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Showing results for tags 'Patient safety incident'.
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News Article
NHS in crisis as almost half of maternity wards are offering substandard care
Patient Safety Learning posted a news article in News
Almost half of all English maternity units are offering substandard care, making it one of the worst performing acute medical services in the NHS, Byline Times analysis has found. The analysis, based on inspections of English hospitals by the Care Quality Commission (CQC), found that 85 of 172 inspected maternity services in England received ratings of ‘inadequate’ (18) or ‘requires improvement (67) at their latest inspection. Some 65% of maternity wards were given subpar ratings for patient ‘safety’ one of several metrics looked at by the CQC. The findings come after the health regulator began a focused inspection programme of maternity wards last year after the a government review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by shoddy care. In one unit at Gloucestershire Royal Hospital, there was a shortage of midwives, not all medicines practices were safe which “potentially placed women at risk of harm” and serious incidents were not being investigated. The report found a backlog of 215 patient safety incidents that had not yet been looked into, as of March this year. Maria Caulfield, Minister for Women’s Health Strategy, told Byline Times that “maternity care is of the utmost importance to this Government” and stressed they have “invested £165 million a year since 2021 to grow the maternity workforce and improve neonatal services”. “Every parent must be able to have confidence in the care they receive when giving birth, and we are working incredibly hard to improve maternity services, focusing on recruitment, training, and the retention of midwives,” she added. Read full story Source: Byline Time, 28 November 2023 -
Content ArticleRetrospective chart review is the standard for estimating prevalence of adverse events. Manual review of the electronic health record (EHR) is resource intensive. This study from Garzón González et al. describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.
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Content ArticleReducing the amount of time to give antibiotics to sepsis patients should contribute to better health outcomes, but the broad impact of reducing time-to-antibiotics may vary significantly, according to an AHRQ-funded study. In the study, published in Annals of the American Thoracic Society, researchers found that in 60% percent of hospitalisations patients received antibiotics within 48 hours of presentation and in 13% of hospitalisations patients experienced an adverse event, based on records of over 1.5 million hospitalised patients. The authors then ran simulations of 12 hospital scenarios based on the volume of sepsis cases (high, medium and low volume), and found that the effect of faster time to antibiotics varies markedly across simulated hospital scenarios, but new antibiotic-associated adverse events were rare.
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Content Article
Can you measure safety? Part 1
NMacLeod posted an article in Improving patient safety
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In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. He argues that, to measure safety, we need to understand the creation of risk. In this first blog, Norman looks at the problems of measuring safety, using an example from aviation to illustrate his points.- Posted
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Content ArticleThe Care Quality Commission's (CQC) annual report on their work to enforce the Ionising Radiation (Medical Exposure) Regulations in England has been published. The regulations protect people from the dangers of being accidentally or unintentionally exposed to ionising radiation in a healthcare setting. Errors can happen when healthcare providers use ionising radiation to diagnose or treat people. Healthcare providers must notify CQC about these. The report gives a breakdown of the number and type errors that CQC was notified about between 1 April 2022 and 31 March 2023. The report also presents the key findings from our inspection and enforcement activity in that time.
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Event
PSIRF embedding webinar 3
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) sets out a new approach to learning and improving following patient safety incidents across the NHS in England. PSIRF embedding webinars will feature presentations from NHS organisations and will focus on sharing experiences, adaptions and learning as the designed systems and processes put in place prior to transition are operationalised. Recordings, slides and Q&As from our transition webinars series can be found on Future NHS alongside other workshops and supplementary materials and resources: PSIRF Presentations - NHS Patient Safety - FutureNHS Collaboration Platform Audience: Embedding webinars are open to everyone to attend, including both NHS and arm’s length bodies. Presenters: Tracey Herlihey, Head of Patient Safety Incident Response, NHS England Further speakers TBC Register -
Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. LFPSE introduces improved capabilities for the analysis of patient safety events occurring across healthcare, and enables better use of the latest technology, such as machine learning, to create outputs that offer a greater depth of insight and learning that are more relevant to the current NHS environment. LFPSE fields can now integrated into Datix incident form, and the information is uploaded to the national database upon the completion of an incident report. After the reviewing manager’s and Patient Safety Team review, any changes are automatically re-uploaded and the information updated in the national database. CSH Surrey share their presentation slides on LFPSE and Datix.
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News Article
Two-thirds of homecare patient safety incidents linked to major provider
Patient Safety Learning posted a news article in News
Two-thirds of patient safety incidents recorded during hospital trusts’ monthly reporting period for homecare medicine provision were for services provided by the company Sciensus, an investigation by The Pharmaceutical Journal has revealed. In response to a freedom of information request sent to 131 hospital trusts in England in August 2023, 32 trusts recorded 417 patient safety incidents during their most recent monthly reporting period, which ranged from May to July 2023. Some 66% of these incidents (277) related to services delivered by homecare provider Sciensus, despite providing medicines to fewer than half (44%) of the 96,849 patients covered in the data. The findings come after the House of Lords Public Services Committee opened an inquiry into homecare medicines services in May 2023 following press reports of complaints from patient organisations and others about the service provided. The inquiry heard evidence from patient groups, regulators, homecare companies and the government during the summer and the committee will publish its report on 16 November 2023. Sciensus was previously known as Healthcare at Home and is one of the UK’s largest homecare companies. The data also uncovered that Sciensus was a poor performer on “failed” deliveries, defined as those that did not arrive on the scheduled day. Read full story Source: The Pharmaceutical Journal, 9 November 2023 -
Content ArticleThrough a data sharing agreement, the Faculty of Intensive Care Medicine can access a record of incidents reported to the National Reporting and Learning System (NRLS). Available information is limited and from a single source; all that is know about these incidents is presented in this report. The safety bulletin aims to highlight incidents that are rare or important, and those where the risk is perhaps something we just accept in our usual practice. It is hoped that the reader will approach these incidents by asking whether they could occur in their own practice or on their unit. If so, is there anything that can be done to reduce the risk?
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Event
SEIPS in learning disability, social care and mental health
Sam posted an event in Community Calendar
untilThe Patient Safety Incident Response Framework (PSIRF) encourages investigations across the NHS to apply SEIPS. This 3 hour masterclass will focus upon using Systems Engineering Initiative for Patient Safety (SEIPS) in Learning Disability, Social Care and Mental Health. SEIPS trainer Dr Dawn Benson has extensive experience of using and teaching SEIPS, as a Human Factors tool, in health and social care safety investigation. She will be joined in these masterclass sessions by clinical subject experts. The masterclass will be limited to a small group to ensure in-depth learning. Register -
Content ArticleSussex Community NHS Foundation Trust share their patient safety newsletters with the hub.
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Content Article
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This blog provides an overview of a Patient Safety Management Network (PSMN) meeting discussion on 27 October 2023. At this meeting, members of the network were joined by Dr Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB). The PSMN, created in June 2021, is an innovative voluntary network for patient safety managers and everyone working in patient safety. It provides a weekly drop-in session with guests to talk through issues of importance to patient safety managers, providing information, peer support and safe space for discussion. Find out more about the Network. -
Content Article
AHRQ: Network of Patient Safety Databases
Patient Safety Learning posted an article in Data and insight
The US Department of Health & Human Services was directed in the Patient Safety and Quality Improvement Act of 2005 to create and maintain a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for healthcare providers, Patient Safety Organisations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ), and others. AHRQ, the lead agency for patient safety in the USA implements the NPSD. Initially, the NPSD contains non-identifiable data derived from patient safety work product submitted by PSOs from across the country. This rich data source makes it possible to identify and track patient safety concerns for the purpose of learning how to mitigate patient safety risks and reduce harm across healthcare settings nationally. -
News ArticleA trust saw nearly 1,000 safety reports filed after introducing a new electronic patient record (EPR) – including one where a patient died and 30 others where they suffered harm. The Royal Surrey Foundation Trust and Ashford and St Peter’s Hospital Foundation Trust installed a new joint EPR system in the middle of last year. But Royal Surrey’s board was told there had been 927 Datix reports — which are used to raise safety concerns — related to the introduction of the “Surrey Safe Care” system, running up until mid September this year. The catastrophic harm involved a patient death which the trust says was not “directly linked to technical problems” with the EPR, as “human factors” were involved, including inexperience or unfamiliarity with the electronic prescribing system. Louise Stead, chief executive of Royal Surrey, said: “Implementing an electronic patient record is a huge shift for any workforce and we experienced some issues with the functionality of the system and getting users sufficiently trained and confident in using it correctly. We have worked hard to address these issues as quickly and responsibly as possible. “Our fundamental aim is for ‘zero harm’ and any harm caused to a patient is taken extremely seriously and investigated. In the case of these Datix incidents the vast majority (over 99%) resulted in low or no harm to patients. “However, one case resulted in the tragic death of a patient and we have been working closely with their family to be transparent and learn every possible lesson. This case was not directly linked to technical problems with the electronic patient record system and human factors did contribute. We are sincerely sorry for the failure in their care and devastating impact upon this person’s family.” Read full story (paywalled) Source: HSJ, 11 October 2023
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News Article
Over 17 000 serious incidents reported in mental healthcare last year
Patient Safety Learning posted a news article in News
The UK’s largest mental health charity, Mind, has published previously unseen data laying bare the full scale of the emergency in mental healthcare, with staff reporting 17,340 serious incidents in 12 months. The Care Quality Commission (CQC) figures shows mental healthcare staff across England reported an incident two times every hour in the last year, where people are treated for issues including self-harm, eating disorders and psychosis. Incidents included: injuries to patients that caused likely long term sensory, movement or brain damage, or physically damaged their body prolonged physical pain or psychological harm, or shortened life expectancy cases of abuse, including those involving the police injuries for which the patient needed treatment to prevent them dying. All of these incidents involved care providers raising concerns with the CQC under their statutory duty under Regulation 18. Dr Sarah Hughes, Chief Executive of Mind, says: “It is deeply worrying that healthcare staff across the country are so concerned about the situation in mental health settings that they are reporting a serious incident once every half an hour. We knew this was a crisis – now we know the scale of this crisis. People seek mental healthcare to get well, not to endure harm. Families are being let down by a system that’s supposed to protect their loved ones when they are most sick. The consequences can be and have been fatal". Read full story Source: Mind, 10 October 2023 -
News Article
‘Vital’ safety deadline thought to have been missed by most trusts
Patient Safety Learning posted a news article in News
Most trusts are thought to have missed the deadline to launch a new national incident reporting system that has already been beset with difficulties and delays. Seventy per cent of more than 150 patient safety managers polled during a patient safety management network meeting last month said their organisation would not meet the 30 September go-live deadline for the new learning from patient safety events (LFPSE) incident reporting system. LFPSE is a key part of NHS England’s safety strategy and replaces the historic national reporting and learning system. The new reporting system was originally due to be implemented by March 2023. However, this deadline was pushed back six months, after widespread concerns were raised by patient safety managers, which included software quality, incident reporting form complexity and lack of time for testing. Managers have pinned the latest launch delay on RLDatix – the vendor which provides incident software for more than 60% of trusts – claiming it could not provide the functionality needed and its releases were “not fit for purpose”. Read full story (paywalled) Source: HSJ, 16 October 2023 -
News Article
Four trusts report quarter of all ‘critical incidents’
Patient Safety Learning posted a news article in News
More than a quarter of ‘critical incidents’ have been declared by just four trusts since the start of the crisis in urgent and emergency care. Data obtained by HSJ shows 241 critical incidents have been declared by organisations due to “operational” or “system pressures” between April 2021, when long waits for urgent care began to surge upwards, and last month. Four trusts account for 68 of these (28%). Critical incidents are declared when the level of disruption “results in an organisation temporarily or permanently losing its ability to deliver critical services, or where patients and staff may be at risk of harm”. These incidents may require “special measures and support from other agencies, to restore normal operating functions,” according to the NHS England definition. Most critical incidents were only in place for a few days before being stood down by the trust or system, but some were in place for much longer – sometimes for several months at a time, the data suggests. Read full story (paywalled) Source: HSJ, 25 October 2023 -
News Article
Strikes caused 22 ‘critical incidents’, government claims
Patient Safety Learning posted a news article in News
The NHS has declared 22 ‘critical incidents’ due to disruption caused by industrial action since December, including having to transfer critical care patients, according to the Department for Health and Social Care. Critical care and gynaecology patients have had to be moved to other hospitals due to staffing shortages, urgent cancer surgery and chemotherapy appointments have had to be rescheduled and urgent surgery on trauma patients “could not go ahead” during critical incidents declared in periods of strike action since December, the Department of Health and Social Care said. There have been strikes by both doctors and Agenda for Change staff over pay during 2023, and Wednesday sees junior doctors and medical consultants strike on the same day for the first time. The DHSC has not previously revealed critical incidents caused by strikes, nor details of them. Trusts typically have different triggers for declaring critical incidents, but they indicate severe strain on services, and it is not unusual for them to happen during high winter pressures. Read full story (paywalled) Source: HSJ, 20 September 2023 -
Content ArticleNHS England wants to find out how people would choose to tell the NHS about things that go wrong in healthcare, to help the NHS do things better. NHS England wants to hear from people of all ages and backgrounds, who use all kinds of NHS services. They want to know how people would choose to give feedback if something went wrong in their care, or in the care of someone they look after, so the NHS can learn. NHS England will use what you tell them to help design a new online service to make care better. Click on the link below to find out more and take the survey. Closing date: 31 December 2023
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Content ArticleNHS England published the new Patient Safety Incident Response Framework (PSIRF) in August 2022 outlining how organisations providing NHS-funded care should respond to patient safety incidents to facilitate ongoing learning and improvement. From Autumn 2023, PSIRF will replace the current Serious Incident Framework. It will change the way all healthcare providers, which deliver NHS funded care, including independent healthcare organisations respond to patient safety incidents. Linda Jones, Head of Patient Safety & Quality Governance at Independent Healthcare Providers Network (IHPN), writes about the significant changes that introducing a new approach to managing risk and patient safety will entail for the independent sector, and how we’re supporting members to be ready.
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Content ArticleAs part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.
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Content ArticleWork to prepare for transition to working within the Patient Safety Incident Response Framework (PSIRF) in the Autumn of 2023 is well underway by healthcare providers across England. Written for all those involved in implementing PSIRF, this article describes some of the reasons behind the challenges being faced and suggests three principles to help navigate through this complex process and offers practical ideas to help.
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Content Article
We have had quite an eventful few weeks in the NHS in England, much of it not very pretty. There have been reports of a consultant dismissed from a Trust for raising concerns about safety, and, following a well-reported series of events, an experienced and essential clinician leaving the workforce. Then there were the events in Manchester where a nurse has been convicted of murdering seven children and the attempted murder of another six children. This despite the raising of concerns by not one, not two but seven senior clinicians. They faced the now repeatedly seen series of actions where they were not believed, faced counteraccusations and threatened with being reported to their regulators. Now we have the inevitable fall out, an incoming inquiry and, no doubt, the same or very similar themes to the many inquiries that have happened in the past. There has been much discussion about these events on social media, mostly focused on Lucy Letby, about patient safety, the actions that people should have taken and reasons why they did not. However, in this blog, I am choosing to look at things from a slightly different perspective, that of the Patient Safety Incident Response Framework (PSIRF).- Posted
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Content ArticleDrawing on his research and practice, Steven Shorrock explores the various barriers that we face when trying to make sense of Just Culture, inviting readers to refl ect on the intricate nature of justice and safety in our complex world
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Content ArticleOn 29 September 2023, a group of NHS staff and Experts by Experience joined a Teams meeting to help the National Patient Safety team in NHS England (NHSE) to answer two important questions. 1. Is it a good idea to keep asking NHS staff to record the level of psychological harm experienced by patients and service users, after a patient safety incident? 2. If so, how we can help make sure this is done as well and accurately as possible? Here is the write up of the workshop.
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