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Found 63 results
  1. News Article
    A woman who had her ovaries removed by mistake was one victim of the hundreds of “never events” that occurred in the NHS over the past year. Between April 2021 and March 2022 more than 400 patients in England’s hospitals suffered errors so serious that they should never have happened according to data released by NHS England. They include the wrong hips, legs, eyes and knees being operated on, and diabetic patients being given too much insulin. Foreign objects were left inside 98 patients after operations, including gauzes, swabs, drill guides, scalpel blades and needles. Vaginal swa
  2. Content Article
    Never Events 1 April 2021 – 31 March 2022 by type of incident: Wrong site surgery – 171 Retained foreign object post procedure – 98 Wrong implant/prosthesis – 47 Misplaced naso or oro gastric tubes and feed administered – 31 Administration of medication by the wrong route – 21 Unintentional connection of a patient requiring oxygen to an air flowmeter – 13 Overdose of insulin due to abbreviations or incorrect device – 11 Transfusion or transplantation of ABO incompatible blood components or organs – 7 Falls from poorly restricted windows –
  3. Event
    Never Events and serious Incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commision (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified and errors attributed to processes and individual staff. In this webinar, we welcome representatives from the CQC and the National Orthopaedic Alliance (NOA) to discu
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    In his report, the Coroner lists the following matters of concern: Using a misplaced nasogastric tube is recognised as a 'never event', namely an event which is wholly preventable and should never happen. The court heard evidence at the inquest that an NHS improvement patient safety alert issued in 2016 identified that between 2011-2016 there had been 95 incidents of misplaced nasogastric tubes used to administer fluids or medication, 32 of which resulted in death. The court heard that Barts NHS Trust had at least seven incidents relating to misplaced nasogastric tube since
  6. Content Article
    Case submission When submitting a case, the following information is required. Title (please provide an appropriate title for the case). Patient Description (describe the patient [as much as you would in a case summary] at the time of the event of interest) Nature of Error (the nature of the error and any relevant events or contributing factors) Impacts/Effects (describe the impact of the error on the patient and state whether the patient was harmed or required increased level of care, even if only temporarily) How Error was Recognised (if not noted above,
  7. Content Article
  8. Content Article
    Following the recent House of Commons debate on the prevention of surgical fires in the NHS, the AfPP is calling for: the Expert Working Group to reconvene and produce guidance on the prevention of surgical fires for review by NHS England. the four recommendations made by the Expert Working Group in their 2020 report to be implemented in both the NHS and the independent sector: Professional associations to explore the value of a national awareness campaign for healthcare professionals. Mandating of surgical perioperative education and training syllabus on surgical
  9. Content Article
    Background A surgical fire is one that occurs in, on or around a patient undergoing a surgical procedure and is an internationally recognised patient safety issue. Although rare, these incidents can cause serious harm to both patients and healthcare professionals and, in some cases, result in life-changing injuries. House of Commons Debate Key points raised in this debate included: There is a discrepancy in how surgical fires are reported, which raises questions about the true numbers of how many of these incidents occur annually in the NHS. Training courses and educ
  10. Content Article
    The prevention of surgical fires (one that occurs in, on, or around a patient undergoing a surgical procedure) is an internationally recognised patient safety issue. Although rare, these incidents can cause serious harm to both patients and healthcare professionals and, in some cases, result in life-changing injuries. How frequently do surgical fires occur in the NHS? The Short Life Working Group for the prevention of surgical fires looked at this issue in their report published last year, A case for the prevention and management of surgical fires in the UK.[1] They found that: fr
  11. News Article
    Changes must be made across services at one of England's biggest NHS trusts following its first wide-ranging inspection, a health watchdog said. Mid and South Essex NHS Foundation Trust - which runs Basildon, Southend and Broomfield hospitals - has been rated as "requires improvement". The Care Quality Commission (CQC) turned up unannounced after concerns over standards were raised. Philippa Styles, the CQC's head of hospital inspection, said they "found a mixed picture" of positive improvements and areas of concern. "Following the trust's formation in 2020, leaders should
  12. News Article
    A young woman was left with a retained foreign object, after surgery in an India hospital. A checklist could have avoided her death. The response from the health officials was: “We have issued a show-cause notice to the staff seeking an explanation. We will initiate departmental action based on their replies and finding of our inquiry.” In the fields of healthcare quality and patient safety, such punitive measures of “naming and shaming” have not worked. T.S. Ravikumar, President, AIIMS Mangalagiri, Andhra Pradesh, moved back to India eight years ago with the key motive to improve ac
  13. Content Article
    We are currently developing the Open Registry infrastructure in South West England, and are bringing together medical device manufacturers (from the world's largest to the smallest) and NHS trusts, with their surgeons that already have relationships with specific manufacturers. Using the system: a patient example Imagine that you are in a consultation with your surgeon, who advises that the mitral valve in your heart needs to be repaired. Your surgeon advises that this procedure can be done with minimally invasive surgery. They recommend using Device-X and you ask, "Why, what evidence
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  16. News Article
    A trust which had four ‘never events’ where patients were connected to air rather than an oxygen supply could have avoided them if it had been more proactive when a national patient safety alert was sent out several years earlier, a report has found. In one case, a baby being investigated for sepsis had oxygen saturation levels of just 75% before the mistake was realised. In another, a woman with COPD and pneumonia had oxygen saturation at 80% when she was connected to the air outlet. Calderdale and Huddersfield Foundation Trust asked the Royal College of Physicians to carry out an i
  17. Content Article
  18. News Article
    The Care Quality Commission has ordered immediate improvements to a trust after it reported six never events inside eight months. The watchdog has issued a warning notice to Royal Cornwall Hospitals Trust after it carried out an announced inspection which focused on the trust’s surgical care group – where six never events had occurred between February and October last year. In November, HSJ reported that a total of eight never events had been recorded in 2020, with trust chief executive Kate Shields saying it had raised fears the trust had not fully embedded safety improvements initi
  19. News Article
    Clinicians within a major teaching hospital’s cancer services have raised multiple concerns over patient safety, which they believe have resulted from badly planned service changes in response to the covid crisis. HSJ has spoken to several staff members who have worked in the haematology speciality at University Hospitals Birmingham Foundation Trust since last June, when the services underwent significant changes to free up capacity for coronavirus patients. This involved most haematology services at Heartlands Hospital in east Birmingham moving to the trust’s main Queen Elizabeth Ho
  20. Content Article
  21. Content Article
    Key points include: Misplacement and use of nasogastric feeding tubes leads to ongoing avoidable complications and deaths classified as Never Events despite multiple NHS Alerts since 2005. The most common cause relates to use of X-rays to confirm intragastric placement, followed by poor adherence to guidance on use of gastric aspirate pH, although the vast majority of nasogastric feeding tubes in the UK are passed safely and have their position confirmed using pH checks without issue. The root cause of these problems is a failure by Hospital Trusts and Health Boards to implement gu
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    During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution
  25. Content Article
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