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Showing results for tags 'Recommendations'.
Found 479 results
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News ArticleThe Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found. Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015. His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015. “The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.” Read full story Source: The Independent, 22 January 2020
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News Article
Earlier recognition of aortic dissection needed to prevent deaths
Patient Safety Learning posted a news article in News
Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report. The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey. The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition. It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years." Read full story Source: HSIB, 23 January 2020 -
Content ArticleThe aorta is the largest artery in the body. Acute dissection occurs when a spontaneous tear allows blood to flow between the layers of the wall of the aorta, which may then rupture with catastrophic consequences. There are about 2,500 cases per year in England, with around 50% of patients dying before they reach a specialist centre for care and 20-30% of patients dying before they reach any hospital. This Healthcare Safety Investigation Branch (HSIB) report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. Although sudden severe chest or back pain is the most common symptom, the picture can vary or mimic other conditions, which may lead to an incorrect diagnosis or delays in recognising a life-threatening condition which needs urgent treatment.
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News Article
Hundreds of serious incidents recorded at struggling small trust
Patient Safety Learning posted a news article in News
One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal. Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019. There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply. The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm. The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. Read full story (paywalled) Source: HSJ, 22 January 2020 -
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 ArticleHow are trauma-informed approaches being implemented by public services – and what are the barriers to embedding the approach more widely? Produced jointly by the Centre for Mental Health and the Agenda, the alliance for women and girls at risk, this reports explores how trauma-informed approaches are being implemented by public services including women’s centres, prisons and mental health services. Evidence has shown that there are strong links between traumatic experiences and poor mental health. The need for public services to be trauma-informed has been repeatedly demonstrated. A sense of safety summarises the findings of interviews and site visits to a range of public services for women, including substance misuse, homelessness, mental health, the criminal justice system, and domestic and sexual abuse and exploitation. It found that services taking a holistic approach to supporting women’s needs were best able to make the change to becoming trauma-informed. However, many organisations faced barriers including short-term and fragile funding.
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News ArticleTen years on from the Mid Staffordshire NHS trust scandal, the man who led the inquiry into one of the worst care disasters in the service’s history has said he remains worried about the safety of patients and a culture that leaves staff too frightened to speak up. Sir Robert Francis QC said some safety risks highlighted a decade ago remain unresolved and he threw his weight behind calls for senior managers in the NHS to be regulated. The barrister said he believed the NHS was safer now than a decade ago but added he worried whether actions taken since the disaster had made a real difference. “What keeps me awake at night is not so much has anyone implemented recommendation 189 or not, but more whether the collectivity of what has happened since has actually resulted in things being better for patients and staff,” he told The Independent. Read full story Source: The Independent, 15 January 202
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Content ArticleThe reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery. The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
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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. However, doing this in practice is complex and challenging. This report from the National Institute for Health Research (NIHR) 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. The report found that although a lot of resource and energy goes into collecting feedback data, less goes into analysing it in ways that can lead to change or into sharing the feedback with staff who see patients on a day-to-day basis. Patients’ intentions in giving feedback are sometimes misunderstood. Many want to give praise and support staff and to have two-way conversations about care, but the focus of healthcare providers can be on complaints and concerns, meaning they unwittingly disregard useful feedback. The report provides insights into new ways of mining and analyzing big data, using online feedback and approaches to involving patients in making sense of feedback and driving improvements.
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Content ArticleSHOT is the United Kingdom independent, professionally led haemovigilance scheme. Since 1996 SHOT has been collecting and analysing anonymised information on adverse events and reactions in blood transfusion from all healthcare organisations that are involved in the transfusion of blood and blood components in the United Kingdom. Where risks and problems are identified, SHOT produces recommendations to improve patient safety. The recommendations are put into its annual report which is then circulated to all the relevant organisations including the four UK Blood Services, the Departments of Health in England, Wales, Scotland and Northern Ireland and all the relevant professional bodies as well as circulating it to all of the reporting hospitals. As haemovigilance is an ongoing exercise, SHOT can also monitor the effect of the implementation of its recommendations.
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News Article
Death review backlog still growing despite NHSE commitment
Patient Safety Learning posted a news article in News
A backlog of thousands of deaths of people with learning disabilities awaiting official review has grown further, despite NHS England committing in spring last year to “address” the buildup. Information obtained by HSJ shows the number of incomplete reviews increased slightly between May and November last year – from 3,699 to 3,802. The “national learning disabilities mortality review” programme – known as LeDeR – was launched in 2016 and is meant to review all deaths of people aged four and over. Mencap head of policy and public affairs, Dan Scorer, said: “It is unacceptable that thousands of deaths have still not been reviewed despite NHS England announcing further funding to make sure all reviews were carried out quickly and thoroughly. These latest figures show that little progress has been made; the programme is still failing to address outstanding reviews as well as keep pace with incoming referrals." “Behind these figures are families whose loved ones’ deaths may have been potentially avoidable and they have a right to know that health and care services are learning and acting on LeDeR reviews’ recommendations.” Read full story (paywalled) Source: HSJ, 8 January 2020 -
Content ArticleThis report from Verita, an independent consultancy, provides an independent account into the disciplinary process regarding Nurse Amin Abdullah in late 2015. It was commissioned by Imperial College Healthcare NHS Trust (‘the trust’) in 2017 to review the process that it followed in dealing with Nurse Abdullah’s case and whether fair and appropriate action was taken
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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 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.
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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 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. -
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 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 Article
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 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 ArticleThis article, published by Medium, looks at the story of a woman who had a stroke while pregnant. Both survived. The authors highlight a growing concern that the US is in the midst of a maternal morbidity and mortality crisis.
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Content ArticleThis video supports the launch of our thematic review that presents a detailed analysis of claims made after an individual has attempted to take their life. Claims relating to completed suicide and attempted suicide are reviewed, regardless of whether the claim resulted in financial compensation. It identifies common problems with care and provides recommendations for improvement to support service delivery.
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Content ArticleSocial care in England is at a crossroads. All three major political parties in the 2019 general election have recognised in their manifestos that the social care system is in need of change. So what needs to be done?
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Content ArticleWomen can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. That’s the safety risk the Healthcare Safety Investigation Branch (HSIB) highlights in this report.
