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Content Article
In this blog Patient Safety Learning considers the safety concerns highlighted by a recent report by the Healthcare Safety Investigation Branch (HSIB) into the administration of high-strength insulin from pen devices in hospitals. This blog argues that without specific and targeted recommendations to improve patient safety in this area, patients will continue to remain at risk from similar incidents. -
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation aims to help improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting. As its ‘reference case’, the investigation uses the experience of Kathleen, a 73 year old woman with type 2 diabetes who received two recognised overdoses of insulin while she was in hospital. On both occasions she became hypoglycaemic, received medical treatment, and recovered. Patient Safety Learning has published a blog reflecting on some of the key patient safety issues highlighted in this report.
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Content ArticleIn this editorial, published in the British Journal of Hospital Medicine, Dr Paul Grime reviews the report 'Mind the implementation Gap: The persistence of avoidable harm in the NHS', which calls on the government, parliamentarians and NHS leads to take action to address the underlying causes of avoidable harm in healthcare.
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Content ArticleICS Futures is a roundtable series held by the Public Policy Projects ICS Network and chaired by Matthew Swindells, Chair of the North West London Acute Collaborative and former Deputy CEO of NHS England. The Network is made up of senior leaders from across the health and care sectors. The Network convened for three Chatham House roundtables between 16 May and 17 June 2022. The objective of discussions was to highlight challenges and opportunities in integrated care based on real-world examples, to scale best practice and provide ongoing practical advice for system leaders and care providers. Thoughts were also given on key legislative developments, with some national policy recommendations highlighted. This document summarises the key findings and recommendations from each meeting. It is not an exhaustive description of health and care system leaders’ views but rather provides a snapshot into the thoughts and concerns of a specific cohort of senior stakeholders
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Content ArticleThe maternity services at the Royal Devon and Exeter NHS Foundation Trust share their infographic which informs their staff of the 15 Immediate and Essential Actions from the Ockenden report and the action plan needed to implement these.
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Content ArticleThis article in The Milbank Quarterly summarises an extensive literature review addressing the question, "How can we spread and sustain innovations in health service delivery and organisation?" The authors identify three key outputs of the systematic review: A parsimonious and evidence-based model for considering the diffusion of innovations in health service organisations Clear knowledge gaps on which further research on the diffusion of innovations in service organisations should be focused A robust and transferable methodology for systematically reviewing complex research evidence
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Content ArticleThis article highlights two written questions tabled in the House of Commons relating to recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review concerning surgical mesh implants.
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Content ArticleThis thesis by Suzette Woodward describes a project that aimed to identify how the National Patient Safety Agency (NPSA) could support improvement in implementing patient safety guidance. It explored the factors that help or hinder successful implementation and its findings led to the design and development of an implementation toolkit, initially targeted at NPSA staff and other national bodies responsible for issuing guidance about safer practices.
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Content ArticleDerek Richford shares Harry's Story from last year's HSJ Patient Safety Congress. Derek is grandfather of Harry Richford who died seven days after an emergency delivery at East Kent Hospitals Trust. Derek is joined by Donna Ockenden, Chair of the Independent review of maternity services at Shrewsbury & Telford Hospital, and Sarah-Jane Marsh, Chair of NHS England's Maternity transformation programme, in the 'Actioning recommendations from the Ockenden report' session at the Congress.
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Content ArticleThe Belfast Health Trust failed to intervene quickly enough in the practice of a doctor which led to Northern Ireland's largest ever patient recall, the Independent Neurology Inquiry has found. More than 5,000 former patients of neurologist Michael Watt were invited to have their cases examined for possible misdiagnoses. Among the conditions being treated were stroke, Parkinson's disease and multiple sclerosis (MS). The inquiry found "numerous failures". The Independent Neurology Inquiry concluded that the combined effect of the failures ensured that patterns in the consultant's work were missed for a decade.
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News Article
Breast surgeon's victim wants faster improvements
Patient Safety Learning posted a news article in News
Victims of breast surgeon Ian Paterson said independent inquiry improvements are not being implemented fast enough. Paterson was jailed in 2017 after he was found to have carried out needless operations on patients across Birmingham and Solihull. The 2020 report's recommendations include the recall of his 11,000 patients to assess their treatment. The Department of Health and Social Care (DHSC) said it is working to stop future patients facing similar harm. On Sunday, ITV screened a documentary 'Bodies of Evidence: The Butcher Surgeon' which featured victim and campaigner Debbie Douglas, who was instrumental in getting the inquiry established. She said the government needs "to put pace behind" the work to implement the 15 recommendations it made. "It is important those recommendations are embedded in legislation, it is important there is governance over those recommendations to stop another Paterson, it is important that there is a proper consent procedure," she said. The recommendations called for consultants to write directly to patients to explain proposed surgical treatment as standard practice, a public register to detail which types of operations surgeons are able to perform and for patients to be given time to reflect on their diagnosis and treatment options before they are asked to consent to surgery. Read full story Source: BBC News, 14 June 2022 -
News Article
Failure to achieve mental health pledge in England ‘inhumane’, say psychiatrists
Patient Safety Learning posted a news article in News
Adult mental health patients in England have spent more than 200,000 days being treated in “inappropriate” out-of-area placements – at a cost to the NHS of £102m – in the year since the government pledged to end the practice. The Royal College of Psychiatrists, which carried out the analysis, says such placements, in which mental health patients can be sent hundreds of miles from home, are a shameful and dangerous practice that must stop. The government said it would end such placements by April last year but, in the 12 months since, 205,990 days were spent inappropriately out of area, at a cost equivalent to the annual salaries of more than 900 consultant psychiatrists, the college found. Dr Adrian James, the college’s president, said: “The failure to eliminate inappropriate out-of-area placements is a scandal. It is inhumane and is costing the NHS millions of pounds each year that could be spent helping patients get better. “No one with a mental illness should have to travel hundreds of miles away from home to get the treatment they desperately need.” He said investment was needed in local, properly staffed beds, alternatives to admission, and follow-up care in the community as well as government backing “to address the workforce crisis that continues to plague mental health services”. Read full story Source: The Guardian, 13 June 2022 -
Content Article
The dangerous practice of sending people with a mental illness hundreds of miles away from home for weeks at a time continues in England, according to new analysis published by the Royal College of Psychiatrists. Despite Government pledges to end the shameful practice, known as inappropriate out of area placements, by March 2021, almost 206,000 days have been spent by patients out of area in the 12 months since the deadline passed. Being far away from home, with friends and family not being able to visit, can leave patients feeling extremely isolated and emotionally distressed with devastating, long-lasting consequences for their mental health. Not only that, but it comes at a huge cost to the NHS. The health service spent £102 million on inappropriate out of area placements last year – the equivalent to the cost of the annual salary of over 900 consultant psychiatrists. The Royal College of Psychiatrists is calling on the NHS to adopt a ‘zero tolerance’ approach to inappropriate out of area placements and to take urgent action to ensure all patients get the care they need from properly staffed, specialist services in their local area. -
Content ArticleThis study by Sir Robert Francis QC looks at options for a framework for compensation for the victims of the infected blood tragedy. Sir Robert will give evidence about his work to the Infected Blood Inquiry in July. Before then, it is important that the Inquiry, and recognised legal representatives of its infected and affected core participants, have an opportunity to consider his work.
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Content Article
The Messenger review is a con (HSJ, 9 June 20220
Patient Safety Learning posted an article in National/Governmental
The Messenger review may be full of well-meaning and often well-judged sentiments – but the recommendations were either peripheral (a five-day course for middle managers) or so vague as to be virtually worthless (proposals to make equality, diversity and inclusion everyone’s business). Lord Rose, Sir Ron Kerr, Tom Kark and indeed Sir Robert Francis all made similar recommendations about ensuring the quality of NHS leadership, but the Messenger review has a slightly different thrust. It aimed to review health and social care leadership. By this measure, the review has failed to do what it set out to achieve. Social care and indeed primary care are an afterthought, with the focus on the acute sector, writes Alastair McLellan and Annabelle Collins for the HSJ. -
Content ArticleIn October 2021 the government announced a review into leadership across health and social care, led by former Vice Chief of the Defence Staff General Sir Gordon Messenger and supported by Dame Linda Pollard, Chair of Leeds Teaching Hospital Trust. The results of the review have now been published and recommendations made.
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Content ArticleMore must be done to avoid harm to patients while waiting for treatment. The backlog for planned care is one of the biggest challenges for the NHS in Wales. Waiting times targets have not been met for many years. This backlog has been made much worse due to the pandemic. In February 2022, there were nearly 700,000 patients waiting for planned care, a 50% increase since February 2020. Over half of the people currently waiting have yet to receive their first outpatient appointment which means that they may not know what they’re suffering from and their care cannot be effectively prioritised. Modelling shows it could take up to seven years or more to return waiting lists to pre-pandemic levels. This report makes five recommendations based on what the Welsh Government needs to do as it implements its national plan.
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Content ArticleSerious incidents not only have a considerable human impact, but they are also detrimental to NHS reputations and finances. The current Serious Incident Framework (SIF) is a reactive, bureaucratic process, where opportunities to reduce the recurrence of a harmful incidence is often missed. With a ‘Get It Right First Time’ mentality, the new PSIRF framework was road-tested by a number of nationally appointed ‘early adopter’ Trusts and commissioners working to implement it during the course of 2021. Now a wider implementation across the NHS is planned, starting spring 2022, with guidance informed by the early adopter pilots. This blog was written by Sian Williams, NHS Team Lead & Managing Consultant, and Paul Binyon, who in a recent assignment has worked with an NHS Trust contributing to an early adopter PSIRF pilot rollout.
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Content ArticleIn this Editorial for the journal Midwifery, maternity experts come together to respond to the Ockenden review and discuss what went wrong and what needs to happen now.
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Content ArticleFollowing the publication of the Independent Medicines and Medical Devices and Safety (IMMDS) Review in July 2022, the UK Government accepted a recommendation to appoint a Patient Safety Commissioner responsible for promoting safety in the context of the use of medicines and medical devices. At the Health Plus Care conference on the 19 May 2022, Patient Safety Learning's Chief Executive Helen Hughes and Marie Lyon, Chair of the Association for Children Damaged by Hormone Pregnancy Tests, considered the key challenges that will faced by the new Patient Safety Commissioner and the importance of implementing in full the recommendations of the IMMDS Review. See attached their presentation slides.
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Content ArticleThis is an Early Day Motion tabled in the House of Commons on 18 May 2022, which calls on the Government to implement the recommendations of the Independent Medicines and Medical Devices Safety Review in full, including paying compensation to people disabled by sodium valproate.
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Content ArticleIn May 2022, the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety to urge health care leaders across the continuum of care to recommit to advancing patient and workforce safety. The NSC called for immediate action to address safety from a total systems approach, as presented in the National Action Plan to Advance Patient Safety, and implored leaders to adopt safety as a core value and foster collective action to uphold this value.
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Content ArticleThe last two years have been unprecedented for the NHS. The COVID-19 pandemic has presented a unique set of challenges and required innovative new ways of working to provide an effective response. As part of that response, the NHS adopted special payment arrangements for 2020/21 and 2021/22, removed the requirement for trusts to sign formal contracts and disapplied financial sanctions for failure to achieve national standards. The Commissioning for Quality and Innovation (CQUIN) financial incentive scheme was also suspended for the entire period. To support the NHS to achieve its recovery priorities, CQUIN is being reintroduced from 2022/23. This document sets out the requirements for all providers of healthcare services that are commissioned under an NHS Standard Contract (full-length or shorter-form version) and are within the scope of the Aligned Payment and Incentives (API) rules, as set out in the National Tariff and Payment System. These requirements take effect from 1 April 2022.
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News Article
The trusts making least progress in improving maternity services
Patient Safety Learning posted a news article in News
The trusts that have made the most and least progress on urgent recommendations set out by the Ockenden review have been revealed Published in December 2020, the interim Ockenden review set out 12 immediate and essential actions for all trusts with maternity provision, grouped into seven themes, and in its latest board papers NHS England has set out the progress they have made. The actions which trusts are struggling with most include “risk assessment throughout pregnancy” and clearly describing pathways of care in written information and posted on the trust websites. According to the data, Sheffield Teaching Hospitals Trust is the least compliant provider in England to date, as it is only fully compliant on one action. Last summer Sheffield’s maternity service plunged to “inadequate” from “outstanding” following a Care Quality Commission inspection, with concerns raised about staffing numbers, training and a lack of an open culture. Mid and South Essex Hospitals and York and Scarborough Teaching Hospitals were compliant on five actions each. MSE is rated “requires improvement” by the CQC for maternity care, whereas YSTH is “good”. Read full story (paywalled) Source: HSJ, 20 May 2022 -
Content ArticleThe Regulation and Quality Improvement Authority (RQIA) has published its independent 'Review of the implementation of recommendations to prevent choking incidents in Northern Ireland'. The Review examined the measures and governance arrangements in place to prevent choking, in line with current guidance, focusing on the work undertaken in high-risk areas across health and social care, including stroke care, care of the elderly and services for those with physical and/or mental health and learning disabilities. The Review found that there was a clear and urgent need to improve the quality and safety of care provided to people at risk of choking. The key recommendations in the Review include: training for staff including clinicians, catering and domestic teams; shorter waiting times for assessment by Speech and Language Therapy; better systems for communication between staff, and safer systems for ordering and storing food.
