg, also found endotracheal tubes, ventilator hoses, and arterial lines were also associated with high mishap rates. “Risk events are common and some result in harm. Risk factors include a high equipment number, transport to a ward and some abnormal vital signs. As many risk events are likely preventable, our identified predisposing factors may inform preventative strategies that may benefit other emergency departments.” The authors have said. Read full story. Source: Nursing Times, 24 August 2021
  19. News Article
    BBC News Research has revealed disabled and vulnerable adults in England will face a steep rise in the amount they have to pay towards their care, with Directors of council services blaming years of government funding cuts. One woman, Saskia Granville earlier this year was shocked when she found her care charges had increased from £92 to £515 per month. A sum of almost £1,500 was also taken out of Saskia's bank account as a backdated payment, in March, leaving her in debt. Her mother, Bobbie, says: "Without my intervention, she wouldn't have had any food that week. She wouldn't have been able to pay her gas, electricity or water bills." Read full story. Source: BBC News, 24 August 2021
  20. News Article
    Midwives at Suffolk Hospital have spoken out in a whistleblowing letter describing problems in their department as ‘demoralising and heartbreaking’. In the letter, written by midwives who declined to give their names "for fear of retribution", describe constant staff shortages, a culture of blame and fear, a high pressure environment and substandard care, saying " We entered midwifery to be able to give women centred, holistic care. Instead it feels like we are being overwhelmed by the unmanageable and relentless workload, and as a result are giving substandard care which is demoralising and heartbreaking. We are all feeling like we are now desperate for change. This change is beyond what we can achieve ourselves so we urge you to please help us to generate it. It should not be accepted or tolerated for us to be forced into giving unsafe care entirely due to unsafe staffing". In response, Karen Newbury, head of midwifery at the trust, said: “We are working exceptionally hard to recruit additional midwives and we are very grateful for the flexibility and dedication of our staff in ensuring that we provide a safe and caring service – this was recognised by our Care Quality Commission inspection in April which found we managed safety well. We have recently completed recruitment so there will be at least two senior midwives on every shift to provide flexible and experienced support to our maternity teams, and we are working with colleagues regionally to recruit staff both locally and internationally as well as running a full student training programme.” Read full story. Source: Suffolk News, 20 August 2021
  21. News Article
    Almost 100 members of the army have been brought in to help four ambulance trusts amid staff shortages in the South Central, South West, North East and East areas of England, with Unison saying it was a sign "things were not right". Vicky Court, assistant chief operating officer at North East Ambulance Services has said "It will ensure everyone continues to get the care they need by freeing up paramedics to be more available to attend potentially life-threatening incidents." Read full story. Source: BBC News, 21 August 2021
  22. News Article
    Ashford and St Peter’s Hospitals Foundation Trust, has apologised after nearly 1,000 patients faced delays due to a breakdown of referral systems. It was found 175 of these patients were considered urgent cases by their GPs and are now being reviewed for clinical harm. When the error was discovered, the patients were added to the referral tacker by 9 July, however until that point, they had not been on any patient waiting list, nor were they visible to either operational management or clinical teams. Trust chief executive Suzanne Rankin said in a statement: “We are very sorry for any inconvenience these delays may have caused patients and we contacted all concerned and issued appointments where necessary.” Read full story (paywalled). Source: HSJ, 19 August 2021
  23. News Article
    According to recent reports, the number of patients on waiting lists for non-urgent hospital treatment in Wales has again hit record levels. Data has revealed there were 624,909 people waiting in June, and those waiting the longest, more than nine months, rose again to 233,210. A Welsh government spokesperson said: "Waiting times for treatment continue to grow. However, it is encouraging to see progress being made with the number of patients waiting over 52 weeks falling for the third month in a row. We also saw the largest number of specialist consultations completed and treatments started in any month since the start of the pandemic." A&E time performance has been at its worst on record, with 94,176 attendances to emergency units over the month. Health spokesman Russell George said: "To record the worst ever A&E waiting times and the longest NHS treatment waiting list in the same month shows a complete lack of leadership." Read full story. Source: BBC News, 19 August 2021 Related Reading Patient Safety Learning blog: Tackling the care and treatment backlog safely (19 August 2021)
  24. News Article
    According to public health reports, there has been a sharp rise in drug overdoses, particularly heroin, over the past 10-14 days with the synthetic opioid isotonitazene implicated in some cases. In several areas of the country including five London boroughs, Hampshire, Essex, West Sussex, Dorset and Thames Valley, there has been 46 poisonings, resulting in 16 deaths, although currently, investigations are still ongoing. In a National Patient Safety alert issued on 18 August 2021, Public Health England (PHE) have instructed all NHS organisations to ensure staff are made aware of the risk of severe toxicity resulting from the synthetic opioid, and that all organisations that treat emergency cases should ensure staff are able to treat suspected cases “using naloxone and appropriate supportive care”. Roz Gittins, director of pharmacy at the charity Humankind, said "People also need to know where they can get hold of naloxone, as well as being reminded to carry it with them and to let people know where they keep it. If advice and support is required then the local substance misuse service should be contacted for specialist support. We hope that the current consultation to widen naloxone provision will be successful and that improved funding will lead to naloxone being distributed more widely to help reduce the risk of accidental opioid overdoses." Read full story. Source: The Pharmaceutical Journal, 18 August 2021
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