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News ArticleAn NHS hospital has admitted it failed to properly anaesthetise a patient who was operated on while conscious – leaving her with post-traumatic stress disorder (PTSD) and recurring nightmares. The woman, who has chosen to remain anonymous, said she screamed out as the gynaecological surgery at Yeovil District Hospital began to operate, but could not be heard through her oxygen mask as the surgeon cut into her belly button. Medical negligence lawyers said she was given a spinal rather than general anaesthetic during the procedure at the hospital in Somerset last year. She remained conscious while a laparoscope – a long camera tube – was placed inside her, and her abdomen was filled with gas. Her law firm Irwin Mitchell said that an increase in blood pressure had alerted staff to her discomfort, but that the procedure was continued. The woman, who is in her 30s, said: “While nothing will change what has happened to me, I just hope that lessons can be learned so no one else faces similar problems in the future." A spokeswoman for Yeovil Hospital said the incident was the result of “a breakdown of communication” which “led to the use of a different anaesthetic to that normally required for such an operation”. Read full story Source: The Independent, 10 December 2019
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News Article
GP Manish Shah guilty of sex assaults on 23 female patients
Patient Safety Learning posted a news article in News
Manish Shah preyed on cancer concerns to carry out invasive intimate examinations for his own sexual gratification, the Old Bailey heard. He convinced his victims to have unnecessary checks between May 2009 and June 2013. He was convicted of 25 counts of sexual assault and assault by penetration. Jurors acquitted 50-year-old Shah, of Romford, of five other charges. They were told afterwards he had already been found guilty of similar allegations relating to 17 other women, bringing the total number of victims to 23. Prosecutor Kate Bex QC told the trial: "He took advantage of his position to persuade women to have invasive vaginal examinations, breast examinations and rectal examinations when there was absolutely no medical need for them to be conducted." The NHS in London said it "extended sympathies" to the victims and added: "As soon as the allegations came to light, swift action was taken and we have supported the police throughout their investigation." Read full story Source: BBC News, 11 December 2019 -
News Article
Royal Bolton Hospital on 'black alert' due to winter pressures
Patient Safety Learning posted a news article in News
A hospital in Greater Manchester has declared a "black alert" due to "heightened pressure," the Bolton NHS Foundation Trust has said. The Royal Bolton Hospital triggered the alert on Monday, which is the highest level of escalation in the NHS for measuring demand against capacity. NHS chief Rae Wheatcroft said patient safety remained a "top priority". "We have been busier than we would have expected across the hospital," the deputy chief operating officer added. "We are working hard to ensure that everyone who needs a bed is admitted and treated as quickly as possible." Read full story Source: BBC News, 9 December 2019 -
Content ArticlePublic Health England have estimated that on an average day in England, between 30,000 and 35,000 adults with a learning disability, autism or both are taking a prescribed antipsychotic, an antidepressant or both without appropriate clinical indications (psychosis or affective/anxiety disorder). A substantial proportion of people with a learning disability, autism or both who are prescribed psychotropic drugs for behavioural purposes can safely have their drugs reduced or withdrawn. This research showed that among adults known to their GP to have a learning disability, (excluding only those in hospital as inpatients) on any average day: 17.0% were taking prescribed antipsychotic drugs, 16.9% antidepressants, 7.1% drugs used in mania and hypomania, 4.2% anxiolytics and 2.7% hypnotics. STOMP stands for stopping over medication of people with a learning disability, autism or both with psychotropic medicines. It is a national project involving many different organisations which are helping to stop the over use of these medicines. STOMP is about helping people to stay well and have a good quality of life.
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News ArticleToday marks the seventh annual Patient Solidarity Day, where people and organisations across the world rally around one of the key issues facing patients and help to raise awareness of this. The theme this year is ‘Acceleration for Safe Patient-Centred Universal Health Coverage’ with a call to hold leaders accountable for the commitments they have made to ensure safe and patient-centred universal health coverage for all. In a bog released today, Patient Safety Learning's Helen Hughes discusses why patient engagement is essential for a patient-safe future and how we are currently working with Joanne Hughes, founder of Mother’s Instinct, to take action to help patients engage for patient safety. Read blog
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News Article
Father-to-be died in hospital 'screaming in pain'
Patient Safety Learning posted a news article in News
The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life. Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December. The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate". The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance." At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset". It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient". The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety". Read full story Source: BBC News, 5 December 2019 -
Content Article
Safe practices for drug allergies using CDS and health IT (2019)
Claire Cox posted an article in Allergies
The Partnership for Health IT Patient Safety, a national collaborative convened by ECRI Institute, has released a new report on drug allergy interactions and how clinical decision support (CDS) and health information technology (IT) can be used to improve safety. Drug allergy alerts, a feature of clinical decision support (CDS), incorporated within the electronic health record (EHR), act as a safeguard against prescribing or dispensing a medication to which a patient has a documented allergy that could cause an adverse event for a patient. Drug allergy interactions are an important patient safety concern. Inadequate communication and display of drug allergy interaction information may result in incorrect treatment, delay care, or result in additional or prolonged care for a patient. -
News ArticleNHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years. The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”. The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service. Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time. A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes. Read full story Source: The Independent, 4 December 2019
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Content ArticleHomerton University Hospital describes how they have embedded the Redthread Youth Violence Intervention Programme into their A&E department.
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Content ArticleThe Buurtzorg model of care, developed by a social enterprise in the Netherlands in 2006, involves small teams of nursing staff providing a range of personal, social and clinical care to people in their own homes in a particular neighbourhood. There’s an emphasis on one or two staff working with each individual and their informal carers to access all the resources available in their social networks and neighbourhood to support them to be more independent. The nursing teams have a flat management structure, working in ‘non-hierarchical self-managed' teams. This means they make all the clinical and operational decisions themselves. They can access support from a coach, whose focus is on enabling the team to learn to work constructively together, and a central back office.
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Content Article
Our son's final days: "It was like he didn't matter"
Patient Safety Learning posted an article in Patient stories
Mark Stuart spent five days in agony and died following a catalogue of failings by NHS staff. His parents say they have been battling for answers for four years. They tell their story to BBC News. -
News Article
Let’s do our duty: Top nurse leads NHS staff flu jab drive
Patient Safety Learning posted a news article in News
England’s most senior nurse has called on the NHS’ million-plus frontline workers to protect themselves and their patients this year by taking up their free flu jab. Ruth May, the Chief Nursing Officer for England, is spearheading this year’s drive to ensure that as many NHS staff as possible get vaccinated against seasonal flu – meaning they are both less likely to need time off over the busy winter period, and less likely to pass on the virus to vulnerable patients. Since September, hospitals and other healthcare settings across the country have been laying on special activities designed to highlight the importance of the flu vaccine, and celebrate those staff who choose to protect themselves and their patients. A record 70% of doctors, nurses, midwives and other NHS staff who have direct contact with patients took up the vaccine through their employer last year, with most local NHS employers achieving 75% or higher. Ruth has been joined in writing an open letter to NHS staff by other heads of professions like the NHS National Medical Director, Professor Stephen Powis, Chief Allied Health Professions Officer, Suzanne Rastrick, Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent, and Chief Pharmaceutical Officer, Dr Keith Ridge. In it they urge every member of the NHS’ growing frontline workforce to work together to achieve even higher level of coverage this year. Read full story Source: NHS England, 25 November 2019 -
Content ArticleKaren Harrison from Hull University Teaching Hospitals NHS Trust writes about her experience of winning the Patient Safety Learning Culture Award and what she plans to do next.
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Content ArticleChristine Reddall talks about the diagnosis and subsequent care of her daughter who had young onset dementia.
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News ArticleIn March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua. The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale. James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families." Read full story Source: The Independent, 21 November 2019
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Content ArticleThe home care environment has a number of unique challenges for care providers, partially due to the high amount of variability between patients and their residences. It was identified that a mobile application used to coordinate some home care services in Alberta had opportunities for improvement in how patient specific safety critical information was provided to staff.
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Content Article
My experience in a coroner’s court – a nurse perspective
Anonymous posted an article in Florence in the Machine
This is the story of a nurse's experience when attending a coroner's court and how the Trust supported them through this difficult time.- Posted
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Content Article
Re-writing conversations
Claire Cox posted an article in By patients and public
The language we use in healthcare can have a huge impact on our patients and families. What we say and how we say it could have a negative or a positive impact. As clinicians we need to be mindful in how we say things and relay information. This short blog illustrates this. -
Content ArticleShrop Community Health have produced this video to help patients prevent pressure ulcers by learning about the 5 key messages: SSKIN: Surface Skin Keep moving Incontinence and increased moisture Nutrition and hydration
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News Article
War veteran, 99, left 'crying out in pain' on A&E trolley for 10 hours
Patient Safety Learning posted a news article in News
A 99-war-old war veteran was left in agony on an A&E trolley in a hospital for almost 10 hours. Brian Fish, a former captain in the Royal Engineers, was left “crying out in pain” as he endured the long wait at Margate’s Queen Elizabeth Queen Mother Hospital, his daughter said. Mr Fish had been urgently admitted to hospital with gall bladder problems. Details of his ordeal emerged as figures showed the queues at NHS emergency departments are now the longest on record, with one in four patients at major A&Es waiting longer than four hours to be seen or treated in October. His daughter Hilary Casement, who witnessed her father’s hospital ordeal, said: “It was traumatic for him. He lay for hours crying out in pain on a hard trolley. Eventually, with much pleading from me, he was transferred, actually tipped, on to a slightly more comfortable hospital bed and eventually seen by the kind, but overworked, medical team". Read full story Source: The Independent, 19 November 2019 -
Content ArticleHospital Watchdog is a nonprofit patient advocacy organisation in the US that champions safe hospital care for patients. They are a diverse group that includes nurses, physicians, pharmacists, healthcare experts, attorneys and members of the public. Some of them have experienced or witnessed medical errors that led to an extremely serious or tragic outcome. They are committed to improving unsafe conditions in hospitals. In February 2019, Hospital Watchdog conducted an in-depth interview with Ms. Dena Royal, a former paramedic, and respiratory therapist. Dena’s mother, Martha Wright, bled to death following a colonoscopy and a series of tragic nursing mistakes at Cass Regional Medical Center in Harrisonville Missouri.
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Content ArticleA powerful account from a daughter on the care her mum and dad received in hospital.
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Content ArticleAntibiotic resistance is increasing worldwide due to overuse and misuse of antibiotics. Newborn baby Amala has a life-threatening infection called septicemia. Will her antibiotic treatment work? This video from the World Health Organization (WHO) explains what people can do to prevent the spread of antibiotic resistance.
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Content Article
A dropped instrument, washed in theatre and immediately reused: a story from a theatre nurse
Anonymous posted an article in By health and care staff
What happens if a surgeon accidentally drops an instrument on the floor, picks it up and reuses, without it going through a steriliser? Should this be allowed to happen? Well it did!- Posted
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Content Article
The sepsis song
Claire Cox posted an article in Learning disabilities
Sepsis can be difficult to spot or articulate. This short video by MiXiT days, a theatre company made up of people with and without learning difficulties, describes the symptoms of sepsis in song format.
