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Found 104 results
  1. Content Article
    The NHS England National Patient Safety Team is seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. The consultation runs from the 7 February until the 7 May 2024.
  2. News Article
    Women in labour at a London maternity unit deemed “inadequate” were left alone with unsupervised support workers who were not given any guidance, an NHS safety watchdog has found. In a scathing report of North Middlesex Hospital’s maternity services, the Care Quality Commission also found examples of delays to induction of birth for women, and one case of a woman with a still-born baby who was left waiting for the unit to call her in for an induction. Inspectors have downgraded the maternity unit from “good” to the lowest possible rating “inadequate” following an inspection earlier this year. Staff reportedly told inspectors they felt they were “criticised” or “bullied” when reporting safety incidents within the unit. “We heard that the criticism or bullying was worse if the incident reported was relative to other staff and their perceived behaviours,” the report said. There was also evidence the hospital was not recording the severity of safety incidents correctly for example two “never events”, which are among the highest category incidents, were categorised as “low harm”. Other findings included women and babies came to harm as the hospitals did not follow standards to language interpretation despite covering a higher than average minority ethnic population. Read full story Source: The Independent, 11 December 2023
  3. Content Article
    This investigation explores the patient safety risk of unintended retention of surgical swabs after surgery. Surgical swabs are sterile pieces of gauze which are used to absorb bodily fluids, such as blood, during a surgical procedure. The investigation will: explore the factors associated with unintentional retained surgical swab events identify alternative safety controls to reduce the likelihood of foreign objects being unintentionally retained. The interim report analyses the findings of 31 NHS trust serious incident reports.
  4. News Article
    A teaching trust has reported six ‘never events’ in less than two months, including incidents in a specialty already under review for errors. The incidents occurred at University Hospitals Birmingham between 26 July and 10 September, including two wrong-side lesion biopsies in dermatology, two incorrect blood transfusions, one injection to the incorrect eye, and one misplaced nasogastric tube. The two incorrect blood transfusions involved the same patient at Heartlands Hospital and were reported after a biomedical scientist carried out a retrospective investigation into the case. On both occasions, the patient was transfused with incorrect red blood cells. It brings the total number of blood transfusion events reported at UHB to seven since 2020-21. The issue is already subject to a review by the Royal College of Physicians after Mike Bewick identified concerns in his review of patient safety at the trust. It comes after clinicians working within the haematology specialty raised multiple concerns over patient safety in 2021 and intervention from the General Medical Council over concerns around junior doctors. John Atherton, chair of UHB’s clinical quality and safety committee, told the board a preliminary review into never events had identified that “maybe we weren’t addressing these [incidents] seriously enough”. Read full story (paywalled) Source: HSJ, 1 December 2023
  5. News Article
    Moving less complex procedures out of operating theatres and into other care settings to free up capacity to support elective recovery has ‘inadvertently’ increased the risk of ‘never events’ at an acute trust, a report has warned. The warning was made in a report into four never events at North Bristol Trust’s Southmead Hospital between November 2022 and January 2023 – two of which involved the same patient. The review was commissioned by Bristol, North Somerset and South Gloucestershire integrated care board to examine common issues in never events involving invasive procedures. It found an increase in never events when procedures were moved away from operating theatres to other care settings. The review found moving procedures from theatres to outpatient or day case facilities to “support the reduction in the [elective] backlog and improve the waiting times for patients… may also inadvertently increase the risk of never events”. It added: “It is likely that a theatre environment has more established and embedded safety control mechanisms. Governance processes in moving such procedures should consider the impact on quality, for example, the gaps between safety processes and consideration of the minimum requirements for the new procedure location.” Read full story (paywalled) Source: HSJ, 29 November 2023
  6. News Article
    NHS staff are carrying out the equivalent of one 'never-event' every day, figures show. This is despite the Government ordering a crackdown on the mistakes, which cost hospitals an estimated £800million in compensation each year. Experts today demanded further action on 'unacceptable' levels of never-events, blaming inadequate staffing levels and a lack of investment in the NHS. A MailOnline audit of a decade's worth of NHS data found a colossal 4,328 never-events have occurred in England since 2013. This equates to roughly eight a week. Shocking incidents uncovered include women getting parts of their reproductive anatomy cut out instead of an appendix, men getting unwanted circumcisions and laser procedures to the wrong eye. The Royal College of Surgeons said the level of never-events was 'unacceptable' and blamed NHS staffing levels for increasing the risk to patients. "Surgeons will be working hard to do their best for patients, but they do so in difficult circumstances," a spokesperson said. "The NHS is overstretched, with staff shortages, a workforce suffering from burn-out and pressure to get record waiting times down. "This increases the risk of mistakes happening." Read full story Source: MailOnline, 10 October 2023
  7. Content Article
    On Monday 10 July 2023 the Centre for Perioperative Care (CPOC) and Patient Safety Learning jointly hosted a webinar on the new National Safety Standards for Invasive Procedures 2 (NatSSIPs 2). This article contains links to video recordings of this webinar.
  8. 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 swabs were left in patients 32 times and surgical swabs were left 21 times. Other objects left inside patients included part of a pair of wire cutters, part of a scalpel blade, and the bolt from surgical forceps. On three separate occasions part of a drill bit was left in a patient. “Wrong-site surgery” was carried out on 171 patients and six patients had injections to the wrong eye. The wrong hip implant was put in 12 times, a wrong knee implant was performed 11 times, and patients were connected to air instead of oxygen 13 times. Seven patients were given the wrong type of blood during a transfusion. Some patients were given doses of drugs that were far too high, including the immunosuppressant methotrexate, which is used for severe arthritis, psoriasis and leukaemia. There were 11 overdoses of insulin. Read full story (paywalled) Source: The Times, 19 May 2022
  9. News Article
    A fifth patient has been given the wrong blood at a major teaching hospital’s haematology department where patient safety concerns were raised by clinicians last year. The incident, at University Hospitals Birmingham Foundation Trust, is the fifth never event involving patients being transfused with the wrong blood at the trust since April 2020. Only 15 such never events have been recorded in England in the last two financial years, which means UHB accounted for a third of the total in 2020-21 and 2021-22. HSJ revealed last year that several clinicians had raised safety concerns at the trust’s haematology specialty after most of its services at Heartlands Hospital were moved to Queen Elizabeth Hospital as part of the trust’s pandemic response. The latest never event, which occurred in March, saw a patient being given an “unintentional transfusion of ABO-incompatible blood components” – according to papers provided to the trust’s council of governors. Read full story (paywalled) Source: HSJ, 14 June 2022
  10. News Article
    A record number of "foreign objects" have been left inside patients' bodies after surgery, new data reveals. Incidents analysed by the PA news agency showed it happened a total of 291 times in 2021/22. Swabs and gauzes used during surgery or a procedure are one of the most common items left inside a patient, but surgical tools such as scalpels and drill bits have been found in some rare cases. A woman from east London described how she "lost hope" after part of a surgical blade was left inside her following an operation to remove her ovaries in 2016. The 49-year-old, who spoke to PA on condition of anonymity, said: "When I woke up, I felt something in my belly. "The knife they used to cut me broke, and they left a part in my belly." She added: "I was weak, I lost so much blood, I was in pain, all I could do was cry." The object was left inside her for five days, leading to an additional two-week hospital stay. Commenting on the analysis, Rachel Power, chief executive of the Patients Association, said: "Never events are called that because they are serious incidents that are entirely preventable because the hospital or clinic has systems in place to prevent them happening. "When they occur, the serious physical and psychological effects they cause can stay with a patient for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS. "While we fully appreciate the crisis facing the NHS, never events simply should not occur if the preventative measures are implemented." Read full story Source: Sky News, 4 January 2022
  11. News Article
    A hospital is investigating how a pair of metal surgical forceps were left inside a patient after they had been stitched up after abdominal surgery. Worcestershire Acute Hospitals NHS trust has apologised unreservedly and said the incident at Redditch’s Alexandra hospital was “exceptionally rare”. The medical blunder only became apparent after a seven-hour abdominal procedure last month, according to BBC Midlands, when the forceps were reported to be missing. The worst fears of medics were confirmed when the missing 15cm arterial clamp was found by an X-ray while the patient was still under anaesthetic. The surgical instrument could not be immediately removed and the patient was moved to intensive care overnight before another operation was performed the next day to retrieve the clamp. It is understood the trust’s investigation will look at whether the required double-checking of all instruments was conducted before the patient was stitched up after surgery. It will also examine the end of operation signing-out process, which is supposed to ensure such errors do not happen. Read full story Source: The Guardian, 23 December 2022
  12. Content Article
    In this BMJ opinion piece, Scarlett McNally discusses the revised National Safety Standards for Invasive Procedures (NatSSIP2). The original NatSSIPs were designed to prevent “never events”—yet more than 300 occurrences of wrong site surgery, retained objects after procedure, or wrong implant insertion still occur yearly in the UK.  NatSSIP2 brings in safety science and human factors, with expectations for organisations including standardisation, harmonisation, training, and audit. "The biggest danger is if the new standards sit on the shelf. With their benefits for patient safety and teamworking, we must accept the repetitive elements and consistently apply these new standards, every time, in every department", writes Scarlett.
  13. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.
  14. Content Article
    This report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
  15. Content Article
    This paper asked healthcare workers who are considered to be theatre safety experts—theatre managers, matrons and clinical educators—to take part in the second round of a Delphi study. These individuals work at the coalface in operating theatres and deliver the surgical safety checklist daily. It addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the second Delphi study round was to establish the views of theatre users on the theatre checklist and local safety standards for invasive procedures. Likert scale responses and a combination of closed and open-ended questions solicited specific information about current practice and researched literature that generated ideas and allowed participants freedom in their responses of how the World Health Organisation’s (WHO's) Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. The paper is part of a literature review undertaken by the author towards a Doctor of Philosophy (PhD). Read the findings of round one of the Delphi study
  16. News Article
    Hundreds of patients with metallic implants narrowly avoided death or serious injury after being wrongly referred for MRI scans, an investigation revealed yesterday. The powerful magnets used in the machines can displace and damage metallic items such as pacemakers, ear implants and aneurysm clips. Doctors should question patients and check medical records before requesting a scan because of the risk of injury. But hospitals in England recorded 315 near-misses from April 2020 to March 2022 involving patients sent for an MRI. An MRI scan at Mid Yorkshire Hospitals Trust was ditched after staff confirmed the skin over the patient’s pacemaker had begun heating up. Another patient – at Wrightington, Wigan and Leigh Trust – told staff about a metal plug implanted in their nose only after the scan had begun. Many of the incidents involved forms being filled out incorrectly on behalf of elderly and disoriented patients. At East Kent Hospitals University Trust, a patient described as ‘not compos mentis’ was given the all-clear by a care home nurse and again by a clinician for MRI – only for staff to realise at the last moment that metal clips were implanted in their chest. Information about the incidents was obtained using freedom of information requests. Helen Hughes of Patient Safety Learning, said: "It is vital that near-misses are regularly reported, their causes understood, and that this learning is acted on to prevent future avoidable harm." Read full story Source: MailOnline, 15 October 2022
  17. News Article
    Surgical blunders have soared 60% in five years – and extreme mistakes are now a daily occurrence in the NHS. Some 13,921 people were treated for damage caused by botched operations in the year to March 31 – up from 8,695 in England in 2016/17. Cases involved an “unintentional cut, puncture, perforation or haemorrhage”. Separately, a report from NHS England shows 134 patients fell victim to so-called Never Events from April 1 to July 31. Extreme errors included two women left infertile after their ovaries were wrongly removed. Injections and invasive tests were given to the wrong patients and in 39 cases foreign objects, such as drill bits and wires, were left inside bodies. There were 57 cases of surgery on the wrong body part and 12 instances of patients being given the wrong implant or prosthesis. The Royal College of Surgeons in England said: “If the system is overstretched, there is a risk that mistakes will happen.” Rachel Power, chief executive of the Patients Association, said: “When Never Events occur, the physical and psychological effects can stay with a patient for life.” Read full story Source: The Mirror, 1 October 2022
  18. Content Article
    Can you imagine the distress of going to hospital for an operation and having to return to theatre to have forceps removed because they were left inside your abdomen. Or going in for a left hip operation because of years of agonising pain and waking up to find out they had operated on your good hip. Or having surgery to preserve your ovaries — but they are accidentally removed. Or, worst of all, realising you have had a procedure intended for a different patient. Fanciful stories made up for a TV drama? Sadly not. These were just some of the awful mishaps that occurred in hospitals in England over the space of just ten months. Professor Rob Galloway, writing for the Daily Mail, shares his tips on what patients can you do to protect themselves.
  19. Content Article
    National Education for Scotland research and evaluation work has shown wide variations in the standard of significant event analysis (SEAs) undertaken by frontline healthcare teams. The direct implication is that there are many missed opportunities to learn from and improve the safety of patient care. As a consequence, NES developed a robust educational model to enable clinicians, managers and healthcare teams to submit SEA reports for feedback from trained peer groups.
  20. Content Article
    Air flowmeters attached to piped medical air outlets are primarily used to drive the administration of nebulised medication; typically for short periods to manage respiratory conditions. Most other uses of piped medical air do not require an air flowmeter. Due to the proximity of the piped medical air and oxygen outlets at the bedside, and the similarity in design of flowmeters, there is a significant risk when using air flowmeters that patients may be inadvertently connected to medical air instead of oxygen. A previous alert and additional communications have sought to minimise the use of air flowmeters by encouraging their replacement with compressor or ultrasonic nebulisers, alongside additional risk reduction methods if air flowmeters remained in use. However, despite the measures outlined above, 108 Never Events describing unintentional connection were reported in a recent three-year period ; over a third of incidents occurred in emergency departments. Consequences included respiratory arrest, cardiac arrest, collapse (requiring ITU admission and ventilation), and nine incidents of incorrect connection when responding to cardiac arrest, which will have impacted on the chance of successful resuscitation; six patients subsequently died.
  21. Content Article
    In this article, John Tingle, Assistant Professor at the University of Birmingham Law School, discusses recent developments in patient safety in the context of possible reform of the clinical negligence system in the UK.
  22. Content Article
    In this blog, the Healthcare Safety Investigation Branch (HSIB) reflects on the recent publication of the new National Safety Standards for Invasive Procedures (NatSSIPs 2) by the Centre for Perioperative Care. It outlines how these standards can help NHS organisations provide safer care and reduce the number of patient safety incidents, including a comment on this from Deinniol Owens, Associate Director of National Investigations at HSIB.
  23. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care. The Centre for Perioperative Care shares their slideset on the revised standards.
  24. Content Article
    The Centre for Perioperative Care (CPOC) has published new safety standards (NatSSIPs2) to enable all hospitals in the UK to improve patient safety by applying a consistent and proportionate set of safety checks for all invasive procedures. Listen to the podcast from the Royal College of Anaesthetists on the new standards.
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