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Content ArticleDraft resolution proposed by Albania, Australia, Bangladesh, Belarus, Bhutan, Botswana, Brazil, Canada, Chile, Colombia, El Salvador, Guatemala, Iceland, India, Indonesia, Japan, Mexico, Monaco, Montenegro, Mozambique, New Zealand, North Macedonia, Norway, Paraguay, Peru, Republic of Korea, Republic of Moldova, Russian Federation, San Marino, Sierra Leone, South Africa, the European Union and its Member States, Turkey, Ukraine, United Kingdom of Great Britain and Northern Ireland and Zambia following the 73rd World Health Assembly.
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Content ArticleIf a nasogastric tube (NGT) has been misplaced into the respiratory tract and this is not detected before fluids, feed or medication are given, death or severe harm can be caused. The consequences are even more likely to be fatal for patients who are already critically ill. Most nasogastric ‘Never Events’ of feeding into the respiratory tract through a misplaced tube continue to arise from misinterpretation of x-rays by staff who had not been given training in the ‘four criteria’ technique and were unaware that relying on the position of the tube tip alone on a radiograph can be a fatal error. BAPEN has produced this easy reference guide.
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Content ArticleOn 4 May 2020, a 13-strong committee convened by former UK government Chief Scientific Adviser Sir David King discussed some aspects of the science behind the UK strategy in a two and a half hour meeting. Leading experts in public health, epidemiology, primary care, virology, mathematical modelling, and social and health policy, raised ideas and issues for consideration which are shared in this report. The report does not aim to critique such work. Rather, it recognises that such solutions will take time and will still require an appropriate public health infrastructure to maximise their benefit. This is the focus of this first report and the meeting aimed to offer some constructive ideas to the governments of the UK and the devolved nations about how best to tackle this crisis, to save lives, suppress the coronavirus and get the economy moving again.
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Content ArticleThis is part 5 of a series of blogs about human factors and investigations in healthcare. The theme is ‘when’ and that covers ‘when’ to investigate and ‘when’ to try any remedies or interventions your investigation data suggests might prevent the incident occurring again. As this blog can be explained by a photo and a graph, we have some time to recap the story so far and, perhaps, predict a bit of the future.
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Content Article
Human medicines: highlights of 2019
Claire Cox posted an article in Medication including labelling
The European Medicines Agency (EMA) has published an PDF icon overview of its key recommendations in 2019 on the authorisation and safety monitoring of medicines for human use. Innovative medicines are essential to advancing public health as they bring new opportunities to treat certain diseases. In 2019, EMA recommended 66 medicines for marketing authorisation. Of these, 30 had a new active substance which had never been authorised in the EU before. The infographic includes a selection of medicines that represent significant progress in their therapeutic areas. Once a medicine is authorised by the European Commission and prescribed to patients, EMA and the EU Member States continuously monitor its quality and benefit-risk balance and take regulatory action when needed. Measures can include a change to the product information, the suspension or withdrawal of a medicine, or a recall of a limited number of batches. An overview of some of the most notable recommendations is also included in the document. -
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Capnography: No Trace = Wrong Place
Patient Safety Learning posted an article in High risk areas
The Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) have collaborated to create the video resource Capnography: No Trace = Wrong Place. Presented by Professor Tim Cook, the video shares the important message that during cardiac arrest, if a capnography trace is completely flat, oesophogeal intubation should be assumed until proven otherwise. -
Content ArticlePatient Safety Learning's Chief Executive Helen Hughes, alongside Professor Alison Leary and Professor Sara Ryan, talk on BBC Radio 4 about coroner reports that are specifically designed to help prevent future deaths and question whether it's working in practice. Health researchers warn that lives are at risk because warnings from Coroners are not being acted upon. Analysis of more than 1000 Prevention of Future Death reports has identified five themes that come up time and time again. Patient Safety Learning has written to the Chief Coroner because of their concerns about this. Sara Ryan is a mother who believes lessons from her son's death have not been learned.
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Content ArticleThe Health Foundation commissioned the Institute of Health Equity to examine progress in addressing health inequalities in England, 10 years on from the landmark study Fair Society, Healthy Lives (The Marmot Review). Led by Professor Sir Michael Marmot, the review explores changes since 2010 in five policy objectives: giving every child the best start in life enabling all people to maximise their capabilities and have control over their lives ensuring a healthy standard of living for all creating fair employment and good work for all creating and developing healthy and sustainable places and communities. For each objective the report outlines areas of progress and decline since 2010 and proposes recommendations for future action, setting out a clear agenda at a national, regional and local level.
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Content ArticleAvoidable unsafe care kills and harms thousands of people in the UK each year. When a person dies as a result of a preventable error it is vital that we learn from these tragic events and take action to ensure that this does not reoccur. Coroners' Prevention of Future Deaths (PFD reports) are a crucial resource for this and should be used to make healthcare safer. Are we utilising these to their full extent to improve our safety practice and to achieve their aim, to prevent future deaths?
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Content ArticleThe government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round. This study, published by Health Services and Delivery Research, aimed to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances.
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Content ArticleThis study, published in Health Services and Delivery Research, identified five key themes that help explain how patient experience data work could lead to quality improvements in acute hospital trusts.
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Content ArticleIn this BMJ Opinion article, David Rowland from the Centre for Health and the Public Interest discusses why he thinks the Independent Inquiry into the issues raised by Paterson is yet another missed opportunity to tackle the systemic patient safety risks which lie at the heart of the private hospital business model. David believes that although the Inquiry provided an important opportunity for the hundreds of patients affected to bear witness to the pain and harm inflicted upon them it fundamentally failed as an exercise in root cause analysis. None of the “learning points” in the final report touch on the financial incentives which may have led Paterson to deliberately over treat patients. Nor do they cover the business reasons which might encourage a private hospital’s management not to look too closely. Yet these concerns about how the private hospital system works and the associated patient risks it produces had been established in a number of previous inquiries. He suggests that the Inquiry report threw the responsibility for managing patient safety risks back to the patients themselves in two of its main recommendations but that it should be for the healthcare provider first and foremost to ensure that the professions that they employ are safe, competent and properly supervised, and for this form of assurance to be underpinned by a well-functioning system of licensing and revalidation by national regulatory bodies.
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Journey to the Genie – a blog from Eve Mitchell
Patient Safety Learning posted an article in Safe staffing levels
hub Topic Lead, Eve Mitchell, describes how her passion to change care quality and to put workforce at the centre of every health and social care organisation’s planning processes led her on a journey to create the innovative tech start-up, ‘Establishment Genie’: an online workforce planning, safe staffing and benchmarking tool. -
Content ArticleThe independent inquiry into how the rogue breast surgeon Ian Paterson was able to inflict harm on patients over more than decade described the UK healthcare system as “dysfunctional at almost every level.” In this BMJ analysis, Gareth Iacobucci summarises the findings of the inquiry.
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Content ArticleThis inquiry looked at the current and future scale of the shortfall of nursing staff and whether the Government and responsible bodies have effective plans to recruit, train and retain this vital workforce. It assessed the impact of new routes into nursing (including student funding reforms, the Apprenticeship Levy, Nurse First and nursing associates). In particular, the inquiry examined the effect of changes to funding arrangements for nurse training, including the withdrawal of bursaries, and consider alternative funding models and incentives.
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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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CQUIN for deteriorating patients: proforma (February 2020)
PatientSafetyLearning Team posted an article in CQUIN
Dr Matt-Inada-Kim, National Clinical Lead for Sepsis and Deterioration, shares the proforma he has developed to document management and treatment for the deteriorating patient for the new CQUIN, coming soon. This proforma ensures that all the CQUIN data is captured when it comes to audit. He has shared his accompanying slide set explaining about the CQUIN.- Posted
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Content ArticleThe Independent Inquiry into the Issues raised by Paterson, published on Tuesday 4 February 2020, was prompted by the case of Ian Paterson, a breast surgeon who was convicted of wounding with intent some of the 11,000 patients he treated and jailed for 20 years in 2017. More than 200 patients and family members gave evidence as part of the Inquiry and it is estimated that he could have harmed more than 1000 patients.[1] The Inquiry gave those involved an opportunity to be heard and to learn how this happened, in both the NHS and the independent sector. It found that this “is the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe, and where those who were the victims of Paterson’s malpractice were let down time and time again”.[2] At Patient Safety Learning we have reflected on some of the key patient safety themes that have emerged from this Inquiry and the actions required these issues. You can read Patient Safety Learning's full response here.
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Content ArticleIn April 2017, Ian Paterson, a surgeon in the West Midlands, was convicted of wounding with intent, and imprisoned. He had harmed patients in his care. The scale of his malpractice shocked the country. There was outrage too that the healthcare system had not prevented this and kept patients safe. At the time of his trial, Paterson was described as having breached his patients’ trust and abused his power. In December 2017, the Government commissioned this independent Inquiry to investigate Paterson’s malpractice and to make recommendations to improve patient safety. This report presents the Inquiry’s methodology, findings and recommendations. More importantly, it tells the story of the human cost of Paterson’s malpractice and the healthcare system’s failure to stop him, and something of the enduring impact this has had on the lives of so many people.
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Content ArticleThe Royal College of Physicians has published ethical guidance for frontline staff dealing with the COVID-19 pandemic, supported by more than a dozen other health organisations. Members of the RCP’s Committee on Ethical Issues in Medicine, chaired by Dr Alexis Paton, developed the guidance, which is supported by nine other Royal Colleges and five medical faculties. It takes into consideration recent joint statements from the General Medical Council (GMC), the NHS and the UK’s four Chief Medical Officers. The guidance reminds frontline staff that while so much has changed during the pandemic, they still need to ensure that care is provided in a fair and equitable way.
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RCOG: Each Baby Counts 2019 progress report
Patient Safety Learning posted an article in Maternity
Each Baby Counts is a national quality improvement programme led by the Royal College of Obstetricians and Gynaecologists (RCOG) to reduce the number of babies who die, or are left severely disabled, as a result of incidents occurring during term labour. The Each Baby Counts programme brings together the results of local investigations into stillbirths, neonatal deaths and brain injuries occurring during term labour to understand the bigger picture, share the lessons learned and prevent babies from dying or suffering brain injuries in the future. This report presents key findings and recommendations based on the analysis of data relating to the care given to mothers and babies throughout the UK, to ensure each baby receives the safest possible care during labour. -
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COVID-19: Information from the Intensive Care Society
Patient Safety Learning posted an article in Guidance
The Intensive Care Society has created a page to provide the critical care community with resources and information on COVID-19. The Society is collaborating with Government, FICM and other agencies to ensure they provide consistent, up to date and relevant messaging to support your understanding of and management of COVID-19. -
Content ArticleAdvice from the World Health Organization.
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NHS England: Coronavirus guidance for clinicians
Patient Safety Learning posted an article in Guidance
NHS England has provided links to the up-to-date guidance healthcare professionals need to respond to coronavirus (COVID-19). Clinicians and members of the public can check the government’s response to coronavirus and travel advice on gov.uk. -
Content ArticleThe Health and Social Care Select Committee is currently holding an Inquiry into Delivering Core NHS and Care Services during the Pandemic and Beyond. It’s stated aim is to ‘give focus to these upcoming strategic challenges, and give those working in the NHS and care sectors an opportunity to set out what help they will need from Government in meeting them’[1]. In its call for evidence the Inquiry has specifically identified ‘meeting the needs of rapidly discharged hospital patients with a higher level of complexity’ as one of the issues it will cover [2]. This is a joint submission (see attachment) to the Inquiry by Patient Safety Learning and CECOPS which is focused on this specific issue.
