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Showing results for tags 'Patient safety incident'.
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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 -
News Article
Trust CEOs could ‘end up in prison’ because of ‘unsafe’ hospitals, warns chief
Patient Safety Learning posted a news article in News
An acute trust chief executive has criticised the lack of communication during last month’s nursing strike, warning that he and other accountable officers could face manslaughter charges if patients are put in danger by decisions made by senior colleagues elsewhere in the system. Matthew Hopkins told a board meeting that Worcestershire Royal Hospital’s emergency department was “pushed to the extreme” on 20 December, with 176 people squeezed into a facility originally built for 50. He said that without warning from regional colleagues, an additional 18 people were brought in to the hospital by the ambulance service and ended up in corridors, at which point the trust declared a critical incident. The chief executive officer said he wanted to put on record an apology to staff for the incident, adding that he was “not aware” of the situation until it unfolded. Read full story (paywalled) Source: HSJ, 17 January 2023 -
News Article
Police and CQC investigate serious incidents at trust
Patient Safety Learning posted a news article in News
A series of concerns about serious incidents at a mental health trust are being investigated by the Care Quality Commission, with a referral also made to the police, HSJ has learned. HSJ understands that various incidents at Black Country Healthcare Foundation Trust have been raised with the Care Quality Commission by whistleblowers. According to a well-placed source, one of the alleged incidents involved alleged inappropriate sexual behaviour, and this has been referred to West Midlands police. Other complaints are understood to include staff using mental health inpatients’ rooms to sleep in, and an information governance breach in which patient information was shared with members of staff who did not need to receive them. It is understood this was in an email raising patient safety concerns. Read full story (paywalled) Source: HSJ, 17 January 2023 -
News Article
Inquiry into deaths after Northern Ireland ambulance delays
Patient Safety Learning posted a news article in News
The Northern Ireland Ambulance Service (NIAS) is investigating whether a delayed response contributed to the deaths of eight people in recent weeks. All eight deaths occurred between 12 December and the start of January. The NIAS is treating four of the deaths as serious adverse incidents, which is defined as an incident that led to unintended or unexpected harm. The remaining four deaths are being investigated to see whether they meet that criteria. The patients' identities have not been disclosed, but it is understood one of the eight people was a man who waited more than nine hours for an ambulance in mid-December. The man's condition deteriorated and he died before paramedics arrived. The delays are a cause of "great concern," but there is "no end in sight to the pressures we are facing," according to the ambulance service's medical director Nigel Ruddell. He said the ambulance service conducts an internal review whenever "there is a delayed response to the call and a poor outcome from the call" to see whether delays contributed to a death. "That process involves liaising with the family and being open and clear with them about what happened on the day - whether it was because of pressures and demand on the day or whether there was something that, potentially, we could have done better." Read full story Source: BBC News, 4 January 2022 -
News Article
Record number of 'foreign objects' left inside patients after surgical blunders
Patient Safety Learning posted a news article in News
A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who spoke to PA on condition of anonymity, said: "When I woke up, I felt something in my belly. "The knife they used to cut me broke, and they left a part in my belly." She added: "I was weak, I lost so much blood, I was in pain, all I could do was cry." The object was left inside her for five days, leading to an additional two-week hospital stay. Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: "Never events are called that because they are serious incidents that are entirely preventable because the hospital or clinic has systems in place to prevent them happening. "When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS. "While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventative measures are implemented." Read full story Source: Sky News, 4 January 2022 -
News Article
Over 1000 'adverse events' in women and infants' care in Scotland
Patient Safety Learning posted a news article in News
More than 1000 investigations have been launched in Scotland over the past decade into adverse events affecting women and infants' healthcare. Figures obtained by the Herald show that at least 1,032 Significant Adverse Event Reviews (Saers) have been initiated by health boards since 2012 following "near misses" or instances of unexpected harm or death in relation to obstetrics, maternity, gynaecology or neonatal services. The true figure will be higher as two health boards - Grampian and Orkney - have yet to respond to the freedom of information request, and a number of health boards reported the totals per year as "less than five" to protect patient confidentiality. Saers are internal health board investigations which are carried out following events that could have, or did, result in major harm or death for a patient. Major harm is generally classified as long-term disability or where medical intervention was required to save the patient's life. They are intended as learning exercises to establish what went wrong and whether it could have been avoided. Not all Saers find fault with the patient's care, but the objective is to improve safety. NHS Lanarkshire was only able to provide data from April 2015 onwards, but this revealed a total of 194 Saers - of which 102 related to neonatal or maternity services, and 80 for obstetrics. A Fatal Accident Inquiry involving NHS Lanarkshire has already been ordered into the deaths of three infants - Leo Lamont and Ellie McCormick in 2019, and Mirabelle Bosch in 2021 - because they had died in "circumstances giving rise to serious public concern". Read full story (paywalled) Source: The Herald, 10 December 2022 -
News Article
Revealed: The specialties with rocketing litigation costs
Patient Safety Learning posted a news article in News
Litigation costs for specialties including intensive care, oncology and emergency medicine have rocketed by up to five times as much as they were before the pandemic, internal data obtained by HSJ reveals. HSJ's data reveal costs for claims relating to intensive care, oncology, neurology, ambulances, ophthalmology and emergency care have increased – both for damages and legal costs – by significantly more than average. The steepest cost rise was in intensive care, which saw the bill increase fivefold from £4.3m in 2019-20 to £23.7m in 2021-22. Other specialisms which reported higher than average percentage increases were oncology, a 159% increase from £15m to £38.9m, and neurology, a 95% uplift from £18.4m to £36m. Key findings from these reports included missed or delayed diagnosis, missing signs of deterioration, failure to recognise the significance of patients re-attending accident and emergency multiple times with the same problem, and communication issues. Adrian Boyle, president of the Royal College of Emergency Medicine, said: “I’m extremely worried about the amount of money we’re spending on litigation… There’s a good reason we must not normalise an abnormal situation and we need to invest in an emergency care system which avoids these huge costs.” Read full story (paywalled) Source: HSJ, 23 June 2023 -
News Article
Error causes 800 patients to be wrongly removed from waiting list
Patient Safety Learning posted a news article in News
A trust is carrying out a review after hundreds of patients were wrongly removed from the waiting list and potentially missed out on treatment. York and Scarborough Teaching Hospitals Foundation Trust told HSJ that roughly 800 patients of its referral to treatment waiting list, were affected. A serious incident was declared after it emerged some patients “had their referral to treat clocks stopped erroneously, resulting in patients not receiving treatment”, according to a report to the trust board. The trust said reviews were under way but had not yet identified any cases of “moderate or significant clinical harm”, although it admitted some patients had been significantly delayed. Read full story (paywalled) Source: HSJ, 2 June 2023 -
News ArticleWomen are waiting too long for abortions, according to a major review into a leading UK provider. The Care Quality Commission (CQC) review of the leadership at the abortion provider the British Pregnancy Advisory Service found there were “delays” in “investigating incidents”. The remains of some pregnancies were sometimes not stored properly and there were issues were record keeping, patient monitoring and safe care, the review found. The watchdog also noted “women did not always receive care in a timely way to meet their needs”. The health watchdog said: “In August 2021 we found significant concerns in we found that safe care was not being provided; ineffective safeguarding processes; incomplete risk assessments were not fully completed; observations were not monitored or recorded; records were not fully completed, clear or up to date.” Read full story Source: The Independent, 2 June 2023
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News Article
Metropolitan Police: Move to attend fewer mental health calls sparks alarm
Patient Safety Learning posted a news article in News
The Met Police's plan to stop attending emergency mental health incidents is "potentially alarming", a former inspector of constabulary has said. From September, officers will only attend mental health 999 calls where there is an "immediate threat to life". The Met argues the move will free up officers after a significant rise in the number of mental health incidents being dealt with by the force in the past five years. Metropolitan Police Commissioner Sir Mark Rowley wrote to health and social care services in Greater London to inform them of the plan last week. In the letter, which has been seen by the BBC, Sir Mark said it takes almost 23 hours on average from the point at which someone is detained under the Mental Health Act until they are handed into medical care. He writes that his officers are spending more than 10,000 hours a month on "what is principally a health matter", adding that police and other social services are "collectively failing patients" by not ensuring they receive appropriate help, as well as failing Londoners more generally because of the effect on police resources. However Zoe Billingham, who is now chair of the Norfolk and Suffolk NHS mental health trust after 12 years as Her Majesty's Inspector of Constabulary and Fire and Rescue, warned mental health services are "creaking" and "in some places are so subdued with demand they are not able to meet the requirements of people who need it most". Speaking to BBC Radio 4's Today programme, she warned there is "simply no other agency to call" other than the police for people in crisis, adding: "There isn't another agency to step in and fill the vacuum." Read full story Source: BBC News, 29 May 2023 -
News Article
Update on LFPSE implementation deadline
Patient Safety Learning posted a news article in News
In an email to staff today (9 May 2023) NHS England (NHSE) have confirmed that to meet the deadline for implementing the new Learn From Patient Safety Events (LFPSE) service, Trusts will only need to ensure this is underway by the 30 September 2023, rather than fully implemented. LFPSE is a new central national service for recording and analysing patient safety events that occur in healthcare. Some NHS organisations are now using this system, instead of the National Reporting and Learning System (NRLS), and all organisations will be expected to transition to this. The original date for Trusts to implement LFPSE was the 31 March 2023. However, in response to concerns about the achievability of this deadline, on the 18 October NHSE announced an optional six-month extension, meaning that Trusts needed to deploy the new system by the 30 September 2023. Today’s email to NHS staff noted that some Trusts “are still anticipating challenges with the time scales”. Responding to this, NHSE clarified that provided the LFPSE transition within organisations Local Risk Management Systems was underway by the end of September, and that application of the guidance to configure formals and fields was being actively worked on, this milestone should be considered as having been met. Commenting on this Helen Hughes, Chief Executive of charity Patient Safety Learning, said: “This is a welcome announcement by NHS England, reducing the immediate pressure on staff who had raised serious concerns on the ability to have LFPSE configured and ready to submit events by the 30 September deadline. This flexibility will ensure that the new LFPSE service has a stronger chance of successful transition and to enable patient safety improvement”. -
News ArticleFresh concerns have been raised about the launch of the national incident reporting system, despite Steve Barclay taking a ‘personal interest’ in hitting the tight timetable, HSJ has learned. NHS England already delayed the launch of the “learning from patient safety events” database by six months, to September this year. It is due to replace the existing national reporting and learning system (NRLS) which is considered to be outdated and at risk of failing. But serious concerns are now being raised again by trust safety managers about whether the revised launch date can be met, HSJ has been told, with calls for it to be extended again until next year. HSJ has heard concerns from several managers that an upgrade due in July to the RLDatix risk management system – which is used by the majority of trusts – will cause knock-on problems implementing LFPSE in September. They said the timeframe was too short for testing and delivering the upgrade in time to make the transition and decommission the old NRLS. The creation of LFPSE is a key part of NHSE’s safety strategy, along with replacing the serious incident reporting system, with an aim of making it easier for staff to record safety events across all services, including primary care, which is excluded from NRLS. Read full story (paywalled) Source: HSJ, 3 May 2023
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Content ArticleThis policy provides a national framework for health and disability providers in New Zealand to continually improve the quality and safety of services for consumers, whānau and healthcare workers. It provides a consistent way to understand and improve through reporting, reviewing and learning from all types of harm. The policy will guide the process for reporting to the Health Quality & Safety Commission in New Zealand and for using the information gathered from learning reviews, along with quality improvement approaches, to strengthen system safety.
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Content Article
When patients are left to blow the whistle on unsafe care
Steve Turner posted an article in Whistle blowing
This short blog highlights the situations where patients, carers, parents and relatives are failed by healthcare systems and by the leadership. They are left to stand alone against powerful institutions, because when staff speak up and 'blow the whistle' it often results in retaliation. Investigating and resolving the patient safety issue then becomes buried under an employment issue. -
Content ArticleIn this podcast to support providers with the transition to the Learn from Patient Safety Events (LFPSE) service, the NHS's new national system for the recording and analysis of patient safety events, NHS England talks to Zahra and Mandy, NHS England reporting leads, about the practical steps providers can take to get connected to LFPSE. It covers how to get started, what to do with your old data, the kinds of support available, what transition means for ICBs, and what the Reporting Leads have learned from the process so far.
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Content ArticleThis report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
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Content ArticleThis study, published in The New England Journal of Medicine, looks at the frequency, preventability and severity of patient harm in a random sample of admissions from 11 Massachusetts hospitals during 2018. From this sample, it identified adverse events in nearly one in four admissions, approximately a quarter of which were deemed as preventable.
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Content ArticleIn this blog, Matthew Wain highlights how NHS organisations can support staff with patient safety investigations, and more generally, in the face of increased pressure. He looks at missed learning opportunities, psychological impact, and the support tools and programmes available for staff. Further reading: Patient Safety Learning's Staff Support Guide: a good practice resource following serious patient harm
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Content ArticleLaura Pickup and Suzy Broadbent present on the impact staff fatigue has on patient safety.
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Content Article
HSIB: Safety investigation jargon buster
Patient Safety Learning posted an article in HSSIB investigations
A guide to the terms commonly used in safety investigations and their definitions. -
Content ArticleIn this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
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Content ArticleNHS England has recorded two podcasts sharing insight and advice from organisations that have completed the transition from the National Reporting and Learning System (NRLS) to the new Learn from Patient Safety Events (LFPSE).
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Content ArticleIncident reporting is a crucial tool for improving patient safety, alongside an open culture that supports this. In the NHS the new Learn from Patient Safety Events (LFPSE) service is now being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). This article details correspondence between Patient Safety Learning and NHS England in relation to concerns raised by staff about the development and implementation of the LFPSE service
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Content ArticlePatient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
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Content ArticleThis article provides an overview of the National Patient Safety Board Act of 2022; legislation which has been introduced in the USA to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms.
