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Content ArticleThis case will be of interest to capacity assessors, practitioners, healthcare providers and commissioners because it provides further guidance on the Court of Protection’s approach to capacity and best interests in relation to clinically assisted nutrition and hydration for victims of abuse and trauma.
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Content ArticleThe Healthcare Safety Investigation Branch (HSIB) reiterates the importance of clear personal protective equipment (PPE) guidelines to reduce the risk of COVID-19 transmission when delivering care in people’s homes.
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Content ArticleThis animation has been made to help patients stay safe while they are in hospital. It has been developed by Haelo, an innovation and improvement centre in Salford, in partnership with Guy’s and St Thomas’, and is based on the airline-style safety card developed by Guy’s and St Thomas’. Designed as part of their award-winning Welcome Pack, the safety card supports our commitment to patient safety and enables patients to play an active role in their care.
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Is doing nothing, doing no harm?
Dr Mark Lomax posted an article in How to engage for patient safety
Dr Mark Lomax, CEO of PEP Health, the social listening tool of patients, talks about the lack of discussion following the “First Do No Harm” Cumberlege Report and why patient safety and experience should be viewed differently. -
Content ArticleThe Care Quality Commission (CQC) inspected 65 services that provides solely cosmetic surgery and/or hair transplant surgery. This represents just under two thirds of those currently registered. Professor Ted Baker, CQC’s Chief Inspector of Hospitals has written to all independent cosmetic surgery providers. His letter highlights these emerging concerns and clarifies the standards of patient care that CQC expect and patients deserve. It also reminds providers of their responsibility to deliver safe and effective services.
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Content ArticleNHS England and Improvement set out the NHS's priorities for the remainder of 2020-21 in a “phase three letter” sent to local leaders.
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Content ArticleReport from the Saudi Patient Safety Center on: 1. Hospital Survey on Patient Safety Culture National Recommendations Cycle 2: (2019), and 2. National Supplementary Recommendations related to COVID-19.
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Content ArticleThe government-commissioned review, First Do No Harm, into why mesh implants and other treatments were allowed to harm hundreds of women said the failings were “caused and compounded by failings in the health system itself”. HSJ's Health Check podcast considers why it is being buried by government.
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Content ArticleOn Wednesday 8 July 2020 the Independent Medicines and Medical Devices Safety Review published its report First Do No Harm, examining how the healthcare system in England responds to reports about the harmful side effects from medicines and medical devices. Chaired by Baroness Julia Cumberlege, the review focused on looking at what happened in relation to three medical interventions: hormone pregnancy tests, sodium valproate and pelvic mesh implants. In this blog Patient Safety Learning consider the reports findings in more detail, highlighting the key patient safety themes running through this, which are also found in many other patient safety scandals in the last twenty years. It also looks at what needs to change to prevent these issues recurring and asks whether NHS leaders stick with the current ways of working, make a few improvements, or take this opportunity for transformational change.
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Content ArticleHealthcare staff have had to adapt their way of working as a result of the pandemic, which has made pre-COVID guidance obsolete. Different Trusts are doing different things. Associate Director of Patient Safety Learning and Critical Care Outreach Nurse, Claire Cox, outlines the challenges and asks, what is the solution?
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Content ArticleThis Review was announced in the House of Commons on 21 February 2018 by Jeremy Hunt, the then Secretary of State for Health and Social Care. Its purpose is to examine how the healthcare system in England responds to reports about harmful side effects from medicines and medical devices and to consider how to respond to them more quickly and effectively in the future. The Review was asked to investigate what had happened in respect of two medications and one medical device: hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages; sodium valproate – an effective anti-epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy; and pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future. The Review was prompted by patient-led campaigns that have run for years and, in the cases of valproate and Primodos over decades, drawing active support from their respective All-Party Parliamentary Groups and the media.
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Content ArticleThis is a true story of ordinary people showing extraordinary determination and courage in the face of adversity. It is an unconventional, honest and deeply personal attempt to bring what has been hidden into the light for all to see. Alison was a vulnerable mentally ill patient taken advantage of by an older male nurse. She became pregnant and a crisis abortion was arranged by staff at the mental health hospital. Alison took her life on what would have been her child's third birthday. Though the names are known, no one has ever been held accountable for the crimes committed against her. Alison and her family have been lied to and failed by the NHS, the Police and Crown Prosecution Service. While this book pays tribute to the many leaderless heroes on the frontline of health services, it is scathing about the lack of honesty and integrity in their leaders and managers. This is a story of the abuse of power, the hiding of wrongdoing, and a quest for truth, accountability and justice that is not yet over.
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Content ArticleThis joint report by the Prison Reform Trust (PRT), INQUEST and Pact (the Prison Advice and Care Trust) reveals that most prisons in England and Wales are failing in their duty to ensure that emergency phone lines are in place for families to share urgent concerns about self-harm and suicide risks of relatives in prison. This is in serious breach of government policy that families should be able to share concerns ‘without delay’.
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Content ArticleThe Care Quality Commission (CQC) is the independent regulator of health and social care in England. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and they encourage care services to improve.
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Content Article
Primary care cancer toolkit
Claire Cox posted an article in Cancers
This Primary Care Cancer Toolkit provides a collection of key resources about cancer prevention, diagnosis and care relevant for the primary care setting. It provides links to current guidance, continuing professional development resources, patient information, and information for those involved in commissioning. -
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Chemotherapy safety - precautions for the public
Claire Cox posted an article in Cancers
Chemotherapy is strong medicine, so it is safest for people without cancer to avoid direct contact with the drugs. That’s why oncology nurses and doctors wear gloves, goggles, gowns and, sometimes, masks. When the treatment session is over, these items are disposed of in special bags or bins. After each chemotherapy session, the drugs may remain in your body for up to a week. This depends on the type of drugs used. The drugs are then released into urine, faeces and vomit. They could also be passed to other body fluids such as saliva, sweat, semen or vaginal discharge, and breast milk. Some people having chemotherapy worry about the safety of family and friends. There is little risk to visitors, including children, babies and pregnant women, because they aren’t likely to come into contact with any chemotherapy drugs or body fluids. -
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Commissioning for Quality and Innovation (CQUIN)
Claire Cox posted an article in CQUIN
CQUIN stands for Commissioning for Quality and Innovation. This is a system introduced in 2009 to make a proportion of healthcare providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care. This means that a proportion of a Trusts income depends on achieving quality improvement and innovation goals, agreed between the Trust and its commissioners. The sum attached to the CQUINs is variable each year based on a percentage of the contract value and depends on achieving quality improvement and goals. -
Content ArticleThis report from the Action against Medical Accidents (AvMA), authored by Dr David Cousins, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. The report recommends a number of urgent actions to address these risks to patients.
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Content Article
Managing healthcare fire safety (updated April 2013)
PatientSafetyLearning Team posted an article in Processes
This guidance (HTM 05-01) sets out the Department of Health’s policy on fire safety in the NHS in England. It includes best practice guidance on management arrangements for fire safety. -
Content ArticleThis review has examined the commissioning and use of clinical advice by the Parliamentary Health Service Ombudsman’s (PHSO) service during the assessment and investigation of complaints made by (or on behalf of) recipients of NHS care. In establishing findings, conclusions, and recommendations, the author, Liam Donaldson, has asked a series of important questions, including: Does the current process for engaging clinical advice work effectively? What, if any, are the main problems, risks, and areas of dysfunction? Does the process need to be improved and if so why and how?
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Content ArticleAs healthcare organisations seek to enhance safety and quality in a changing environment, organisational learning practices can help to improve existing skills and knowledge and provide opportunities to discover better ways of working together. Leadership at executive, middle management, and local levels is needed to create a sense of shared purpose. This shared vision should help to build effective relationships, facilitate connections between action and reflection, and strengthen the desirable elements of the healthcare culture while modifying outdated assumptions, procedures, and structures.
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Content ArticleWhen it was initiated in 2001, England's national patient survey programme was one of the first in the world and has now been widely emulated in other healthcare systems. The aim of the survey programme was to make the National Health Service (NHS) more 'patient centred' and more responsive to patient feedback. The national inpatient survey has now been running in England annually since 2002 gathering data from over 600,000 patients. The aim of this study is to investigate how the data have been used and to summarise what has been learned about patients' evaluation of care as a result.
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Content ArticleAn effective complaints system is a vital part of high-quality health and social care, helping services and individuals learn how to do better when things don't go according to plan. For people to speak up about their concerns, they need to be confident that the system will act in response. In order to build the trust the NHS needs to consistently demonstrate that they are taking people's complaints seriously. This report investigates how well NHS trusts across England communicate about their work on complaints and whether current effort are sufficient to build that public trust.
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Content ArticleThe findings in this report followed a 14-year inquiry into hyponatraemia-related deaths in five children in Northern Ireland. The inquiry was set up in 2004 to investigate the deaths of Adam Strain, Claire Roberts, Raychel Ferguson, Lucy Crawford and Conor Mitchell. The chairman said that the deaths of Adam Strain, Claire Roberts and Raychel Ferguson were the result of "negligent care".
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Content ArticleDespite increasing recognition of the potential risks associated with in-hospital newborn falls among health professionals, new parents are frequently unaware of the possibility of dropping their newborn, especially in the hospital. Although most newborn falls do not result in lasting harm to the newborn, they may need additional healthcare services and cause stress to the parents.
