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News ArticleThe number of notified “extreme” and “major” incidents involving serious harm to patients and others in hospital has risen significantly in the Republic of Ireland in recent years, new figures reveal. Reported “extreme” incidents, which can involve death or permanent incapacity, rose from 373 in 2017 to 579 last year. The number of cases classified as “major”, where there is long-term disability or incapacity, climbed from 46 to 82 in the same period. “Moderate” incidents, when there is a patient injury involving medical treatment, also increased from 9,219 in 2017 to 13,563 last year. Minor incidents, involving injury or illness needing first aid, also increased over the same time from 9,210 to 15,483. The figures, involving patients, staff, visitors, contractors and the public, were released by the HSE in response to a parliamentary question from Aontú leader Peadar Tóibín. A spokewoman for the HSE said: “It is HSE policy that all incidents are identified, reported and reviewed so that learning from events can be shared to improve the quality and safety of services.” “The number of reported incidents has increased year on year since 2004 with a significant increase noted since 2015, with the introduction of the National Incident Management System.” Read full story Source: Independent.ie, 3 May 2022
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News Article
Surge in serious incidents caused by ambulance delays
Patient Safety Learning posted a news article in News
Ambulance trusts are seeing rising numbers of serious incidents resulting from delays in reaching patients, research by HSJ has uncovered. Serious incidents are defined by the NHS as a patient safety failure “where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified.” East Midlands Ambulance Service Trust saw 71 serious incidents in 2021-22 compared with 38 in the financial year before. The trust’s board papers attribute the increase in SIs related to delayed responses since June 2021 to “sustained pressure on the service” and the resulting growing handover times at accident and emergency departments. Of 14 SIs reported in February and the first half of March 2022, seven were due to “prolonged waits for an ambulance response”. West Midlands University Ambulance Service Foundation Trust has also seen an increase in SIs. Its board papers report that half of the SIs are due to “delays in reaching patients resulting in harm, serious harm, and deaths”. It has given the issue of “hospitals, breaches, delays and turnaround times” the maximum rating of 25 on its risk register. Long delays – especially for category two patients, where average performance last month was above an hour – are causing increasing concern. Stroke Association chief executive Juliet Bouverie said the organisation was hearing “shocking accounts from stroke survivors who have waited hours for an ambulance… We are extremely worried that stroke survivors’ lives and recoveries are being put at extreme risk.” Read full story (paywalled) Source: HSJ, 20 April 2022 -
News ArticlePatients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership. Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations. “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.” The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement. Read full story Source: BMJ, 8 April 2022
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News Article
Nurse suspended after forcing medication into patient’s mouth
Patient Safety Learning posted a news article in News
A nurse has been suspended for three months by the Nursing and Midwifery Council (NMC) after forcing medication into a person with dementia's mouth. An NMC Fitness to Practise (FtP) panel found Reni Kirilova had forced medicine into the patient’s mouth, held her mouth closed and shouted ‘take your tablets’ while working at the Chocolate Quarter Care Home in Bristol, run by the St Monica Trust. Patient was reportedly distressed, waving her hands and shouting The incident occurred on 30 May 2019, seven days after Ms Kirilova began working at the care home on 23 May. She was suspended on 7 June pending a police investigation and she resigned the same day. One witness told the NMC hearing that they saw the nurse’s fingers go over the patient’s mouth for around 30 seconds while the patient was ‘flapping her hands’ and ‘trying to spit them out’. They added the patient was distressed and was ‘waving her hands everywhere’ and shouting ‘no, no, no’. Ms Kirilova denied the allegations and said that she had given the patient some water and then tilted the patient’s chin to help her swallow. The panel found that the allegation she held her hand over the patient’s mouth was not true but that she had held it closed in some way, after three witnesses corroborated this. The panel said they were not satisfied that she had considered how she would cope with stressful situations in the future and there was a risk it could happen again. Read full story Source: Nursing Standard, 7 April 2022 -
News Article
Acute trust to be prosecuted by CQC
Patient Safety Learning posted a news article in News
The Care Quality Commission is to prosecute an acute trust after a patient was injured when allegedly exposed to “avoidable harm”. United Lincolnshire Hospitals Trust is due to appear tomorrow afternoon at Boston Magistrates’ Court. The alleged incident took place at Lincoln County Hospital, the CQC said. Although the CQC declined to comment further, Lincolnshire Live reported the alleged incident involved 91-year-old Iris Longmate and relates to a failure to provide safe care and treatment on or before 3 March 2019. The local publication added court papers claimed “at the same time ULHT also failed to give safe care and treatment to patients on Greetwell Ward, who were ‘being exposed to a significant risk of avoidable harm occurring’”. Proceedings are being brought under sections 22 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These rules require providers to take reasonable steps to minimise risks to people’s health and safety during treatment, and make it a criminal offence if a provider fails to comply and a patient suffers avoidable harm or is exposed to a risk of this happening. Read full story (paywalled) Source: HSJ, 24 March 2022 -
News Article
Trust loses whistleblowing case over ‘pioneering’ procedure
Patient Safety Learning posted a news article in News
A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using. An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous. The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre. The process saw a Care Quality Commission complaint, an independent investigation and multiple referrals to the General Medical Council. Employment Judge Fowell said: “The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed.” Dr Macanovic resigned from the regional renal transplant team in July 2016 when she discovered two incidents had occurred that “had not been reported by either surgeon” and felt that one of the surgeons had misled the medical director over the issue, the tribunal heard. In an email sent after the resignation meeting, Dr Macanovic said the practice was considered inappropriate by the vast majority of experts in the field and that no other renal unit in England was using it. The case exposes some worrying governance, both within the trust and between it and the Care Quality Commission, with which the issues were raised in 2016. When the CQC asked the trust for more information the unit’s clinical director responded that in his view that the deaths and infections were not due to the buttonholing. The CQC made no further enquiries and wrote back saying “they were satisfied that there were no safety concerns and that appropriate governance had been followed”. Read full story Source: HSJ, 24 March 2022 -
News Article
NHS Trust declares two critical incidents as Covid admissions double
Patient Safety Learning posted a news article in News
A hospital in Devon has declared a second critical incident following extreme pressures, as Covid-19 admissions in the region double, The Independent has learnt. North Devon Healthcare Trust declared a critical incident on Monday, after it declared another earlier this month it has confirmed. The news comes as the number of people with Covid-19 across two hospitals in Devon has doubled in just two weeks. As of Thursday, there were 292 Covid positive patients in across hospitals in Devon, with a further 37 awaiting test results. According to a statement from healthcare leaders in Devon, Plymouth and Torbay, as of Thursday there were almost 1,200 NHS staff off work due to Covid. Meanwhile 183 care services, such as care homes and other social care providers, in the area have reported Covid outbreaks, making it harder to discharge patients, the leaders said. NHS data published on Thursday showed there were 213 patients across three hospitals in Devon, waiting to be discharged. Covid-19 infections are also continuing to rise across most of the UK, with levels in Scotland hitting another record high, new figures show. Read full story Source: The Independent, 19 March 2022 -
News Article
Patients will be endangered by flaws in health bill, says NHS ombudsman
Patient Safety Learning posted a news article in News
Patient safety will be harmed and victims of medical negligence denied justice because of flaws in the government’s health and care bill, the NHS ombudsman has told the Guardian. Rob Behrens, the parliamentary and health service ombudsman, fears he and his staff will not be able to get to the bottom of clinical blunders because under the bill he will be denied potentially vital information collected by the NHS’s Healthcare Safety Investigation Branch (HSIB). The ombudsman said the legislation would allow the HSIB to “operate behind a curtain of secrecy” and undermine his own investigations into lapses in patient safety and could deny grieving families the full truth about why a loved one died. Behrens has spoken out because he is concerned about government plans for NHS staff involved in an incident to give evidence about mistakes privately in a “safe space” to the HSIB, which cannot be shared with anyone else except coroners. His exclusion from seeing material gathered in that way could force him to take the agency to the high court to access it, he said. “If the ‘safe space’ provisions become law as drafted there is a real risk to patient safety and to justice for those who deserve it. This is a crisis of accountability and scrutiny,” he said. Julia Neuberger, a crossbench peer who chairs University College hospitals NHS trust, has tabled an amendment to the bill in the House of Lords seeking to give the ombudsman access to information obtained via “safe space” processes. Unless ministers rethink the plan “there could be serious consequences for members of the public who use the ombudsman service”, she recently told a Lords debate. “If the ombudsman is unable to investigate robustly all aspects of complaints about the NHS, except with the permission of the high court, patients may find it harder to get access to justice. The NHS may well become less accountable for its system failings,” she said. Peter Walsh, chief executive of patient safety charity Action Against Medical Accidents, backed Behrens. “The so-called safe space is a red herring with serious unintended consequences. There is no evidence staff do not take part in investigations for fear of information being known. It is bullying employers and over-zealous regulators that staff fear. Denying people their right to have the ombudsman investigate properly does nothing to address that.” Read full story Source: The Guardian, 28 February 2022 -
News ArticleMore than 3,000 patients have died following incidents in the Irish health service since 2018, new data shows. New HSE data shows more than 480,000 incidents potentially causing harm were recorded across hospitals and community healthcare groups since 2018. These include falls, attacks on patients or staff, problems with medication, treating the wrong limb, or reactions to medical devices, among other issues. Last year’s total of 106,967 was the highest of five years recorded, up from 94,422 in 2018. While around half the incidents annually led to no injury, last year 0.65% or 556 led to a death. That stood at 0.59% or 557 deaths in 2018. A spokesperson for the Irish Nurses and Midwives Organisation (INMO) said the figures are very high, but not surprising. “Hospitals are not supposed to be dangerous places," she said. "No matter how highly skilled your staff are, patient safety issues and the risk of missed care incidents are inevitable in a situation where patients are lining corridors on trolleys and there aren’t enough staff to care for them." Read full story Source: Irish Examiner, 18 August 2023
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News ArticleMinisters are backing a potentially “dangerous” new model allowing police to reduce their response to mental health incidents after failing to formally assess the risk of harm or death. Officials are monitoring any “adverse incomes” from the National Partnership Agreement, which will see police forces stop attending health calls unless there is a safety risk or a crime being committed. Policing minister Chris Philp said a pilot by Humberside Police gave him confidence in national roll-out, which aims to “make sure that people suffering mental health crisis get a health response and not a police response”. Mental health charities and experts have warned the plans could be “dangerous”, and a coroner raised the alarm following a woman’s suicide after police failed to respond to her disappearance. A report published last month said action was needed to prevent future deaths, warning that the new model could “allow each agency to regard such a situation as the other’s responsibility, whilst nobody is on the ground attempting to retrieve a seriously ill patient”. Read full story Source: The Independent, 26 July 2023
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News Article
West Midlands Ambulance Service mistakes caused serious incidents
Patient Safety Learning posted a news article in News
More than half of all serious incidents where patients came to harm involving West Midlands Ambulance Service were due to clinical errors. A trust audit found choking management, cardiac arrests and inappropriate patient discharges as themes. It also noted a decision to close all community ambulance stations was taken without first doing a full risk assessment of the impact on safety. After the number of serious incidents increased from 138 in 2021-22 to 327 in 2022-23, an audit by WMAS found 53% were due to mistakes with their treatment. A situation where a person comes to significant harm in care is identified as a serious clinical incident. Sources say the trust also delayed looking into 5,000 serious patient incidents. Read full story Source: BBC News, 29 June 2023 -
News Article
Burnout in doctors doubles chances of patient safety problems, study finds
Patient Safety Learning posted a news article in News
Doctors suffering from burnout are far more likely to be involved in incidents where patients’ safety is compromised, a global study has found. Burned-out medics are also much more likely to consider quitting, regret choosing medicine as their career, be dissatisfied with their job and receive low satisfaction ratings from patients. The findings, published in the BMJ, have raised fresh concern over the welfare and pressures on doctors in the NHS, given the extensive evidence that many are experiencing stress and exhaustion due to overwork. A joint team of British and Greek researchers analysed 170 previous observational studies of the links between burnout among doctors, their career engagement and quality of patient care. Those papers were based on the views and experience of 239,246 doctors in countries including the US, UK and others in Africa, Asia and elsewhere globally. They found that burned-out medics were twice as likely as their peers to have been involved in patient safety incidents, to show low levels of professionalism and to have been rated poorly by patients for the quality of the care they have provided. Doctors aged 20 to 30 and those working in A&E or intensive care were most likely to have burnout. It was defined as comprising emotional exhaustion, depersonalisation – a “negative, callous” detachment from their job – and a sense of reduced personal accomplishment. Read full story Source: The Guardian, 14 September 2022 -
News Article
New approach to safety incidents will see fewer investigations
Patient Safety Learning posted a news article in News
Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families. The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations. According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework. NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition. However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required. Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”. However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements. She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.” Read full story (paywalled) Source: HSJ, 16 August 202 -
News Article
Multiple reporting systems undermine patient safety, says watchdog
Patient Safety Learning posted a news article in News
A single system to report patient safety concerns would “keep people safer”, a newly appointed NHS watchdog has told HSJ. Henrietta Hughes – who will take up the post of patient safety commissioner in September – said both clinicians and patients faced a bewildering choice when looking to raise a safety concern, and that there was a need for a “report once” system. She said that when ”exhausted” clinicians “come to the end of a 12-hour shift, they don’t want to have to do a Datix report and a yellow card report, and if they’ve got a safeguarding concern or a concern about an individual condition, [to have to] send that somewhere else”. Dr Hughes added: ”Wouldn’t it be better if we had one report that you do, and all the information that comes from that report just gets sent to the appropriate authority? That’s the type of change that I think we’d like to see. I know, as a GP myself, that’s what I would rather do as a professional. But also, I think, for all the organisations, we could get so much more richness of information, we would get more reporting, and we’d keep people safer as a result of it.” She added that if a patient “wanted to report an individual clinician” they often ended getting bounced around the system, like a pinball. They get sent from pillar to post.” Read full story (paywalled) Source: HSJ, 8 August 2022 -
News Article
London NHS trust cancels operations as IT system fails in heatwave
Patient Safety Learning posted a news article in News
One of the NHS’s biggest hospital trusts is facing major problems after its IT system failed because of the extreme temperatures earlier this week. Guy’s and St Thomas’ trust (GSTT) in London has had to cancel operations, postpone appointments and divert seriously ill patients to other hospitals in the capital as a result of its IT meltdown. The situation means that doctors cannot see patients’ medical notes remotely and are having to write down the results of all examinations by hand. They are also unable to remotely access the results of diagnostic tests such as X-rays and CT and MRI scans and are instead having to call the imaging department, which is overloading the department’s telephone lines. GSTT has declared the problem a “critical site incident”. It has apologised to patients and asked them to bring letters or other paperwork about their condition with them to their appointment to help overcome doctors’ loss of access to their medical history. One doctor at GSTT, speaking on condition of anonymity, said: “This is having a major effect. We are back to using paper and can’t see any existing electronic notes. We are needing to triage basic tests like blood tests and scans. There’s no access to results apart from over the phone, and of course the whole hospital is trying to use that line. “Frankly, it’s a big patient safety issue and we haven’t been told how long it will take to fix. We are on divert for major specialist services such as cardiac, vascular and ECMO.” Read full story Source: The Guardian, 21 July 2022 -
News Article
Medical expert witnesses ‘should not scapegoat doctors’
Patient Safety Learning posted a news article in News
Medical experts in cases involving doctors should have a mandatory duty to consider systems issues such as inadequate staffing levels to avoid them being scapegoated for wider failures, the Medical Protection Society (MPS) has said. The MPS, which supports the the professional interests of more than 300,000 healthcare professionals around the world, says medical expert reports focus on scrutinising the actions of the individual doctor even when failings are a result of the setting in which they work. Its report on the issue, shared with the Guardian before publication, points out that for doctors “adverse opinion can lead to loss of career or liberty”. It references the case of Dr Hadiza Bawa-Garba who was convicted of gross negligence manslaughter in 2015 and handed a 24-month suspended sentence for her part in the death of six-year-old Jack Adcock from sepsis. She was later struck off by the General Medical Council before the court of appeal overturned the GMC’s decision. Dr Rob Hendry, the MPS medical director, said: “In giving an opinion on whether or not the care provided by a doctor has fallen short of a reasonable standard, it would seem fair to the doctor that the medical expert considers all relevant circumstances. Any individual performance concerns must of course be addressed, but doctors should not be scapegoats for the failings of the settings in which they work. Sadly, we see this all too often in cases against doctors … “Many expert reports focus solely on the actions of the individual without considering the wider context. In reality, patient harm arising from medical error is rarely attributable to the actions of a single individual. Inadequate staffing levels, lack of resources, or faulty IT systems are just some issues which can contribute to adverse incidents. Doctors confront these issues every day and have little influence over them.” Read full story Source: The Guardian, 18 July 2022 -
News Article
Ambulance serious incidents triple
Patient Safety Learning posted a news article in News
Serious incidents causing patient harm have increased steeply compared to previous years at an ambulance service whose nursing director still expects will “fail” next month under mounting service pressures. There were 98 patient harm incidents at West Midlands Ambulance Service in June, official data obtained by HSJ suggests, up from 49 in the same month last year. The figures show that from April-June this year, 262 harm incidents have been logged – a 240% on 77 in the same period in 2019 and a 71% on 153 last year. Nursing director Mark Docherty, who previously warned the service was facing a “Titanic moment” and would “all fail” around a specific date of 17 August, said much of the increase can be attributed to worsening hospital handover delays. More than 700 people at one time waited for ambulances “that were not going to turn up” on Monday, according to Mr Docherty, who described the situation as a “really dangerous place to be”. Mr Docherty explained how the harm incidents, including deaths, resulted from growing delays: ”You can’t underplay the risk. If you’ve got 750 patients like we did on Monday waiting, none of those patients have been assessed. “Sadly, amongst them there will have been patients with stroke who won’t be treated because they’ve waited too long." Read full story (paywalled) Source: HSJ, 15 July 2022 -
News ArticleMore than one fifth of complaints about Irish hospitals were deemed ‘high severity' including one from a person who claimed their mother should not have died and another who alleged a patient was turned away from an A&E even though she was at risk of self-harming. An analysis of 641 complaints about HSE hospitals between October and December 2019 by NUI Galway and the HSE separated them into high severity (22%), medium severity (56%) and low severity (also 22%). Among those complaints highlighted as potentially linked to ‘catastrophic harm’ was this: “My mother would still be alive if this had not happened." However the largest number were about hospital systems at 392 — including complaints about waiting lists. “I was left on a waiting list for surgery for years,” at least one person wrote. The analysis also found 322 complaints centred around patients’ arrival into hospitals including emergency departments (ED). “She was turned away instead of admitted even though she was at risk of self-harming,” one person wrote. Some 92 complaints related to staff not listening to patients, including new parents who said: "While our newborn son was on the ward they took too long to notice his difficulty breathing and transfer him to the NICU (neonatal intensive care unit)." Read full story Source: Irish Examiner, 11 July 2022
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News Article
Hospital turns away patients as heatwave forces critical incident
Patient Safety Learning posted a news article in News
Patients may be turned away at A&E in Portsmouth as the UK’s heatwave drives extreme hospital pressures. Staffing pressures coupled with additional strain from the current heatwave have forced Portsmouth Hospitals University Foundation Trust to declare a critical incident. The trust said it only had space in its emergency department for patients with life-threatening illnesses and critical conditions and so would be forced to redirect other patients elsewhere. In a statement, Portsmouth Hospitals University FT said: “Our emergency department remains full with patients and we have very limited space to treat emergency patients. We are only able to treat patients with life-threatening conditions and injuries, so anyone patients who arrive at ED without a life-threatening condition or injury, will be redirected to alternative services that can help... “Our immediate priority is to ensure there are beds available to admit our most seriously ill patients into and we are focusing on safely discharging as many patients as possible. We ask that families and loved ones support us with this and collect patients as soon as they are ready to be discharged.” Read full story Source: The Independent, 11 July 2022 -
News Article
Northern Ireland: Serious adverse incidents 'likely to be repeated'
Patient Safety Learning posted a news article in News
Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system. The reviews take place after unintended incidents of harm and ensure improvements are made. The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness. It found the process was not "sufficiently robust". In the RQIA report, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an understanding of what factors, both systems and people, have led to a patient or service user coming to harm". It added: "The reality is that similar situations, where events leading to harm have been inadequately investigated and examples of recognised good practice have not been followed, have been and are likely to be repeated in current practice." It identified failures in the SAI procedure, including failures to: Answer patient and family questions. Determine where safety breaches have occurred. Achieve a systemic understanding of those safety breaches. Design recommendations and action plans to reduce the opportunity for the same or similar safety breaches in future. Read full story Source: BBC News, 7 July 2022 -
News Article
‘Innovation put over safety’ at world-famous hospital
Patient Safety Learning posted a news article in News
A world-famous hospital has a culture where some staff may put research interests above patient safety, according to an external investigation. A report published yesterday cited some employees at Great Ormond Street Hospital for Children Foundation Trust as saying “they feel that the hospital sometimes put too much emphasis on pushing the boundaries of science” and “are concerned [this] may lead to a culture where some prioritise innovation over safety in their practice”. The trust’s medical director Sanjiv Sharma commissioned the report into the effectiveness of its safety procedures, from consultancy Verita, in 2020, after families of several patients who died at the hospital raised concerns in the media about how it responded to safety incidents. The report said: “We believe that it is sometimes culturally difficult within Great Ormond Street to accept that things can go wrong and to respond appropriately. We were told that some see the organisation as ‘bullet-proof’ in the face of criticism." “There is also a view outside the trust that some clinicians at Great Ormond Street can find it difficult to accept that something had gone wrong. Some believe that this reflex is deeply ingrained. This is potentially indicative of a culture of defensiveness. Acknowledging this trait is the first step on the road to changing it.” Dr Sharma said in a statement yesterday that GOSH had already taken steps to improve its culture and systems, appointing patient safety educators and patient safety leads in each directorate. Read full story (paywalled) Source: HSJ, 7 July 2022 -
News Article
Patient safety incidents are the third leading cause of death in Canada
Patient Safety Learning posted a news article in News
The COVID-19 crisis has both divided and galvanised Canadians on healthcare. While the last three years have presented new challenges to healthcare systems across the country, the pandemic has also exacerbated existing challenges, most notably the high levels of errors and mistreatment documented in Canadian health care. According to a 2019 report from the Canadian Patient Safety Institute, Canada was already facing a public health crisis prior to the pandemic: a crisis of patient safety. As the report details, patient safety incidents are the third leading cause of death in Canada, following cancer and heart disease. Few studies calculate national data on this topic, but a 2013 report found that patient safety events resulted in just under 28,000 deaths. Many Canadians who have experienced these errors have shared their experiences with media in an effort to raise awareness and demand change. The impact of the COVID-19 pandemic has created a moment of dual crises. First, the pre-existing crisis of patient safety, and second, healthcare overall is now at a breaking point after three years of COVID-19, according to healthcare workers. Edmonton physician Dr. Darren Markland, for example, recently closed his kidney specialist practice after making a few "profound mistakes." In an interview with Global News, he explains he could no longer work at the current pace. He is not alone in this decision. Across the country, there have been waves of resignations in health care, leaving some areas struggling with a system that is "degrading, increasingly unsafe, and often without dignity." Read full story Source: MedicalXpress, 17 June 2022 -
News Article
Trust branded ‘inadequate’ for leadership and maternity
Patient Safety Learning posted a news article in News
One of the trusts worst affected by coronavirus has been issued with two warning notices and rated ‘inadequate’ for leadership, following a Care Quality Commission inspection. The regulator raised serious concerns about the safety of Countess of Chester Hospital Foundation Trust’s maternity services, as well as the oversight and learning from incidents. It also found staff were experiencing multiple problems with a newly installed electronic patient record, while systems for managing the elective waiting list were said to be unsuitable. In maternity services, the inspectors flagged severe staff shortages and a failure to properly investigate safety incidents. They said there were three occasions during the inspections when the antenatal and post-natal ward was served by only one midwife, despite the interim head of midwifery saying this would never happen. Inspectors also highlighted five incidents last year where women had suffered a major post-partum haemorrhage, involving the loss of more than two litres of blood and which resulted in an unplanned hysterectomy. The CQC said two were not reported as serious incidents, and where learning had been identified from the others, action plans were not being completed on time. The CQC said it was only made aware of the incidents by a whistleblower, while internal actions agreed in December 2021 had still not been implemented two months later. Read full story (paywalled) Source: HSJ, 15 June 2022 -
News Article
Patient safety concerns over 'toxic culture' hospital probe
Patient Safety Learning posted a news article in News
An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust. The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB). Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England. The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like". One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns. The trust denies this and says its "first priority is patient safety". The ombudsman, however, said he was sceptical about the reviews' transparency and independence. His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death. Read full story Source; BBC News, 14 March 2023 -
News Article
'Potential harm' review ordered into county's cancer patients
Patient Safety Learning posted a news article in News
Commissioners have begun a ‘serious incident review’ across their integrated care system after early indications showed patients may have suffered harm due to long waits for cancer treatment. The review has been launched by Somerset Integrated Care Board into dermatology services after an initial review found five of 50 patients had seen their skin lesions increase in size since being referred to hospital by their GPs. ICB board papers stated “potential patient harm has been identified” for those patients, who were on the two-week wait pathway to be seen by a specialist following a referral by their GP. Read full story (paywalled) Source: HSJ, 3 February 2023
