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Content Article
At 10.45am on 23 November 2024, Peter Anzani sadly died from a pulmonary embolism in Birmingham Heartlands Hospital. He had been admitted to hospital the day before and was receiving treatment for a community acquired pneumonia when he suddenly and unexpectedly collapsed due to a pulmonary embolism. Peter had previously suffered a number of falls at home in August and September 2021 and was subsequently diagnosed with suffering a spontaneous infection of the cervical vertebral canal which caused a complete spinal cord injury and left him tetraplegic. This made him more vulnerable to chest infections and pulmonary embolisms which he experienced in the years that followed. There is no evidence of any human intervention that rendered his death unnatural. Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be: 1a Pulmonary Embolism 1b 1c 1d II Pneumonia Spinal cord injury resulting in Tetraplegia Matters of concern To The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust I considered evidence from a [REDACTED] who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by theTrust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms…” It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed. To NHS England / Department of Health and Social Care I heard evidence that The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust (“The Trust”) have been experiencing difficulties with patient waiting lists – due to both an increase in the quantity of patients being treated and staffing shortages – which has led to patients waiting longer than is reasonable or necessary for reviews and treatments. As part of the inquest, there was evidence that Peter Anzani himself had been waiting for nearly a year for a follow-up review, which should have been carried out after no more than 6 months. I heard evidence from representatives of the Trust that they have repeatedly requested additional funds for workforce development and expansion to assist with cutting patient waiting lists and waiting times. I understand that an initial Workplace Funding Review was submitted in 2023 but was rejected by NHS England due to a funding shortage. I understand that a further Workplace Funding Review was submitted in the Autumn of 2024, but in February/March of this year, NHS England indicated that the same would again be rejected under a “no growth policy”. Whilst naturally I am aware of the pressures on the public purse and on the NHS generally, it is concerning to hear that the Trust do not appear to be being adequately supported financially by NHS England, and do not currently appear to be able to address their workplace staffing issues without additional financial support (which does not appear to be forthcoming). It is obvious that where patients are waiting for longer than is reasonable or necessary for treatment or reviews, there is a real risk of deaths occurring. No patient should be waiting longer than absolutely necessary for treatment. In light of HM Government’s decision on 13 March 2025 to abolish NHS England and for its role to be subsumed within the Department of Health and Social Care, this report is being sent to both Agencies to consider, as it relates to issues of both a local and national significance.- Posted
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Content Article
Making data on medical interventions easier to collect and collate would increase the odds of spotting patterns of harm, according to the panel of a recent HSJ webinar. When Baroness Julia Cumberlege was asked to review the avoidable harm caused by two medicines and one medical device, she encountered no shortage of data. “We found that the NHS is awash with data, but it’s very fractured,” says Baroness Cumberlege, who chaired the Independent Medicines and Medical Devices Safety Review and now co-chairs the All-Party Parliamentary Group which raises awareness of and support for its findings. It was a challenge on which Professor Sir Terence Stephenson had cause to deeply reflect back in 2014. That was the year in which he was asked to chair an independent review of medical devices, following concerns about the safety of metal-on-metal hip replacements and PIP silicone breast implants. “The NHS stepped up to the plate really quickly and said: ‘Even if it’s a private hospital that put this in, we will take it out to protect your safety,’” recalled Sir Terence, now Nuffield professor of child health at Great Ormond Street Institute of Child Health and chair of the Health Research Authority for England. “But the big problem was they couldn’t identify who had which implants. No doubt somebody somewhere had written this down with a fountain pen and then someone spilt the tea over it and the unique information was lost.”- Posted
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Content Article
Potential serious risks to patient safety have been identified with the use of Magentus Software Limited’s Euroking maternity information system. These concern specific data fields: certain new patient information, recorded during a patient contact, can overwrite ('back copy') information previously recorded in the patient’s pregnancy record. certain pregnancy-level data (information relevant only to a specific pregnancy event) can be saved at a patient level (where information relevant throughout a person's life is recorded), causing new information to overwrite (‘back copy’) previously recorded data across an entire patient record. certain recorded pregnancy-level data can pre-populate into new pregnancy records (‘forward copy’), which can mean clinicians will see incorrect patient information, and attempts to correct this can result in the issue described at (ii) above. Actions Organisations using Euroking: 1. must consider if Euroking meets their maternity service’s needs and ensure that their local configuration is safe. To do this they will need to work with their supplier to make changes to their existing system, and this will need to be overseen by their clinical safety officer. 2. must review and ensure that each data field within the system does not copy forward or backward. 3. if procurement of a new system is deemed necessary, organisations must ensure that all clinical information is appropriately backed-up, accessible for any future requirement and, when Euroking becomes a legacy system, must comply with action Organisations with legacy Euroking contracts: 4. must implement a process to ensure users who access any legacy Euroking records will be alerted to the issues identified in this alert. Organisations currently using another maternity information system/EPR: 5. must reassess the clinical safety of their maternity EPR with a suitably qualified clinical safety officer and, as a minimum, must ensure that the issues listed under ‘Additional information’ relating to the back and forward copying of information do not occur. 6. must assess that their current maternity EPR complies with the core maternity capabilities in the Maternity Digital Capabilities Framework.- Posted
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Content Article
Between 2009 and 2010, 48 year-old David Richards was admitted to intensive care during the ‘swine flu pandemic’. He spent six weeks in an intensive care unit (ICU), first on mechanical ventilation and later receiving extra-corporeal membrane oxygenation (ECMO) treatment. He recovered and became a survivor of severe acute respiratory distress syndrome (ARDS). During his 50 days in intensive care, David's former partner Rose kept an ‘ICU diary’. Rose recorded clinical updates as well as conversations with relatives and staff who were by David's bedside. In this article, David describes how important this diary has been to him understanding and processing his experience. It forms a record not just of procedures, treatments and clinical signs but of how he reacted, how he appeared to feel and how he tried to communicate during a time that were permeated by delirium.- Posted
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For many years the NHS has talked about the need to shift to a more personalised approach to health and care—where people have choice and control over the way their care is planned and delivered, based on “what matters” to them and their individual strengths, needs and preferences. In this HSJ article, Ben Wilson, product solution director at Orion Health, discusses the progress, benefits and future possibilities for an integrated, patient-centric healthcare system.- Posted
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News Article
Trust told it ‘lacks skills or integrity’ to carry out suicides review
Patient Safety Learning posted a news article in News
A senior clinician has raised fundamental concerns about a trust’s probe into dozens of suicide cases, which was sparked by his allegations that staff had tampered with the notes of a patient. Cambridgeshire and Peterborough Foundation Trust announced in July there would be an internal review of 60 suicide cases dating back to 2017. But a key whistleblower told HSJ he fears it could be a “whitewash” and it should be carried by an external, independent investigator rather than led by the trust. The suicides review was prompted by allegations staff had added a care plan into the patient record of a patient a day after the 33-year-old had died by suicide in 2017. The allegations, not contested by the trust, were based on the findings of an internal investigation in 2021 of the trust’s conduct around the patient's case. Read full story (paywalled) Source: HSJ, 6 September 2023- Posted
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- Investigation
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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. Maureen discusses the important role of professional standards in building a patient safety infrastructure, the need to reframe safety as a positive idea and her experience of implementing learning processes during her time as a GP.- Posted
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Content Article
Hindsight bias (colloquially known as ‘the retrospectoscope’) is the tendency to perceive past events as more predictable than they actually were. It has been shown to play a significant role in the evaluation of an past event, and has been demonstrated in both medical and judicial settings. This study in Clinical Medicine aimed to determine whether hindsight bias impacts on retrospective case note review, through an internet survey completed by doctors of different grades. The authors found that in some cases, doctors are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. They also suggest that hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.- Posted
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- Investigation
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Content Article
This tool from the Parkinson's Association of Ireland allows people with Parkinson's to record their essential medical information in an easy to access format, should they need assistance or medical treatment. It includes: information about the physical symptoms of Parkinson's, including how it affects speech and movement. instructions on how to interact with the person if they are having difficulty communicating. personal details and emergency contacts details of medications and treatments the person is taking.- Posted
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News Article
Newly installed EPR contributed to A&E death, warns coroner
Patient Safety Learning posted a news article in News
A newly installed electronic patient record contributed to the “preventable” death of a 31-year-old woman in an emergency department, a trust has been warned. Emily Harkleroad died at University Hospital of North Durham in December 2022 following “failures to provide [her] with appropriate and timely treatment” for a pulmonary embolism, a coroner has said. The inquest into her death heard emergency clinicians had raised concerns about a newly installed electronic patient record, provided by Oracle Cerner, which they said did not have an escalation function which could clearly and quickly identify the most critical patients. The inquest heard the new EPR, installed in October 2022, did not have a “RAG rating” system in which information on patient acuity “was easily identifiable by looking at a single page on a display screen” – as was the case with the previous IT system. The software instead relied on symbols next to patients’ names which indicate their level of acuity when clicked on, but did “not [provide] a clear indication at first glance” of their level of acuity. Rebecca Sutton, assistant coroner for County Durham and Darlington, said that “errors and delays” meant Ms Harkleroad did not receive the anticoagulant treatment that she needed and “which would, on a balance of probabilities, have prevented her death”. “It is my view that, especially in times of extreme pressure on the emergency department, a quick and clear way of identifying the most critically ill patients is an important tool that could prevent future deaths.” Read full story (paywalled) Source: HSJ, 23 February 2024- Posted
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- Electronic Health Record
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News Article
NHSE warns widely used EPR could pose ‘serious risks to patient safety’
Patient Safety Learning posted a news article in News
NHS England has issued a national alert to all trusts providing maternity services after faults were discovered in IT software that could pose “potential serious risks to patient safety”. According to the alert, the Euroking electronic patient record provided by Magentus Software could be displaying incorrect patient information to clinicians. The Euroking EPR is used in the maternity departments of at least 15 trusts according to information held by HSJ. These organisations have been asked to “consider if Euroking meets their maternity service’s needs” and to “ensure their local configuration is safe”. Trusts with different maternity EPR providers have also been asked to reassess the clinical safety of their solutions. The potential “serious risks” relate to a fault in the Euroking EPR which allows new patient information to overwrite previously recorded information, which could lead to “incorrect management of the pregnancy and subsequent harm”. Read full story (paywalled) Source: HSJ, 8 December 2023 -
News Article
A world-leading children’s hospital has been accused of a “concerted effort” to cover up the mistakes that led to the death of a toddler. Jasmine Hughes died at London’s Great Ormond Street Hospital aged 20 months after suffering acute disseminated encephalomyelitis (ADEM), a condition in which the brain and spinal cord are inflamed following a viral infection. Doctors said that her death in February 2011 had been caused by complications of ADEM. But an analysis of detailed hospital computer records shows the toddler died after her blood pressure was mismanaged – spiking when she was treated with steroids then allowed to fall too fast. Experts say this led to catastrophic brain damage. Although the detailed computer records were supplied to the coroner who carried out Jasmine’s inquest, crucial information concerning her blood pressure was not included in official medical records that should hold the patient’s entire clinical history. Dr Malcolm Coulthard, who specialises in child blood pressure and medical records examination, carried out the analysis of the files, comprising more than 350 pages of spreadsheets. Dr Stephen Playfor, a paediatric intensive care consultant, examined the computer records and came to the same conclusion as Dr Coulthard, that mismanagement of Jasmine’s blood pressure by Great Ormond Street and Lister Hospital, in Stevenage, was responsible for her death. Dr Coulthard told The Independent: “As a specialist paediatrician, it is with great regret and disappointment that I have concluded that the doctors' records in Jasmine Hughes’ medical notes fail to reflect the truth about her diagnosis and treatment.” Read full story Source: The Independent, 20 November 2020- Posted
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News Article
Hancock extends emergency patient data sharing rules
Patient Safety Learning posted a news article in News
Matt Hancock has extended four national data sharing orders which allow GPs and NHS organisations to share confidential patient information, as part of the ongoing response to the COVID-19 pandemic. The data sharing instructions were initially put in place in March when the pandemic broke out in earnest, and they were due to expire at the end of September. Under the arrangement GPs, NHS providers, NHS Digital, NHS England/Improvement, local authorities and the UK Biobank can share information about patients’ treatment and medical history - if doing so would help their response to COVID-19. The data sharing instructions have now been extended until 31 March next year. According to the Department of Health and Social Care’s update which notified organisations of the extension, NHS entities can share information for reasons such as helping to support the NHS Test and Trace service, identifying further patients at risk of COVID-19, and understanding information about patient access to health and adult social care services. Read full story (paywalled) Source: HSJ, 20 August 2020 -
Content Article
NHSX information governance portal
Patient Safety Learning posted an article in NHS X
NHSX has launched a brand new information governance portal providing a 'one-stop shop' for NHS policies and guidance. -
Content Article
NHSX recently launched a brand new information governance portal providing a 'one-stop shop' for NHS policies and guidance. The new portal covers everything from GDPR in research to record management. But even with the new portal, navigating NHS guidance on data isn't easy. This article in Global Compliance News picks out six essential items to have on your radar if your organisation accesses or uses NHS data.- Posted
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News Article
GPs will now be able to access records for patients registered at other practices during the coronavirus epidemic in a major relaxation of current rules. The move will allow appointments to be shared across practices, and NHS 111 staff will also have access to records to let them book direct appointments for patients at any GP practice or specialist centre. The change in policy has been initiated by NHS Digital and NHSX to enable swift and secure sharing of patient records across primary care during the covid-19 pandemic. It means that the GP Connect1 system, currently used by some practices to share records on a voluntary basis, will be switched on at all practices until the pandemic is over. In addition, extra information including significant medical history, reason for medication, and immunisations will be added to patients’ summary care records and made available to a wider group of healthcare professionals. Usually, individuals must opt in but following the changes only people who have opted out will be excluded. Read full story Source: The BMJ, 27 April 2020- Posted
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News Article
MedStar Health launched a new tool that automatically calculates a patient's risk of having a heart attack or stroke within 10 years. The tool enables doctors to more easily show patients their personal risk for heart disease, stroke and other cardiovascular diseases over time using easy-to-read graphics. "Seeing their risk on a visual display is more powerful than me telling them their risk,” said Ankit Shah, Director, Sports and Performance Cardiology for the MedStar Heart & Vascular Institute at Union Memorial Hospital in Baltimore. The tool is embedded in MedStar's Cerner electronic health record (EHR), making it easier for physicians to use it during patient visits, health system officials said. The project highlights how MedStar Health National Center for Human Factors focuses on human factor design to improve technology for patients as well as providers. Final rules from the US Department of Health and Human Services (HHS) will make it easier in the future for patients to share their health data with third-party apps. Read full story Source: FierceHealthcare, 9 March 2020- Posted
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News Article
Complaints about NHS care cannot always be investigated properly because of medical records going missing, the public services watchdog has said. Ombudsman Nick Bennett said many people were left "suspicious" and thought there was a "darker motivation". One woman whose notes went missing said she no longer trusted what doctors said and had lost faith in NHS transparency. The Welsh NHS Confederation said staff were "committed to the highest standards of care". In a report called Justice Mislaid: Lost Records and Lost Opportunities, Mr Bennett found 70% of 17 cases he looked at in Welsh NHS hospitals and care settings could not be properly investigated because of lost documents. Read full story Source: BBC News, 10 March- Posted
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News Article
NHS to benefit from digital 'Redbook' app
Patient Safety Learning posted a news article in News
As part of the NHS Digital Child Health programme, Personal Child Health Records or “Redbook” will receive a digital makeover. NHS Digital has considered the limitations of the physical Redbook and decided that digitalisation is the way forward for parents to easily access important health and development information. Nurturey has been evolving its product to align with NHS' Digital Child Health programme. It aims to be an app that can make the digital Redbook vision a reality and currently in the process of completing all the necessary integrations and assurances. It is hoped that by using smart digital records, parents will be more aware of their child’s health information like weight, dental records, appointments and other developmental milestones. Tushar Srivastava, Founder and CEO of Nurturey, said: “Imagine receiving your child's immunisation alert/notification on the phone, clicking on it to book the immunisation appointment with the GP, and then being able to see all relevant immunisations details on the app itself. As a parent myself, I see the huge benefit of being able to manage my child’s health on my fingertips. We are working hard to deliver such powerful features to parents by this summer.” Read full story Source: National Health Executive, 5 February 2020- Posted
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News Article
Ways to identify EHR usability issues and reduce patient harm
Patient Safety Learning posted a news article in News
An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety. “Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence. “In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.” EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting. Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication. A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained. Ratwani also wants to ensure that certification testing is as realistic as possible. He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing. “One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said. “They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.” Read full story Source: EHR Intelligence, 13 January 2020- Posted
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Content Article
Alzheimer's Society: 'This is me' leaflet
Patient-Safety-Learning posted an article in Dementia
'This is me' is a simple leaflet for anyone receiving professional care who is living with dementia or experiencing delirium or other communication difficulties. 'This is me' can be used to record details about a person who can't easily share information about themselves. For example, it can be used to record: a person’s cultural and family background important events, people and places from their life their preferences and routines. -
News Article
NHS e-health systems 'risk patient safety'
Patient Safety Learning posted a news article in News
Hospitals across England are using 21 separate electronic systems to record patient health care – risking patient safety, researchers suggest. A team at Imperial College say the systems cannot "talk" to each other, making cross-referencing difficult and potentially leading to "errors". Of 121 million patient interactions, there were 11 million where information from a previous visit was inaccessible. The team from London's Imperial College's Institute of Global Health Innovation (IGHI) looked at data from 152 acute hospital trusts in England, focusing on the use of electronic medical records on the ward. Around a quarter were still using paper records. Half of trusts using electronic medical records were using one of three systems: researchers say at least these three should be able to share information. 10% were using multiple systems within the same hospital. Writing in the journal BMJ Open, the researchers say: "We have shown that millions of patients transition between different acute NHS hospitals each year. These hospitals use several different health record systems and there is minimal coordination of health record systems between the hospitals that most commonly share the care of patients." Lord Ara Darzi, lead author and co-director of the IGHI, said: "It is vital that policy-makers act with urgency to unify fragmented systems and promote better data-sharing in areas where it is needed most – or risk the safety of patients." A spokesperson for NHSX, which looks after digital services in the NHS, said: "NHSX is setting standards, so hospital and general practioner IT systems talk to each other and quickly share information, like X-ray results, to improve patient care." Read research article Read full story Souce: BBC News, 5 December 2019- Posted
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Content Article
This NHS Resolution video outlines the key components of good medical record keeping and highlights common mistakes to avoid.- Posted
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Content Article
The Patient Safety Authority has put together information and tips for patients on a range of topics. C-Diff Dentures in the healthcare setting Discharge instructions Drug allergies End of life care Falls at home Getting the right diagnosis Handwashing Hospital ratings Influenza (the flu) Latex allergies Medical records Medication safety at home Medication safety: Hospital and doctor's office Metric-based patient weights MRI safety MRSA Neonatal abstinence syndrome (NAS) Norovirus (stomach flu) Obstructive sleep apneoa Pneumonia Pressure injuries (bed sores) Sepsis What is an MRI? Wrong-site surgery -
News Article
‘Total IT failure’ at four hospitals sparks safety concerns
Patient Safety Learning posted a news article in News
Four hospitals in Greater Manchester are struggling with a near ‘total IT failure’ which has forced staff in all key services to use handwritten lists and notes. The problems have affected multiple IT systems across Royal Oldham, Fairfield General, Rochdale Infirmary and North Manchester General hospitals. Staff at the sites are running theatre and emergency departments using handwritten patient lists and notes, while bloods and scan results are also being written by hand. Patient histories are largely unavailable. HSJ spoke to staff who said there are major concerns over patient safety, as the lack of digital systems increases the risk of errors, and also slows down multiple processes. They described the problems as a “total IT failure”. Chris Brookes, deputy CEO and chief medical officer, said: “Patient safety and maintaining essential services remains our priority. We are doing everything we can to fix the IT issues and to limit disruption to patients and our services." Read full story (paywalled) Source: HSJ, 25 May 2022- Posted
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