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Content ArticleAction against Medical Accidents (AvMA) provides a list of patients/family members with lived experience of patient safety issues who can speak at events, help with training, or provide consultancy.
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News Article
Hospital wrong to ban woman visiting partner on his deathbed
Patient Safety Learning posted a news article in News
The partner of a dying man was denied the chance to be at his bedside during his final moments after a hospital wrongly banned her from daily visits, an ombudsman report has found. Brian Boulton, 70, was admitted to Royal Gwent Hospital in Newport, South Wales, after suffering from a chest infection, which was later diagnosed as aspiration pneumonia caused by oesophageal cancer. Celia Jones, his “long term life partner” of twenty years, was accused by hospital staff of giving the retired tailor a larger dose of the prescribed furosemide medication than was allowed. Ms Jones, 65, was restricted to one-hour visits twice a week, meaning she was unable to be with him when he died a day after her last authorised visit on Wednesday 27 September 2017. The Public Services Ombudsman for Wales has upheld her complaints about her “appalling” treatment, ruling that the visiting restrictions were imposed “without warning” and resulted in a “significant injustice”. It found no record of Ms Jones, a retired nurse, admitting to a senior ward manager that she gave the large dose of medicine to her partner. Read full story Source: The Telegraph, 6 January 2020 -
News Article
Anger over UK's failure to ban breast implants linked to 61 cancer cases
Patient Safety Learning posted a news article in News
At least 61 women in the UK have been diagnosed with a potentially fatal cancer linked to breast implants, but the type they received continues to be used, with no plans by the regulator to follow France and Australia in banning them. Lawyers for more than 40 of the women, who are bringing legal action against the manufacturers as well as the clinics and doctors who carried out the surgery, say the textured implants linked to anaplastic large cell lymphoma (ALCL) should be withdrawn from the market. Smooth implants are available instead, which have no proven connection to the cancer of the white blood cells. The Medicines and Healthcare Products Regulatory Agency (MHRA) says the disease is very rare, but Sarah Moore, a solicitor at Leigh Day law firm, believes there are more cases than the regulator is aware of. “I think there has been misdiagnosis and under-diagnosis, and I think we have to bear in mind that in the last 18 months there have been 17 more reported cases of ALCL,” she said. The leading manufacturer of textured implants, Allergan, has withdrawn them from worldwide sale. In December 2018 its European kitemark for the implants expired – the French agency that had granted certification had asked for extra safety data that the company said it could not provide in time. They have not been on sale in Europe since then. The US authorities asked the company to recall its textured implants in July 2019 and Allergan took them off the market. France and Australia have since banned the sales of all textured implants, although neither has suggested that women should actively seek to have them removed. In the UK, other brands of textured implants are still in use. Neither NHS England, the NHS Business Services Authority nor the MHRA could say how many had been given to women in the NHS after a mastectomy for breast cancer. Read full story Source: The Guardian, 7 January 2020 -
News Article
Hundreds of sexual assaults each year on mixed-gender wards
Patient Safety Learning posted a news article in News
Hundreds of sexual assaults are reported each year on mixed-sex mental health wards in England, HSJ can reveal, highlighting the urgent need for investment to improve facilities. New figures obtained by HSJ show there have been at least 1,019 reports of sexual assaults between men and woman on mixed wards since April 2017 to October 2019. This compares to just 286 reports of incidents on single-sex mental health wards over the same period. Of those reports made on mixed-sex wards, 491 were considered serious enough to refer to safeguarding, and 104 were reported to the police. The level of incidents still being reported suggests patients are not being protected from sexual assault on mixed wards, despite the issue being highlighted by several national reports in recent years. Read full story (paywalled) Source: HSJ, 7 January 2020 -
News Article
Myla’s mum left with ‘soul‑destroying sadness’
Patient Safety Learning posted a news article in News
Mother Natalie Deviren was concerned when her two-year-old daughter Myla awoke in the night crying with a restlessness and sickness familiar to all parents. Natalie was slightly alarmed, however, because at times her child seemed breathless. She consulted an online NHS symptom checker. Myla had been vomiting. Her lips were not their normal colour. And her breathing was rapid. The symptom checker recommended a hospital visit, but suggested she check first with NHS 111, the helpline for urgent medical help. To her bitter regret, Natalie followed the advice. She spoke for 40 minutes to two advisers, but they and their software failed to recognise a life-threatening situation with “red flag” symptoms, including rapid breathing and possible bile in the vomit. Myla died from an intestinal blockage the next day and could have survived with treatment. The two calls to NHS 111 before the referral to the out-of-hours service were audited. Both failed the required standards, but Natalie was told that the first adviser and the out-of-hours nurse had since been promoted. She discovered at Myla’s inquest that “action plans” to prevent future deaths had not been fully implemented. The coroner recommended that NHS 111 have a paediatric clinician available at all times. In her witness statement at her daughter’s inquest in July, Natalie said: “You’re just left with soul-destroying sadness. It is existing with a never-ending ache in your heart. The pure joy she brought to our family is indescribable.” Read full story Source: The Times, 5 January 2020 -
Content ArticleJen Gilroy-Cheetham, Programme Manager at the Innovation Agency, talks about her experiences as a patient and makes a plea for a different way of doing things. Jen was speaking at the Innovation Agency's Eco 18 event, held at Haydock Racecourse in March 2019, focusing on innovating to meet NHS and social care workforce challenges.
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Content ArticleThrombosis UK is a charity and a leader in: Identifying, Informing & Partnering the NHS, healthcare providers and individuals to work to improve prevention of venous thromboembolism (VTE) and the management and care of unavoidable VTE events. This short video explains how a blood clot might form, what the risks are and how they might be treated.
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Content ArticleVenous thromboembolism (VTE) is a condition in which a thrombus – a blood clot – forms in a vein. Usually, this occurs in the deep veins of the legs and pelvis and is known as deep vein thrombosis (DVT). The thrombus or its part can break off, travel in the blood system and eventually block an artery in the lung. This is known as a pulmonary embolism (PE). VTE is a collective term for both DVT and PE. With an estimated incidence rate of 1-2 per 1,000 of the population, VTE is a significant cause of mortality and disability in England with thousands of deaths directly attributed to it each year. One in twenty people will have VTE during their lifetime and more than half of those events are associated with prior hospitalisation. At least two thirds of cases of hospital-associated thrombosis are preventable through VTE risk assessment and the administration of appropriate thromboprophylaxis.
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Content Article
INQUEST Handbook
Claire Cox posted an article in Mental health
The INQUEST handbook is a free and trusted guide for bereaved families and friends affected by a sudden death that involves an inquest, available in print and online. It has been developed and shaped by the many families they work with, and helps prepare bereaved people for the inquest process in England and Wales. -
Content Article
BMJ Editorial: Abandon the term "second victim"
Patient Safety Learning posted an article in Second victim
Families of patients who died after medical errors argue that it’s time to abandon the term “second victim” to describe doctors who are involved in a medical error. In an editorial published by The BMJ, Melissa Clarkson at the University of Kentucky and colleagues say that by referring to themselves as victims, “healthcare providers subtly promote the belief that patient harm is random, caused by bad luck, and simply not preventable.” This mindset “is incompatible with the safety of patients and the accountability that patients and families expect from healthcare providers,” they argue. -
Content Article
Why do we need to talk about patient data?
Claire Cox posted an article in Actions in response to data
This short video, by Understanding Patient Data, shows people talking about why it's important to use patient data, and why we need to better explain the benefits and safeguards. -
Content Article
Data saves lives - a series of animations
Claire Cox posted an article in Data and insight
Understanding Patient Data has produced a series of animations to explain how data saves lives. Following the journeys of patients with cancer, a heart attack, diabetes, dementia and asthma, they show the huge range of ways data is used to improve care, and the safeguards that are in place to protect confidentiality. -
Content ArticleThe Care Quality Commission (CQC)’s annual report on Ionising Radiation (Medical Exposure) Regulations in England has been published. The report gives a breakdown of the number and type of statutory notifications of errors received from healthcare providers in 2018/19 where patients were exposed to ionising radiation. These notifications are where there have been significant accidental or unintended exposures, for example where a patient received a higher dose than intended or where the wrong patient was exposed.
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Content Article
Transforming the cycle of cancer care (December 2017)
Claire Cox posted an article in Keeping patients safe
With cancer prevalence in the UK increasing, the Patients Association led a panel of experts in a discussion to address the negative cycle of cancer care that can sometimes exist. -
Content ArticleThe Professioan Records Standards Body are a unique collaboration of groups representing those who receive and provide health and social care across the UK, as well as those providing the IT systems that support care. Emma Robertson is the patient lead on the Professional Records Standards Body (PRSB), work to accredit apps and digital health technologies. She speaks to PRSB about why she got involved with the work and the benefits and challenges of using apps to support health and care.
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Content ArticlePatients have different concerns from clinicians when asked about problems with their care, and may identify preventable safety issues. When trained volunteers surveyed 2,471 patients from three NHS Trusts in England, 23% of patients identified concerns about their care. The biggest category of concerns related to communication, with staffing issues and ward environment the next most common and safety issues. Although the majority of safety issues were categorised as negligible or minor, they were also seen as definitely or probably preventable. Patient-reported concerns identified new areas which may not have been picked up by staff, such as fear of other patients or delays in procedures. This is one of the largest studies to look at patient safety concerns from the patient perspective. This study suggests that inpatient surveys can identify patient safety issues and that collecting this data could help trusts identify areas where patient experience could be improved. However, for the data to be useful, it needs to be routinely collected, reviewed and acted upon, which may be difficult to implement.
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Content ArticleBoth staff and patients want feedback from patients about the care to be heard and acted upon and the NHS has clear policies to encourage this. Doing this in practice is, however, complex and challenging. This report, by the National Institute for Health Research, features nine new research studies about using patient experience data in the NHS. These show what organisations are doing now and what could be done better. Evidence ranges from hospital wards to general practice to mental health settings. There are also insights into new ways of mining and analysing big data, using online feedback and approaches to involving patients in making sense of feedback and driving improvements.
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Content ArticleSouth Australia Health's patient-centred involves engaging with the consumer and the consumer to make sure they are responsive to their needs, values and preferences. One way South Australia Health gathers feedback is to survey people who have spent time in a country or metropolitan public hospital. In 2017, 2228 people were interviewed and their responses were analysed. This report summarises the results of the survey.
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Content Article
What is restorative justice?
Claire Cox posted an article in Harmed care patient pathways/post-incident pathways
Restorative justice brings those harmed by crime or conflict and those responsible for the harm into communication, enabling everyone affected by a particular incident to play a part in repairing the harm and finding a positive way forward. This is part of a wider field called restorative practice. Restorative practice can be used anywhere to prevent conflict, build relationships and repair harm by enabling people to communicate effectively and positively. Restorative practice is increasingly being used in schools, children’s services, workplaces, hospitals, communities and the criminal justice system. Could this be something that we could utilise as a new approach in healthcare? -
Content ArticleNew research by Dr Sabine Nabecker and colleagues, published in the European Journal of Anaesthesiology, suggests surgery patients overwhelmingly prefer pre-surgical safety checklists to be completed in front of them, contrary to what is thought by doctors. Since WHO launched the Safe Surgery Saves Lives Program in 2008, surgery checklists have minimised errors and improve patient safety worldwide. The WHO-approved Safe Surgery checklist includes asking the patient to confirm their name, procedure and consent, and the medical team to check that the anaesthesia machine and medication has been checked. The list also checks if patients have known allergies and if antibiotics have been administered in the previous 60 minutes, as is standard with many surgeries. "Anaesthesia professionals are often reluctant to use checklists in front of patients because they fear causing patients' discomfort before anaesthesia and surgery," explains Dr Nabecker. "Yet our study shows that patients overwhelmingly prefer to see the checklist completed in front of them."
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Content ArticlePatient safety incidents are any unintended or unexpected incident which could have, or did, lead to harm for one or more patients receiving healthcare. Reporting them supports the NHS to learn from mistakes and to take action to keep patients safe. Both healthcare staff and the general public are encouraged to report any incidents, whether they result in harm or not, to the National Reporting and Learning System (NRLS). You can find out how to do this from the link below.
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Content ArticleBabies and young children (under five years) can suffer serious injury if they ingest coin/button batteries or poke them into their nostrils or ears. While the larger lithium batteries have the greatest potential to cause harm, including death, the smaller zinc–air batteries, used in hearing aids, cochlear implants, bone-anchored hearing aids (BAHA) and similar equipment, still present a significant risk. This National Patient Safety Alert requires all organisations supplying NHS-funded hearing aids to ensure those issued to babies and children under five years of age have secure battery compartments. Where hearing aids are issued to older children and adults, organisations are required to consider the need for a secure battery compartment for anyone living with young children and babies, or with a person with additional risk factors, such as those with a significant learning disability, dementia or other cognitive or sensory impairment.
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News ArticleA hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed. Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions. The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded. Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days. An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”. Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made. Read full story Source: The Independent, 12 December 2019
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Content Article
Put an end to cannula site infections!
Claire Cox posted an article in Other hospital-based clinical areas
This presentation written by Dr Gordon Caldwell, a Consultant Physician at Lorn and Islands Hospital, Oban, Argyll, Scotland, highlights the importance of surveillance and actions to be taken around prevention of infection of cannlula sites. -
News Article
The NHS robots performing major surgery
Patient Safety Learning posted a news article in News
How would you feel about a robot performing major surgery on you? 2019 has seen a boom in the use of cutting edge robotic technology and there is more to come. Evidence suggests robotic surgery can be less invasive and improve recovery time for patients. That could be good news with ever growing demand on health services. But how do patients feel? BBC News speaks to a patient as he prepares to put his trust in robotic assisted surgery, hoping it would mean he could get back to work more quickly. Read full story Source: BBC News, 12 December 2019
