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Found 30 results
  1. News Article
    At least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said. The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening. The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth. Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach. In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19. NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen. Read full story Source: The Independent, 21 January 2021
  2. Content Article
    HSIB has made three safety recommendations as a result of this report - two to NHS England and NHS Improvement, and one to the Centre for Perioperative Care. NHS England and NHS Improvement It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers. It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barriers are felt to be possible but are not currently available. Centre for Perioperative Care It is recommended that the Centre for Perioperative Care reviews and revises the National Safety Standards for Invasive Procedures (NatSSIPs) policy to increase standardisation of safety critical steps that are common across all procedures.
  3. Community Post
    Subject: Looking for Clinical Champions (Patient Safety Managers, Risk Managers, Nurses, Frontline clinical staff) to join AI startup Hello colleagues, I am Yesh. I am the founder and CEO of Scalpel. <www.scalpel.ai> We are on a mission to make surgery safer and more efficient with ZERO preventable incidents across the globe. We are building an AI (artificially intelligent) assistant for surgical teams so that they can perform safer and more efficient operations. (I know AI is vaguely used everywhere these days, to be very specific, we use a sensor fusion approach and deploy Computer Vision, Natural Language Processing and Data Analytics in the operating room to address preventable patient safety incidents in surgery.) We have been working for multiple NHS trusts including Leeds, Birmingham and Glasgow for the past two years. For a successful adoption of our technology into the wider healthcare ecosystem, we are looking for champion clinicians who have a deeper understanding of the pitfalls in the current surgical safety protocols, innovation process in healthcare and would like to make a true difference with cutting edge technology. You will be part of a collaborative and growing team of engineers and data scientists based in our central London office. This role is an opportunity for you to collaborate in making a difference in billions of lives that lack access to safe surgery. Please contact me for further details. Thank you Yesh yesh@scalpel.ai
  4. News Article
    NHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients. The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk. The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years. HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident. The patient recovered but the error was not spotted, even after an X-ray. Read full story Source: The Independent, 17 December 2020
  5. Content Article
    Nasogastric (NG) tubes placed incorrectly, going undetected and delivering food, liquid or medication into the lungs is a well-recognised never event in the NHS. Despite safety alerts and various safety initiatives, the investigation identified that this type of never event continues to happen and that there are not strong ‘systemic’ barriers to prevent NG tubes being accidentally placed into the lungs. Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year. The report acknowledges that measures carried out to tackle COVID-19 have also added to the challenges of inserting and confirming placement of NG tubes. The report concludes with five safety recommendations focusing on agreeing standards and specifications relating to procurement and design of devices, researching new technologies and standardising competency-based training for national implementation. The report also sets out eight safety observations and three safety actions taken by the Trust following Fabian’s case. Safety recommendations It is recommended that Health Education England coordinates the development and publication of a national standardised competency based training programme for nasogastric tube placement and confirmation by pH testing. The model may include simulation, observed practical assessment and ongoing competency assessment. The competency-based training programme would need to be defined, developed, and tested using a human factors approach prior to any widespread implementation. The competency based training programme will lead to a recognised accreditation which will be transferable across the NHS care providers in England. It is recommended that NHS England and NHS Improvement works with the Department of Health and Social Care and others, to identify the process by which the NHS can identify and commission necessary research to support improvements in patient safety. This would include research to confirm nasogastric tube placement. It is recommended that NHS Supply Chain and the British Standards Institution work together (engaging other system leaders as appropriate, such as the Medicines and Healthcare products Regulatory Agency and NHS England and NHS Improvement), to develop and publish an agreed standard to minimise the risks relating to human errors in the use of pH strips designed for testing human gastric aspirate at the bedside. The standard should consider product design, regulatory standards, procurement practices and human factors engineering to provide a consistent approach that can be embedded within NHS Supply Chain product specifications. It is recommended that NHS Supply Chain develops essential specifications to support the clinicallyled procurement of devices to include devices to confirm nasogastric tube placement, for example, pH testing strips. The essential specifications should set out a range of factors critical to inform the selection by NHS Supply Chain of a product including, but not limited to: clinical output requirements; design and ergonomics; human factors and intended use; and limitations on use and usability. Critically, these specifications should ideally be established in partnership across the healthcare system with clinicians, healthcare professionals and safety leads, while maximising best practice. It is recommended that the British Society of Gastrointestinal and Abdominal Radiologists, working with Health Education England and the Society and College of Radiographers, develops and publishes a national standardised competency-based training programme for X-ray interpretation to confirm nasogastric tube placement. The competency based training programme will include the referral process for X-ray to confirm nasogastric tube position and the subsequent reviewing, recording and communication of the clinical evaluation of the X-ray findings prior to initiation of feed. The standards must meet the Ionising Radiation (Medical Exposure) Regulations IR(ME)R requirements. The competency-based training programme will lead to a recognised accreditation for those qualified to clinically evaluate and record their findings, for example doctors, radiographers and advanced care practitioners. The accreditation certificate will be transferable across NHS care providers in England.
  6. News Article
    Emergency medics are writing to hospital chief executives warning them that some trusts are being ‘complacent’ about crowding in A&E, they have told HSJ. The Royal College of Emergency Medicine (RCEM) is sending a letter to trust chiefs today calling on them to urgently plan for how they will stop corridor waits and exit blocking ahead of January and February, typically the busiest months. It says some trusts were not treating emergency department crowding as a “high priority”, despite covid risks and pressures. It is also calling for overcrowding in the emergency department (ED) to be classed as a “never event” — a set of major safety risks. RCEM’s concern comes amid apprehension over long ambulance queues at hospitals across the UK, and difficulties enabling social distancing between patients in many EDs. Read full story (paywalled) Source: HSJ, 3 November 2020
  7. News Article
    An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures. The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient. Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”. Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events. She stressed that none of the patients affected had suffered physical harm. Read full story (paywalled) Source: HSJ, 12 November 2020
  8. 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 invited review after the four never events at Calderdale Royal Hospital in 2018 and 2019. The earliest incident happened in February 2018 but was not identified until a retrospective audit nearly a year later. The RCP’s report said that, had this been identified earlier, “steps could have been put in place to avoid such incidents from subsequently occurring”. But it added: “All four never events could have been avoided if the trust had responded more proactively to the previous NHS Improvement patient safety alert about the dangers of erroneously connecting patients to air instead of oxygen and had subsequently restricted access to air outlets.” Read full story (paywalled) Source: HSJ, 2 November 2020
  9. Community Post
    Hi The new Patient Safety Incident Response Framework is due for publication this month for early adopters and as 'introductory guidance' for everyone else: https://improvement.nhs.uk/resources/about-new-patient-safety-incident-response-framework/ I wondered if there is anyone who is involved in an organisation that is an early adopter who can share what has happened so far and also would be willing to share any local learning as the new framework is implemented? Also, more generally wondered if anyone has any initial comments on the proposals which were mentioned in the NHS patient safety strategy and any things in particular which they think will bring benefit or could represent significant challenges or issues?
  10. News Article
    An external review has been launched at a leading children’s hospital after a series of “never events”. According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month. Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to national data. In a statement, Alder Hey claimed it could not provide further details of the incidents. But most have been described in its board papers over the past year. They include a 15-year-old who had the wrong tooth removed by the surgical division, a patient who had the wrong eye operated on, a swab that was left inside a patient having their adenoids and tonsils removed, and an incorrect implant being inserted into an orthopaedics patient. Liverpool Clinical Commissioning’s group’s board papers for September said: “The trust has had a series of seven never events and there is a plan to undertake an external review that has been delayed due to the pandemic response. The trust has approached the Association for Perioperative Practitioners and have agreed the process." “The trust also plans to work with Imperial College London on a peer review and bespoke human factors training to include simulation training and coaching. The trust also plans to produce an overarching action plan to bring together the themes and learning from the seven never events. This work is still underway and NHSE/I and CCG had requested a copy of this plan.” Read full story (paywalled) Source: HSJ, 24 September 2020
  11. Content Article
    Thomas L. Rodziewicz and John E. Hipskind explore medical error prevention in their book and conclude that: All providers (nurses, pharmacists, and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments. Effective communication related to medical errors may foster autonomy and ultimately improve patient safety. Error reporting better serves patients and providers by mitigating their effects. Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to their colleagues after an adverse event occurs. Medical errors and near misses should be reported when they are discovered. Healthcare professionals are usually the first to notice a change in a patient's condition that suggests an adverse event. A cultural approach in which personal accountability results in long-term increased reporting reduces errors.
  12. News Article
    There were 21 “wholly preventable” patient safety incidents of the most serious category at private hospitals last year, new data has shown, as NHS bosses prepare to invest up to £10bn in the sector. This is the first time that a comprehensive dataset of 'never events’ within private hospitals has been published in the UK, and comes ahead of plans to outsource both inpatient and outpatient services, routine surgery operations and cancer treatment to private providers. The audit conducted by the Private Healthcare Information Network (PHIN), established in 2014 to bring greater transparency to the private health sector, showed that 287 out of 595 private hospitals and NHS private patient units (PPUs) provided information on Never Events between 1 January and 31 December 2019. This group accounts for an estimated 86 per cent of privately-funded admitted patient care, PHIN said. It attributed the “gaps in the data” to NHS PPUs, rather than independent hospitals. The fact that more than 300 hospitals or PPUs were unable or unwilling to hand over this data highlights the private sector’s continuing lack of transparency, said the Centre for Health and the Public Interest, a social care and health think tank. Read full story Source: The Independent, 2 September 2020 Private Healthcare Information Network press release
  13. Content Article
    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 of fizz, unaware of the hazards. I believe it is still being used to colour hair, remove blood stains, as a mouthwash gargle and also to whiten teeth. Then suddenly a breakthrough! In 2014, in my email inbox, a yellow sticker warning appeared from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the use of hydrogen peroxide in deep cavities. So why did the MHRA ban the use of hydrogen peroxide in deep cavities? Hydrogen peroxide is contraindicated for use in closed body cavities or on deep or large wounds due to the risk of gas embolism. Hydrogen peroxide breaks down rapidly to water and oxygen on contact with tissues. If this reaction occurs in an enclosed space, the large amount of oxygen produced can cause gas embolism.[1] There has been several case reports that have been published from around the world of life threatening or fatal gas embolism with use of hydrogen peroxide in surgery, of which five were from the UK. Most of the global reports describe cardiorespiratory collapse occurring within seconds to minutes of instillation of hydrogen peroxide as wound irrigation or when used to soak swabs for wound packing. This was sometimes accompanied by features associated with excess gas generation such as surgical emphysema, pneumocephalus, aspiration of gas from central venous lines, or the presence of gas bubbles on transoesophageal echocardiography. Non-fatal events were sometimes associated with permanent neurological damage such as neuro-vegetative state and hypoxic encephalopathy.[1] As the Practice Development Lead for the theatre department where I worked it was my role to pass on and act on the information received from the MHRA, so I discussed it with my very supportive theatre manager and then escalated to the theatre staff. But some consultants still ask for it today; it is always refused. So why do consultants request it when they are aware of the hazards? One theatre never event describes a syringe of hydrogen peroxide given to a consultant and injected into a joint instead of the required local anaesthetic![2] The patient survived but required care in the intensive care unit. As a scrub nurse practitioner this scares me. What about you? Would you now research this yellow sticker alert further, implement best practice and speak up, or would you just keep quiet and go "with the flow?" We all make mistakes, but learning from our errors will always be the ultimate key to improvement in healthcare and best practice and safety for our patients. References 1. Medicines and Healthcare products Regulatory Agency. Hydrogen peroxide: reminder of risk of gas embolism when used in surgery. 19 December 2014. 2. Chung J and Jeong M. Oxygen embolism caused by accidental subcutaneous injection of hydrogen peroxide during orthopedic surgery. A case report. Medicine (Baltimore) 2017; 96(43): e8342.
  14. 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 accountability and safety in healthcare delivery. He believes that we have a long way to go in reducing “preventable harm” in hospitals and the health system in general. "We need to move away from fixing blame, to creating a 'blame-free culture' in healthcare, yet, with accountability. This requires both systems design for safe care and human factors engineering for slips and violations". "Providing safe care without harm is a 'team sport', and we need to work as teams and not in silos, with mutual respect and ability to speak up where we observe any deviation or non-compliance with rules, says Ravikumar. Basic quality tools and root-cause analysis for adverse events must become routine. Weekly mortality/morbidity conferences are routine in many countries, but not a routine learning tool in India. He proposes acceleration of the recent initiative of the DGHS of the Government of India to implement a National Patient Safety Framework, and set up an analytical “never events” or sentinel events reporting structure. Read full story Source: The Hindu, 12 January 2020
  15. News Article
    One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal. Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019. There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply. The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm. The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. Read full story (paywalled) Source: HSJ, 22 January 2020
  16. Content Article
    The patient was a 62-year-old man who underwent hip replacement surgery. During his surgery, incompatible prostheses made by different manufacturers were used. The error was identified when data from the procedure was recorded in the National Joint Registry several days later. The investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again. The investigation focuses on hip replacement surgery but the findings are applicable to all orthopaedic joint replacements.
  17. Content Article
    Some aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive. However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients.
  18. Content Article
    Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete. Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common in the ‘retained foreign objects’ category. The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found. Safety recommendations HSIB made the following safety recommendation to NHS England and NHS Improvement as a result of this investigation. It is recommended that NHS England/Improvement carries out its intention to commission and publish an independent evaluation of its alternative design for swabs and tampons. The evaluation should also consider other solutions or technologies and include usability, cost/benefit analysis and the impact on reducing harm. NHS England and NHS Improvement response The Patient Safety team at NHS England and NHS Improvement is pleased to confirm that in line with its stated intention it had already commissioned a first stage independent evaluation of a proposed new design for swabs and tampons used in healthcare maternity services. Whilst it would not be feasible to commission an evaluation of other solutions or technologies that have not yet been well developed, further independent evaluation to compare this proposed design with other available solutions, and to evaluate potential cost benefit and impact analyses will be considered, conducted and published, should final prototypes prove possible to manufacture to the required specification and standards, and before any staged roll-out is considered. This response was received on 15 July 2020.