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Showing results for tags 'Patient safety incident'.
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News Article
Morecambe Bay inquiry chief voices criticisms over East Kent hospital scandal
Patient Safety Learning posted a news article in News
The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay. On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust. A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog. Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.” Read full story Source: 26 January 2020 -
News Article
East Kent hospitals: Care watchdog inspects trust after baby death apology
Patient Safety Learning posted a news article in News
England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute. It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford. On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC. On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death." Read full story Source: BBC News, 24 January 2020 -
News Article
Care firm's leadership criticised by Care Quality Commission
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has raised concerns about the treatment of patients at mental health units run by Cygnet. It follows inspections in the wake of a BBC Panorama investigation about alleged abuse at Wharlton Hall in County Durham. The CQC found that patients under the firm's care were more likely to be restrained. Higher rates of self-harm were also noted by inspectors who quizzed managers and analysed records at the company's headquarters. The regulator also found a lack of clear lines of accountability between the executive team and its services. It said directors' identity and disclosure and barring service checks had been carried out, butd that required checks had not been made to ensure that directors and board members met the "fit and proper" person test for their roles. Systems used to manage risk were also criticised, while training for intermediate life support was not provided to all relevant staff across services where physical intervention or rapid tranquilisation was used. Cygnet runs more than 100 services for vulnerable adults and children, caring for people with mental health problems, learning disabilities and eating disorders. The CQC says Cygnet must now take immediate action to address the concerns raised. Cygnet said a number of the services highlighted have since been improved, but "we are not complacent and take on board recommendations where we must improve". Read full story Source: BBC News, 14 January 2020 -
News Article
Implementation of safety improvements for the placement of nasogastric tubes
Patient Safety Learning posted a news article in News
The Healthcare Safety Investigation Branch (HSIB) has launched an investigation looking at nasogastric tubes and how previously identified safety improvements for the placement of these tubes are put into practice. Nasogastric (NG) tubes are used to deliver fluid, food and medication to patients via a tube that passes through the nose and down into the stomach. There is a risk of serious harm and risk to life if NG tubes are incorrectly placed into the lungs, rather than the stomach, and feed is passed through them. HSIB has started this investigation after they were notified of a patient who inadvertently had a nasogastric tube inserted into his lung. Further information Source: HSIB, 7 January 2020 -
News ArticleOnly 14% of pharmacy professionals are worried about criminal prosecution when reporting a patient safety incident, compared with 40% in 2016, survey results have showed. The results of the 2019 ‘Patient safety culture survey’ of 917 pharmacy professionals, carried out by the Community Pharmacy Patient Safety Group (PSG) in April and May 2019 came after the introduction of a legal defence for dispensing errors in 2018. The survey also showed that 22% of pharmacy professionals would not report a patient safety incident inside their organisation owing to fears of criminal prosecution. This is compared with 40% of 623 respondents saying in 2016 that they would not report a patient safety incident because of the possibility of criminal prosecution. Janice Perkins, chair of the PSG, said the results “demonstrate that there have been significant positive improvements since 2016”. “Nurturing an open and honest safety culture in community pharmacies is vital. It requires everyone to feel confident in openly sharing when things go wrong to learn from errors and prevent them occurring again,” she added. Read full story Source: The Pharmaceutical Journal. 19 December 2019
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News Article
New legislation to provide for mandatory open disclosure
Patient Safety Learning posted a news article in News
Hospitals will face penalties if staff do not notify patients of serious adverse incidents under proposed new legislation. Due to be brought to Cabinet by the Minister for Health Simon Harris in early December, it will provide for mandatory open disclosure of patient safety issues. It is understood that the new Bill would mean that where a hospital or health service provider was satisfied that a notifiable patient safety incident had occurred, information in its possession on the issue should be disclosed. A doctor or practitioner would be obliged to inform the patient and hospital of the incident. Under the proposals, failure to comply with this requirement on disclosure would mean the health service provider would be penalised. The nature or extent of the proposed penalties is unknown. The department is preparing a list of notifiable patient safety incidents for the mandatory open disclosure proposals. Read full story Source: The Irish Times, 25 November 2019 -
News Article
GP who downplayed symptoms of boy who died from Addison’s disease is suspended
Patient Safety Learning posted a news article in News
A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months. Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black. But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour. Read full story (paywalled) Source: BMJ, 25 November 2019 -
Content ArticleIn a wide-ranging Report on NHS litigation reform, the Health and Social Care Committee finds the current system for compensating injured patients in England ‘not fit for purpose’ and urges a radically different system to be adopted. Reforms would introduce an administrative scheme which would establish entitlement to compensation on the basis that correct procedures were not followed and the system failed to perform rather than clinical negligence which relies on proving individual fault. The new system would prioritise learning from mistakes and would reduce costs. Currently, litigation offers the only route by which those harmed can access compensation. MPs say in addition to being grossly expensive and adversarial, the existing system encourages individual blame instead of collective learning. This is a House of Commons Committee report, with recommendations to government. The Government has two months to respond.
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Content ArticleFalls are the most commonly reported patient safety incident in healthcare, with nearly 250,000 reported from hospitals in England and Wales each year. As well as causing injury to patients, the cost of treating falls is estimated to be around £630 million each year in England. This eLearning course is designed to help healthcare workers prevent patient falls in hospital. There are two modules available: Module 1 is aimed at hospital-based nurses. Module 2 is aimed at foundation level doctors and includes interactive information about patient and environmental falls risk factors, the patient assessment and post fall management. Both modules have been designed to complement, not replace, local falls prevention policies and processes.
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Content Article“Don't go to the hospital alone” has been the advice that safety experts have promoted for many years as a way that patients can help protect themselves. Family members provide an important safety net for patients in the hospital, and across the entire continuum of care—another slice of the Swiss cheese in our defenses against errors. As safety professionals, we hate to have to rely on that safety net, knowing that not all patients and families are able to provide it. Yet, given what we know about the frequency of medical errors, we still recommend it because families provide an additional cross-check of our care. But the COVID-19 pandemic has stripped away the layer of protection provided by families. At the start of the pandemic, visitation was heavily curtailed or stopped entirely due to the risks of spreading the virus. These decisions were not made lightly—concerns about protecting patients and the workforce drove them. Risks of visitation have included risks of infection to visitors and staff, particularly when not enough personal protective equipment (PPE) was available, and added strain on nurses to manage the presence of visitors and visitors’ compliance with PPE protocols. These infection concerns have not borne out, especially after adequate PPE supplies became available.1.,2. Those decisions at the start of the pandemic were necessary, given the uncertainties and the PPE shortages. However, now is the time to learn from that experience and reassess the risks and benefits of limited visitation. Further reading It’s time to rename the ‘visitor’: reflections from a relative Visiting restrictions and the impact on patients and their families: a relative's perspective Q&A: Dr. Tejal Gandhi on refocusing COVID visitation policies through a safety lens
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Content ArticleThis duty of candour animation offers guidance on the importance of being open and honest. Being open and honest with patients and those close to them is always the right thing to do and is often referred to as the duty of candour. NHS Resolution have produced a short animation to help those working in health and social care to better understand the similarities and differences that exist between the professional and statutory duties of candour. The 8-minute animation also offers guidance on how they can be fulfilled effectively.
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Content Article
Safe to speak up? NHS Staff Survey Results 2021
Patient Safety Learning posted an article in Culture
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In this blog, Patient Safety Learning analyses the results of the NHS Staff Survey 2021, specifically focusing on responses relating to reporting, speaking up and acting on safety concerns. It reflects on the importance of staff feeling able to speak up about patient safety incidents and the implications when this is not the case. It describes the NHS’s current approach to creating a patient safety culture and emphasises the need for NHS England and NHS Improvement, in partnership with the National Guardian and Care Quality Commission, to bring forward robust and specific commitments to drive this work forward. -
Content ArticleBlood transfusion is considered one of the safer aspects of healthcare, however potentially avoidable patient-safety incidents led to 14 deaths in the UK in 2017. Improvement initiatives often focus on staff compliance with standard operating procedures. This fails to understand adaptations made in a complex, dynamic environment, so the aim of this study from Watt et al. is to examine the extent and nature of adaptations at all stages of the vein to vein transfusion process.
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Content ArticleThe focus on error detection and its management has not produced the expected gains in patient safety, primarily because these methods are not well suited to a complex adaptive system such as healthcare. Behaviours that produce errors are variations on the same processes that produce success, so focusing on successful practices may be a more effective tactic. One approach to focusing on success is positive deviance. While positive deviance can be used to describe the behaviour of an exemplary individual, the term can also be extended to describe the behaviours of successful teams and organisations. Originating in international public health projects, positive deviance has recently been embraced to improve quality and safety of healthcare delivered in organisations. The premise is that solutions to common problems mostly exist within clinical communities rather than externally with policy makers or managers, and that identifiable members of a community have tacit knowledge and wisdom that can be generalised. Lawton et al. explain more in this BMJ article.
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Content Article
CORESS reports
Patient Safety Learning posted an article in Surgery
CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments. -
Content ArticlePatient safety is typically assessed by the frequency of adverse events or incidents, which means we seek to determine safety by its absence rather than its presence. The Safety-II perspective aspires to overcome this paradox by bringing into focus situations where safety is actually present, that is, in everyday work that usually goes well. Central to Safety-II is the notion that, in complex systems such as healthcare, safety is a consequence of collective efforts to adapt to dynamic conditions and uncertainty, rather than the natural state of a system where nothing untoward happens. This type of thinking has been met with significant interest and enthusiasm in healthcare, because it feeds increased appreciation for the fact that healthcare workers continuously ensure that most patients receive safe and high-quality care in challenging circumstances. However, despite its appeal and potential, significant challenges remain for the fruitful interpretation and application of the Safety-II perspective in healthcare, which could give rise to misinterpretations, misuse and a missed opportunity for the potential enrichment of quality and safety practices in healthcare.
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Content ArticleThis chapter from the book 'Learning from High Reliability Organisations' focuses on a systems-based technique for accident analysis referred to as the AcciMap approach. The technique involves the construction of a multi-layered diagram, in which the various causes of an accident are arranged according to their causal remoteness from the outcome. It is particularly useful for establishing how factors in all parts of a sociotechnical system contributed to an organisational accident and for arranging the causes into a coherent diagram that reveals how they interacted to produce that outcome. By identifying these causal factors and the interrelationships between them in this way, it is possible to identify problem areas that should be addressed to improve the safety of the system and prevent similar occurrences in the future.
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Content ArticleTraditional efforts to detect adverse events have focused on voluntary reporting and tracking of errors. However, public health researchers have established that only 10-20% of errors are ever reported and, of those, 90-95% cause no harm to patients. Hospitals need a more effective way to identify events that do cause harm to patients in order to quantify the degree and severity of harm, and to select and test changes to reduce harm. The IHI Global Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse events over time. Tracking adverse events over time is a useful way to tell if changes being made are improving the safety of the care processes. The Trigger Tool methodology includes a retrospective review of a random sample of patient records using “triggers” (or clues) to identify possible adverse events. Many hospitals have used this tool to identify adverse events, to measure the level of harm from each adverse event, and to identify areas for improvement in their organizations. It is important to note, however, that the IHI Global Trigger Tool is not meant to identify every single adverse event in a patient record. The recommended time limitation for review and the random selection of records are designed to produce a sampling approach that is sufficient for the design of safety work in the hospital.
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Content ArticleMr A experienced mental health issues over a number of years. He was arrested and charged with the murder of Philip Owen in October 2017 and was later found guilty of manslaughter. He was sentenced to an indefinite hospital order to treat his mental illness and has been detained in a secure hospital. This is the report of the independent investigation into his care and treatment under Greater Manchester Mental Health NHS Foundation Trust.
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Content Article
NHS England’s Patient Safety Team will be launching the new Patient Safety Incident Response Framework (PSIRF) in the Spring of 2022, and one of the tools it will recommend to enhance learning from events is After Action Review (AAR). It is likely that each healthcare provider will define its own 'playing field' for AAR as the PSIRF is integrated in daily practice in the months and years ahead, yet this can extend far wider than many assume. In the 12 years since I was trained as an AAR Conductor, I have grown to appreciate its adaptability as well as the many benefits it delivers. The examples of real AARs described here are designed to illustrate some of the many applications. As you will see, these AARs have created opportunities for learning at three levels, all of which contribute to the delivery of safe and effective patient care: the individual, the team and the organisation. -
Content ArticleThis is the report of an independent assurance review of North West Boroughs’ internal investigation which considered the care and treatment of mental health service user A. User A was found guilty of manslaughter in May 2018 and was ordered by the court to be detained under Section 37/41 of the Mental Health Act (1983) in a medium secure hospital. At the time of the homicide, mental health service user A was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust.
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Content ArticleThis independent external quality assurance review looks at the independent investigation into the care and treatment of mental health service user Mr M at Greater Manchester Mental Health NHS Foundation Trust.
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Content ArticlePodcast from the NHS England and NHS Improvement National Patient Safety Team, where Tracey Herlihey, head of patient safety incident response policy, and Lauren Mosley, head of patient safety implementation, talk about the Patient Safety Incident Response Framework (PSIRF) which will be launched in Spring 2022. The framework is a key component of the NHS Patient Safety Strategy, and will outline how NHS providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted. Once implementation is completed it will replace the current Serious Incident Framework. The podcast gives an overview of PSIRF and its key features, talks about findings from work with early adopters over the past two years to pilot an introductory version of the framework, and explains what providers can do now to prepare for its launch in the Spring.
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Content ArticleThis study in the Journal of Patient Safety examined how hospitals outside mandatory 'never event' regulations identify, register, and manage 'never events', and whether practices are associated with hospital size. In Switzerland, there is no mandatory reporting of 'never events' and little is known about how hospitals in countries without 'never event' policies deal with these incidents in terms of registration and analyses. The study found that many Swiss hospitals do not have valid data on the occurrence of “never events” available, and do not have reliable processes installed for the registration and examination of these events. Surprisingly, larger hospitals do not seem to be better prepared for “never events” management.
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Content ArticleThis updated edition includes the latest findings on patient safety by two of the foremost authorities on medical mistakes. Two physician-professors investigate (and re-investigate) the errors endemic to modern medical care and suggest ways to prevent hospitals and doctors from inadvertently killing their patients. Emerging from these compelling stories and insights is a powerful case for change - by policymakers, hospitals, doctors, nurses, and even patients and their families. The authors underscore the depth and breadth of dangers in medical care. They also suggest basic safety procedures and hard-nosed remedies that could make erratic systems fail-safe and save countless lives.
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