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Showing results for tags 'Risk assessment'.
Found 206 results
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News Article
Private hospital rated ‘inadequate’ again amid safety concerns
Patient Safety Learning posted a news article in News
A privately run mental health hospital put in special measures last year has been rated “inadequate” again following a fresh Care Quality Commission inspection. Inspectors raised serious concerns about unsafe ward environments and staff not managing patient risks at the Priory Hospital Arnold, which has beds commissioned by Nottinghamshire Healthcare Foundation Trust. Inspectors said that while the leadership team was experienced, the registered manager had been in post since April last year and the improvements they had made “had not been fully embedded”. The registered manager had changed after the service was placed in special measures. Ligature risks were found in patients’ bathrooms despite the provider making “some progress” and undertaking “substantial work” to remove them, the CQC said. And in one instance, a patient had tried to harm themselves with a plastic bag which was a restricted item on the ward. CQC head of hospital inspection for mental health and community services Craig Howarth said staff “had not followed the patient’s risk assessment” and had not searched the patient on their return from a visit off the ward. He added: “It was also concerning that despite rotas showing enough staff were available across the hospital, staff gave examples of when a lack of staffing had impacted on patient care and safety. “Despite the measures in place, the risks to patients were not reduced and there was evidence of incidents of harm to patients.” Read full story (paywalled) Source: HSJ, 15 March 2022 -
News Article
'Overworked staff' impacting patient safety at Torbay Hospital
Patient Safety Learning posted a news article in News
The Care Quality Commission (CQC) has raised concerns about Torbay Hospital being understaffed and the impact that has had on patient safety. It carried out an unannounced focused inspection of medical care services at Torbay Hospital in December, after receiving information of concern about the service. Cath Campbell, CQC’s head of hospital inspection, said: “When we inspected medical care services at Torbay Hospital, we were mindful of the pressures that the COVID-19 pandemic had had on the trust, and aware that staff were working extremely hard during this time. However, we were concerned to find some of the wards didn’t have enough staff to meet the needs of patients, especially those on a dedicated COVID-19 ward, and the trust wasn’t able to provide us with evidence that there were enough staff on the ward to monitor patients to keep them safe.! “In addition, staff didn’t always complete risk assessments for each patient to remove or minimise risks to people’s safety. Staff also did not always identify patients at risk of deterioration and act quickly to keep them safe." The Torbay and South Devon NHS Foundation Trust says it has taken the CQC’s findings very seriously and made immediate improvements, which the CQC have recognised. Read full story Source: Torbay Weekly, 4 March 2022 -
News Article
Should Ozempic come with a warning about a risk of suicidal thoughts?
Patient_Safety_Learning posted a news article in News
In the U.S., the prescribing label of Ozempic's sister drug, Wegovy, already warns of possible suicidal ideation because of similar side effects linked to other weight loss drugs. Following reports of self-injury and suicidal thoughts among a small number of people who’ve taken Ozempic or Wegovy in Europe and the United Kingdom, health regulators there are investigating whether the drugs carry a risk of these side effects. The European Medicines Agency said last month that it was reviewing 150 such reports from people who took drugs in this class, called GLP-1 receptor agonists, which lower blood sugar and suppress appetite by mimicking a hormone in the gut. Then last week, the U.K.'s Medicines and Healthcare products Regulatory Agency told Reuters that it was reviewing safety data about the drugs following similar reports. Neither Ozempic nor Wegovy, which are both versions of a drug called semaglutide at different dosages, carry warnings about suicidal ideation in Europe or the U.K., since clinical trials have not shown evidence of an increased risk. But in the United States, the Food and Drug Administration requires that medications for weight management that work on the central nervous system carry a warning about suicidal thoughts. Because the agency approved Wegovy as a weight loss treatment, its prescribing label asks medical professionals to monitor for these symptoms and to discontinue the medication if people develop them. Ozempic, which is only FDA-approved to treat diabetes, does not come with that warning. But some patients think it should. Read full story Source: NBC 1 August 2023 -
News Article
Baby died of brain injury after midwives ‘neglected’ mum while breastfeeding
Patient Safety Learning posted a news article in News
Olly Vickers died of a brain injury in February last year just weeks after two midwives at Royal Bolton Hospital let his mother Emma Clark feed him while she was having gas and air – in breach of guidelines. Despite being well when he was born, Olly was found “pale and floppy” hours later due to his airways being obstructed. He developed a brain injury and died five months later. Coroner Peter Sigee ruled his death was a result of “neglect” and due to a “gross failure to provide basic medical care”. An inquest into his death heard a student midwife placed a pillow under his mother’s arm while she was feeding him, “contrary to accepted practice”. Another midwife then gave Ms Clark gas and air while she was feeding Olly as she was stitched up for a tear obtained during labour – which again went against guidance. No risk assessment was carried out and the coroner said Olly’s breastfeeding should have been stopped before the midwives began to suture Ms Clark. Read full story Source: The Independent, 8 July 2023 -
News Article
West Midlands Ambulance Service mistakes caused serious incidents
Patient Safety Learning posted a news article in News
More than half of all serious incidents where patients came to harm involving West Midlands Ambulance Service were due to clinical errors. A trust audit found choking management, cardiac arrests and inappropriate patient discharges as themes. It also noted a decision to close all community ambulance stations was taken without first doing a full risk assessment of the impact on safety. After the number of serious incidents increased from 138 in 2021-22 to 327 in 2022-23, an audit by WMAS found 53% were due to mistakes with their treatment. A situation where a person comes to significant harm in care is identified as a serious clinical incident. Sources say the trust also delayed looking into 5,000 serious patient incidents. Read full story Source: BBC News, 29 June 2023 -
News ArticleThe NHS have duped thousands of women into believing the most common incontinence mesh operation is safe, by not adding loss of sex life into its risk figures, campaigners say. The move keeps figures low so surgeons can reassure women that it is a safe day case operation. The discovery is buried in a report from five years ago, and when questioned on it, the MHRA, tasked with making sure implants are safe for patients, passed the buck and blamed the report authors. The revelation comes after a debate in Westminster, where health minister Jackie Doyle Price said there was not enough evidence to suspend the plastic implants and quoted a risk of 1-3%. However, those figures were blown out of the water just weeks before the debate in a landmark study using the NHS’s own hospital re-admission figures which show TVT mesh tape risk is at least 10%. Campaigners say even that is not a reflection of the true scale of the mesh disaster because it does not take into account women going to doctors for pain medication or those suffering in silence. Read full story Source: Cambs Times, 31 October 201t
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News Article
Inadequate Reading surgery had 'backlogs of test results', CQC says
Patient Safety Learning posted a news article in News
A GP surgery that provides treatment to about 5,600 patients has been placed in special measures by a regulator. London Street Surgery, in Reading, Berkshire, was found to have "significant backlogs of test results and care-related tasks". The Care Quality Commission (CQC) found there was "poor identification of risks to patients" during an inspection in April. The surgery has been approached for comment. The regulator rated the surgery's safety and leadership as inadequate, and said it had insufficient processes to ensure services' safety and effectiveness. Repeat prescriptions and medicines were "not managed safely", which could have posed risks to patients, and there were "risks associated" with the storage of blank prescriptions, it found. Staff training was "not monitored appropriately" and inspectors found patients with learning disabilities were not provided with health checks to make sure their wellbeing was properly monitored. Read full story Source: BBC News, 7 June 2022 -
News Article
Nasal decongestants safety review due to rare brain risk
Patient Safety Learning posted a news article in News
Experts are assessing a very rare but potentially serious brain side effect of nasal decongestants bought on the High Street. Ones containing pseudoephedrine are being reviewed because they may cause vessels supplying the brain to contract or spasm, reducing blood flow. The concern is this could lead to seizures and even a stroke. However, drug regulators stress the likelihood of this happening is extremely low. The UK-wide review for pseudoephedrine was initiated after regulators in France alerted European drugs regulator the EMA, which is also conducting a review, about some recent, rare cases. Experts say anyone with concerns about medication should speak to a doctor or pharmacist. Read full story Source: BBC News, 23 February 2023 -
News Article
‘Risk averse’ NHS 111 algorithm sends too many patients to A&E
Patient Safety Learning posted a news article in News
NHS 111 sends too many people to accident and emergency departments because its computer algorithm is “too risk averse”, the country’s top emergency doctor has warned. Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), said that December was the “worst ever” in A&E with 9 in 10 emergency care leaders reporting to the RCEM that patients were waiting more than 24 hours in their departments. Asked what measures could help improve pressures in emergency care, Dr Boyle said more clinical input was needed in NHS 111 calls. “In terms of how we manage people who could be looked after elsewhere, the key thing to do is to improve NHS 111,” Dr Boyle told MPs. “There is a lack of clinical validation and a lack of clinical access within NHS 111 - 50 per cent of calls have some form of clinical input, there’s an awful lot which are just people following an algorithm.” Dr Boyle added where clinical input is lacking “it necessarily becomes risk averse and sends too many people to their GP, ambulance or emergency department”. Read full story (paywalled) Source: The Telegraph, 24 January 2023 -
News Article
Inadequate maternity unit handed safety warning
Patient Safety Learning posted a news article in News
An NHS maternity department has been handed a warning notice by the health regulator because of safety failings. The Care Quality Commission (CQC) said it was taking the action over the James Paget Hospital in Norfolk to prevent patients coming to harm. Inspectors found the unit did not have enough staff to care for women and babies and keep them safe. The maternity department has been deemed "inadequate" by the CQC, which meant the overall rating for the hospital has now dropped from "good" to "requires improvement". Between June and November 2022 there were 30 maternity "red flags" that the inspectors found, of which more than half related to delays or cancellations to time-critical activity. In one instance, there was a delay in recognising a serious health problem and taking the appropriate action. The report also highlighted the service did not have enough maternity staff with the right qualifications, skills, training and experience "to keep women safe from avoidable harm and to provide the right care and treatment". Read full story Source: BBC News, 31 May 2023 -
News ArticleMaternity services at a trust in Staffordshire have been rated as 'requires significant improvement' by the Care Quality Commission (CQC). University Hospitals of North Midlands NHS Trust in Stoke-on-Trent must now make urgent changes by June 30th 2023, to ensure patients are cared for safely. It follows an inspection in March where inspectors said staff did not have enough effective systems in place to ensure patients were looked after to the standard they should be. Staff also failed to implement a prioritisation process to ensure delays in the induction of labour were monitored and effectively managed, according to the review of services. The CQC said midwives evaluating patients and handling triage processes did not effectively assess, document and respond to the ongoing risks associated with safety through triage. Read full story Source: ITV News, 28 April 2023
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News Article
NHS England warns against block cancellations during ‘unprecedented’ strikes
Patient Safety Learning posted a news article in News
NHS England has told trust, system and regional leaders to avoid “block rescheduling” of elective cases during the four-day junior doctors’ strike next month. In a letter sent by national medical director Sir Steve Powis and NHSE’s chief operating officer Sir David Sloman, NHS leaders are asked instead to use “rolling day-to-day cancellations” and reschedule cases “based on clinical risk”. The letter also urges leaders to maintain “as much day case and outpatient capacity as possible” and to use digital or virtual consultations to support outpatient delivery. However, it acknowledges that because of the “unprecedented scale and timing of these strikes we accept that rescheduling activity is going to be essential to minimise risks to patients”. Read full story (paywalled) Source: HSJ, 31 March 2023 -
Content ArticleThis report from Simon Milburn, Area Coroner for the area of Cambridgeshire and Peterborough, looks at the death of Jonathan Kingsman, who died of pulmonary thromboembolism and deep vein thrombosis on 1 February 2021. Mr Kingsman had been admitted to Fulbourn Hospital, Cambridge under section 2 of the Mental Health Act 1983 on 26 January. It was noted that on admission, Mr Kingsman had not consumed any fluids for several hours. The doctor on call carried out an initial risk assessment for venous thromboembolism (VTE), but as Mr Kingsman's mobility was deemed to 'not have significantly reduced ability', the assessor was directed by the guidance to stop the assessment. It was agreed at the Inquest that Mr Kingsman fell into this category and likewise agreed that throughout his time in hospital that there were no changes to his mobility which would have prompted a renewed risk assessment. However, Mr Kingsman did have other risk factors for VTE, and the coroner raised matters of concern about the risk assessment process as follows: That the risk assessment requires no consideration of risk factors other than mobility unless ‘Step 1’ is passed regardless of the number of other risk factors which may be present and their severity – Mr Kingsman was not obviously at risk of ‘significantly increased immobility compared to his normal state’ but died as a result of a DVT/VTE nonetheless. It is reasonable to expect that others may be in the same position in the future. The risk assessment form contains no guidance on its completion and no definition of certain terms. A copy of the report was sent to The Secretary of State for the Department of Health.
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Content ArticleOn 4 March 2020 an investigation into the death of Yvonne Eaves was opened. The inquest came to a narrative conclusion that "The Deceased suffered from a chronic mental disorder and serious self-neglect. After compulsory admission to hospital under the Mental Health Act there was a gross failure to provide her with basic medical care which contributed to her death and it was possible that if she had received that care and VTE prophylaxis treatment she would not have developed a pulmonary thromboembolism and died."
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Content ArticleEven before the Covid-19 pandemic, rural and remote health services in England faced long-standing workforce, financial and capacity issues. This report by the Nuffield Trust explores the impact the pandemic has had on the delivery of rural and remote health services, highlighting the underlying challenges faced by these services. It outlines how the challenges faced are different for rural areas when compared to more urban areas. The authors also discuss how performance could be monitored to signal the risk of any significant service pressures over the coming months.
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Content ArticleIn this article for The Guardian, an anonymous hospital consultant describes the situation in many NHS emergency departments in January 2023—patients ready for medical admission waiting in ambulances in the hospital car park, patients receiving IV antibiotics in chairs in the corridor and staff completely overwhelmed by the workload. The author highlights that accident and emergency departments are now being used for a purpose for which they were not designed—looking after patients who need to be admitted to hospital wards. They describe the implications of this on patient safety and staff wellbeing and argue that the NHS and Government need to call the situation what it is—a crisis—or we will come to accept poor quality care and low patient safety standards as the norm.
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Content ArticleThis article, published in The international journal for quality in healthcare, looks at the Hierarchy of Risk Controls approach to explore its usefulness and effectiveness in healthcare. To investigate this issue, a team of social scientists examined the risk controls introduced by four hospital teams in England and Scotland after they had identified hazards in their systems.
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News Article
NHS eating disorder services forced to ‘exclude’ patients and ‘ration care’
Patient Safety Learning posted a news article in News
Patients are being excluded from life-saving eating disorder treatment as services are severely underfunded, experts have warned. Adult eating disorder services are so severely underfunded and understaffed that they are having to employ rationing measures and turn away patients, leading psychiatrist Dr Agnes Ayton told The Independent. In their research, Dr Ayton and 22 other psychiatrists found that in 2019-20, just 31% of eating disorder services accepted all patients, regardless of the level of illness. The researchers warned that the situation had become more serious following the pandemic, which had driven a “worsening of the demand and capacity” crisis across the services. Experts have called for emergency funding to meet the needs of adult patients with eating disorders, and say that these services should be receiving at least £7m per million population each year to meet standards. Dr Ayton warned that patients who are “literally on death’s door” are not getting care when they need it. Read full story Source: The Independent, 25 September 2022 -
Content ArticleWhether beginning a new effort or trying to keep people motivated to better prepare for future hazards, applying risk communication principles will lead to more effective results. This self-guided module introduces seven best practices, numerous techniques, and examples to help you improve your communication efforts. Please note that this training focuses on improving risk communication skills for coastal hazards planning and preparedness, however the principles can be adapted for any setting, including healthcare.
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Content Article
This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Beverley talks to us about setting up Thrombosis UK and how it has grown to have a national impact on patient safety in hospitals. She also describes the value of combining policy work with seeing patients face-to-face, and explores the need to find new ways of working to deal with the pressures facing the healthcare system. -
Content ArticleThe African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality rate twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. This aim of this study in The British Journal of Anaesthesia was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was developed using data from 8799 patients in 168 African hospitals. It includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The authors concluded that the ASOS Surgical Risk Calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.
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Content ArticleThe objective of this study from Sharma et al. was to evaluate the accuracy of a new elective surgery clinical decision support system, the ‘Patient Tacking List’ (PTL) tool (C2-Ai(c)) through receiver operating characteristic (ROC) analysis. They found that the PTL tool was successfully integrated into existing data infrastructures, allowing real-time clinical decision support and a low barrier to implementation. ROC analysis demonstrated a high level of accuracy to predict the risk of mortality and complications after elective surgery. As such, it may be a valuable adjunct in prioritising patients on surgical waiting lists. Health systems, such as the NHS in England, must look at innovative methods to prioritise patients awaiting surgery in order to best use limited resources. Clinical decision support tools, such as the PTL tool, can improve prioritisation and thus positively impact clinical care and patient outcomes.
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Content ArticleClinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) aimed to support improvements in the work of community mental health teams (CMHTs). Specifically, the investigation looked at the following four areas: assessing a patient’s risk of self-harm or suicide considering menopause as a risk factor for mental health conditions engaging with families caring for people with a first episode of psychosis. Reference event Ms A was 56 years old when she came into contact with mental health services for the first time in September 2019, following a suicide attempt. Ms A spent a month in hospital, and was then discharged home under the care of a community mental health team (CMHT) with a diagnosis of psychotic depression. At the end of May 2020, Ms A was again admitted to hospital following a second suicide attempt. She again stayed in the hospital for about four weeks before being discharged home under the care of a CMHT. Ms A was seen by CMHT workers regularly throughout July, and had a telephone review with a consultant psychiatrist. At the end of July, Ms A’s family became increasingly concerned about her mental state and were unable to make contact with her. On 2 August, Ms A was found deceased at home having died by suicide.
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Content ArticleIn this blog, Sonia Barnfield, Clinical Adviser for Maternity Investigations at the Healthcare Safety Investigation Branch (HSIB), looks at risk assessments during the maternity care pathway, following HSIB's recent national learning report on the same subject. Sonia outlines the need for change in the way that risk during pregnancy is assessed and managed, highlighting that there is currently no single national guidance and that HSIB identified repeated examples of insufficiently robust, continuous risk assessment in the maternity pathway. She lays out six key themes highlighted in HSIB's report and looks at how risk assessments should change to improve safety for pregnant women and their babies.
