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Found 225 results
  1. 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?
  2. Content Article
    Ehi Iden, Chief Executive Officer of the Occupational Health and Safety Managers, shares with the hub his blog 'Safety of the patients and correlation with the safety of the healthcare workers' (see attachment below). He also share the interview he did for TVC News Nigeria on World Patient Safety Day. Images from the day
  3. News Article
    Accidents on maternity wards cost the NHS nearly £1 billion last year, Jeremy Hunt, the chairman of the Commons health committee, has revealed. The former health secretary said the bill for maternity legal action was nearly twice the amount spent on maternity doctors in England. It was part of the NHS’s £2.4 billion total legal fees and compensation bill, up £137 million on the previous year. Mr Hunt has also told the Daily Mail there is evidence that hospitals are failing to provide details of avoidable deaths despite being ordered to do so three years ago as he highlighted “appalling high” figures which showed that up to 150 lives are being lost needlessly every week in public hospitals. Responding to the figures, Mr Hunt said: "Something has gone badly wrong." In 2017, he told trusts to publish data on the number of avoidable deaths among patients in their care. But freedom of information responses from 59 hospital trusts, about half the total, found less than a quarter gave meaningful data on avoidable deaths. Mr Hunt cited “major cultural challenges” which he blamed for preventing doctors and nurses from accepting any blame. He blamed lawyers who get involved “almost immediately” once something goes wrong with a patient’s care. “Doctors, nurses and midwives worry they could lose their licence if they are found to have made a mistake. Hospital managers worry about the reputation of their organisation,” he added. Mr Hunt said: “We have appallingly high levels of avoidable harm and death in our healthcare system. We seem to just accept it as inevitable.” An NHS spokesman said: “Delivering the safest possible health service for patients is a priority, and the national policy on learning from deaths is clear that hospitals must publish this information every three months, as well as an annual summary, so that they are clear about any problems that have been identified and how they are being addressed. Read full story Source: The Telegraph, 18 September 2020
  4. News Article
    A damning report into Devon’s NHS 111 and out of hours GP service has revealed shocking stories of patients who have either had their health put at risk or tragically died due to the service being in need of urgent improvement. Devon Doctors Limited, which provides an Urgent Integrated Care Service (UICS) across Devon and Somerset, was inspected by independent health and social care regulator the Care Quality Commission (CQC) in July, after concerns were raised about the service. They included the care and treatment of patients, deaths and serious incidents, call waits, staff shortages, and low morale. Inspectors found 'deep rooted issues'. The CQC concluded it was not assured that patients were being treated promptly enough and, in some cases, they had not received safe care or treatment. It is calling for the service to make urgent improvements which will be closely monitored. Since August 2019, the report stated Devon Doctors had received 179 complaints. Nine had been identified by the service as incidents of high risk of harm and six had been identified by the service as incidents of moderate risk of harm. These had been recorded on the service’s significant event log. However, on review, the CQC identified an additional 30 events from the complaints log which could also have been classed as either moderate or high risk of harm. Read full story Source: Devon Live, 15 September 2020
  5. News Article
    A survey of members of the Royal College of Physicians (RCP) has found that almost two thirds (60%) of doctors worry that patients in their care have suffered harm or complications following diagnosis or treatment delays during the pandemic, while almost all doctors (94%) are concerned about the general indirect impact of COVID-19 on their patients. This is also compounded by the difficulty doctors are finding in accessing diagnostic testing for their patients. Only 29% of doctors report experiencing no delays in accessing endoscopy testing (one of the main diagnostic tests used by doctors) for inpatients, decreasing to just 8% for outpatients. Only 5% of doctors feel that their organisations are fully prepared for a potential second wave of COVID-19 infection, and almost two thirds (64%) say they haven’t been involved in any discussions about preparations for a second wave of the virus. While the government’s promise to roll out flu vaccines to millions more people is welcome, the RCP recently set several more priorities to help prepare the health service for future waves of COVID-19, including the need to ensure the NHS estate is fully able to cope. Only 5% say they wanted an antibody test for COVID-19 but were unable to access one. Of those tested, a quarter (25%) were positive, with little or no difference when it came to gender, between white and BAME doctors, trainees and consultants or between London and the rest of England. Professor Andrew Goddard, president of the Royal College of Physicians, said: “Delays to treatment are so often a major issue for the NHS but as a result of the COVID-19 pandemic, it’s fair to say we’ve reached crisis point. Doctors are, understandably, gravely concerned that their patients’ health will have deteriorated to the point where they will need much more extensive treatment than previously, at a time when NHS resources are already incredibly depleted." “We also cannot underestimate the need to prepare for a second wave of COVID-19 infection, which threatens to compound the situation. Without careful and rigorous preparation, a second wave coupled with the winter flu season, could overwhelm the NHS.” Source: Royal College of Physicians, 5 August 2020
  6. Content Article
    In our recent blog Analysing the Cumberlege Review; Who should join the dots for patient safety? we identified a number of key patient safety issues which were reflected in the Review’s findings. One theme running throughout the Review was a failure to engage patients in their care, most noticeably around the issue of informed consent. What is informed consent? The NHS definition of informed consent is that “the person must be given all of the information about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatment does not go ahead”.[1] The landmark UK Supreme Court judgement Montgomery v Lanarkshire Health Board case in 2015 reaffirmed this principle in law, setting out the legal duty of doctors to disclose information to patients regarding risks.[2] Review findings Patients being unable to make decisions on the basis of informed consent was a recurring theme in the review, manifesting itself in several ways: Patients’ consent not being sought - the Review heard from patients where consent was not given for the procedure carried out, particularly in cases for implanting pelvic mesh. The authors of the Review state that they were “appalled by the numbers of women who have come forward to say they never knew they had had mesh inserted, or where they gave consent for ‘tape’ insertion they did not know they were being implanted with polypropylene mesh”.[3] Patients lacking information – this was a consistent issue concerning patients regarding the three interventions considered by the Review: hormone pregnancy tests, sodium valproate and pelvic mesh implants. One specific example of this is the case of pregnant women taking sodium valproate as an epilepsy treatment without knowing that doing so could harm their unborn child. Despite efforts to make patients aware of this, it remains an issue, with women who are taking sodium valproate as a epilepsy treatment “still becoming pregnant without any knowledge of the risks”, lacking the information to make the decision about whether to continue with this medication.[4] Patients not being involved in decision making – the Review also heard from patients who raised concerns about the failure of informed consent as a result of doctors choosing not to share relevant information with patients for their decision-making. They refer to cases where doctors did not discuss the risks with women taking sodium valproate prior to pregnancies and “gave advice based on their own assumptions, without involving patients in the decision-making process”.[5] Concerns around the absence of informed consent go beyond the procedures focused on in the Review. On the hub, we have featured community discussions and patient accounts of these issues in relation to hysteroscopy procedures, while earlier in the year the Paterson Inquiry highlighted concerns about this, recommending that a short period should be introduced into surgical procedures to allow for patients to provide their consent.[6] How can we ensure informed consent is gained? The Cumberlege Review notes that, since the Montgomery ruling in 2015, there has been a significant increase in patient safety leaflets sharing information on risks of specific treatments, but that the sheer variety of these and differing consent forms can be “bewildering and a major source of confusion”.[7] The Review is supportive of an approach where information is conveyed in a clear and direct way, and where patient decision aids are used in complex conversations to support the consent process.[8] At Patient Safety Learning, we believe it is important that patients are not simply treated as passive participants in the process of their care. Informed consent is vital to respecting the rights of the patient, maintaining trust in the patient-clinician relationship and ensuring safe care. We have identified three calls for action which we believe are needed to tackle the failure of informed consent: All patient information should be co-produced with patients to ensure that it meets patient needs for decision-making. Repositories of information and good practice are put in place so that organisations don’t have to re-invent the wheel but instead can learn from experience. Patient information for medication and medical devices should be reviewed and signed off by the NHS to ensure that it is not solely the responsibility of manufacturers. What are your thoughts on this issue? Have you had an experience where you feel that you have not given informed consent before receiving medical care? Are you a healthcare professional who can share resources for good practice? Let us know in the comments below to ensure our calls for action are informed by your experience and insights. References NHS England, Consent to treatment, Last Accessed 16 July 2020. https://www.nhs.uk/conditions/consent-to-treatment/ UK Supreme Court, Montgomery v Lanarkshire Health Board, 2015. https://www.supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf; Lee, Albert. “'Bolam' to 'Montgomery' is result of evolutionary change of medical practice towards 'patient-centred care'.” Postgraduate medical journal vol. 93,1095 (2017): 46-50. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5256237/#R3 The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf Ibid. Ibid. Campaign Against Painful Hysteroscopy, Patients Stories Essay, September 2018. https://www.hysteroscopyaction.org.uk/wp-content/uploads/2018/10/sept-2018.pdf; The Right Reverend Graham Jones, Report of the Independent Inquiry into the Issues raised by Paterson, 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/863211/issues -raised-by-paterson-independent-inquiry-report-web-accessible.pdf The Independent Medicines and Medical Devices Safety Review, First Do No Harm, 8 July 2020. https://www.immdsreview.org.uk/downloads/IMMDSReview_Web.pdf Ibid.
  7. Community Post
    What is your experience of having a hysterscopy? We would like to hear - good or bad so that we can help campaign for safer , harm free care. You'll need to be a hub member to comment, it's quick and easy to do. You can sign up here.
  8. Content Article
    During the debate there were contributions from a range of parliamentarians reflecting on the First Do No Harm report and the implementation of its recommendations in Scotland. Some points of interest from the debate included: Jeane Freeman MSP indicated the intention of the Scottish Government to implement the recommendations of the First Do No Harm report which fall within its remit and powers. Their discussion about the report's recommendation that specialist centres should be set up to provide comprehensive treatment, care and advice for those affected by implanted mesh. While Jeane Freeman noted that a National Mesh Removal Service had been established in Glasgow last year, Neil Findlay MSP expressed concerns that the levels of coproduction involved in the design and delivery of this service were inadequate. Alison Johnstone MSP highlighted the particular impact of these issues on women and noted nthat the findings reflected the ways in which women are disadvantaged in accessed health and social care services. In her closing remarks Clare Haughey MSP, Minister for Mental Health, noted the intention to begin a consultation on the Scottish Government's proposal to introduce a Patient Safety Commissioner. Follow the link below for the full transcript.
  9. Content Article
    I have included this poignant video as a matter of public interest. This is an issue which goes beyond party politics. I use Robbie's story in all of my teaching on ethics and clinical governance.
  10. News Article
    A new study shows a quarter of mothers say their choices were not respected during childbirth, with some left with life-changing injuries as a result, despite Britain’s highest judges establishing women should be the primary decision makers during labour five years ago. A poll of 1,145 women, carried out by leading pregnancy charity Birthrights and shared exclusively with The Independent, also found that a third said healthcare professionals did not even seek their own opinions on the childbirth process, while 14& said their choices were overruled. One woman told The Independent she had been forced to give up her career as a lawyer following what she described as a “violent delivery”, while her baby daughter also sustained serious injuries to her face which can still be seen now – 12 years after she gave birth. Birthrights, which campaigns for respectful pregnancy care for women, pointed to the fact half a decade has passed since Nadine Montgomery’s Supreme Court case proved mothers-to-be are the primary decision-makers in their own care yet this is still not the reality for the majority of women. Read full story Source: The Independent, 3 September 2020
  11. Content Article
    Allow me to start this essay with a real personal story: more than a decade ago, while I was doing my Transplant & Hepato-Biliary Surgery fellowship in the USA, I had to have elective orthopaedic surgery. The good news was the hospital where I was about to have the surgery was the number one in the US News Ranking for Orthopedics that year. The bad news was that I was literally ‘terrified’ while I was in the pre-op holding area, just before I was wheeled into the operating room! How could that be? Me: the surgeon, terrified of having a straightforward orthopaedic procedure in the number one orthopaedic surgery hospital in the US? The answer was yes. It was precisely for this reason – that I am a surgeon who knew what could go wrong in a clinical unit like the OR and that I was terrified of becoming just another casualty of a medical error! Back in 2016, in their book 'Safer Healthcare', Charles Vincent and Rene Amalberti beautifully articulated the safety levels in hospitals where they classified five levels of care: Level 1: The care envisaged by standards. Level 2: Compliance with standards / ordinary care with imperfections. Level 3: Unreliable care / poor quality, but the patient escapes harm. Level 4: Poor care with probable minor harm but overall benefits. Level 5: Care where harm undermines any benefit obtained. As a practicing healthcare professional (a surgeon), I can, unfortunately, say that the majority of clinical units in hospitals are performing around Level 3 (unreliable care / poor quality, but the patient escapes harm) with fluctuations towards Level 4 (poor care with probable minor harm but overall benefits) for below-average performers or Level 2 (compliance with standards / ordinary care with imperfections) for a very few leading medical centres... sometimes! Patient safety was defined as the absence of harm. I believe it is time to define patient safety using a patient-centric approach where patient safety can be defined as the absence of harm for each patient, by the right person(s), at the right time(s) and the right place(s). Such definition would help us think about a systemic and individual framework to safety, where safety is customised to every patient, all the time, in the backdrop of a safe clinical unit. Last year marked the 20th anniversary of the landmark paper 'To Err is Human'. Although the past 20 years have seen much progress in the understanding of the healthcare safety which helped bridge the knowledge gap in this significant field, we still have a significant implementation and structural gap, which continues to contribute to the ongoing inherently weak safety conditions for patients. The main reason for writing this essay is to say that 20 years after To Err is Human, the majority of hospitals are treading around Level 3 (mediocre patient safety conditions to use layman’s terms!). Such a situation is entirely unacceptable for high-reliability industries like aviation, nuclear, and oil and gas. Fifty to sixty years ago, these industries were not as safe as they are today but reached their watershed moments (tipping point) and had to transform their safety practices. This essay is a call for action to highlight the following: Healthcare continues to be structurally weak when it comes to the safety conditions. This lack of resilience leads to ongoing medical errors and harm to patients. There is an urgent need for us to have a paradigm shift in the way we think about patient safety and how we implement it while providing healthcare. As healthcare systems are complex adaptive systems, the only way to do that is to build resilience in the system. Here are my practical solutions: Adopting co-production principles: co-design, co-delivery and co-assessment. Introducing complementary checklists for both patients and healthcare professionals throughout the patient journey. Safety reconciliation: transition of care or any patient transfer carries potential patient harm – e.g., fall, tubes or IV dislodgement, communication failure with new staff members, such as radiology department technicians, etc. Hence, it is vital that a safety reconciliation is performed by both the patient/families and healthcare professionals (co-production) using checklists. Leveraging implementation science: by introducing safety principles into the day to day clinical practices at the bedside (undergraduate, postgraduate, and board-certified practitioners). Human Factors Engineering (HFE): introducing HFE principles into bedside clinical practice – e.g., effective communication, situational awareness, flat hierarchy and team-based simulated learning – will introduce resilience into the system and help reduce potential harm to patients.
  12. News Article
    Theresa May has urged the government to consider “redress” for the victims of a hormone pregnancy test blamed for causing serious birth defects. The former prime minister said that while Primodos victims had received an apology, “lives have suffered as a result” of the drug’s use. In an interview for a Sky News documentary, she praised campaigners who had been “beating their head against a brick wall of the state” which tried to “stop them in their tracks”. A review in 2017 found that scientific evidence did “not support a causal association” between the use of hormone pregnancy tests such as Primodos and birth defects or miscarriage. But Ms May ordered a second review in 2018, because, she said, she felt that it “wasn’t the slam-dunk answer that people said it was”. “At one point it says that they could not find a causal association between Primodos and congenital anomalies, but neither could they categorically say that there was no causal link,” she said. The second review concluded last month that there had been “avoidable harm” caused by Primodos and two other products – sodium valproate and vaginal mesh. An interview for Bitter Pill: Primodos, which will air on Sky Documentaries, Ms May said: “I think it’s important that the government looks at the whole question of redress and about how that redress can be brought up for people. Read full story Source: The Independent, 28 August 2020
  13. Content Article
    Hazardous Hospitals: Cultures of Safety in NHS General Hospitals, c.1960-Present is a three-year research project at the University of Warwick, funded by the Wellcome Trust. It is being conducted by Dr Christopher Sirrs. The publication of the Francis Report into healthcare failures at Mid Staffordshire NHS Foundation Trust in 2013 dramatically refocused public and political attention on issues of ‘safety’ in the National Health Service. ‘Safety’ has increasingly occupied the attention of policy makers in recent decades, with hospital managers establishing various systems and processes to protect patients and staff from harm. These include learning and reporting systems, policies about patient consultation, and campaigns for preventing harms such as falls and healthcare-associated infections. However, little is understood about how and why these ideas and practices around ‘safety’ in the NHS evolved. This three-year project explores the history of safety in the NHS, highlighting how hospitals have promoted ‘safety cultures’: ideas, values and behaviours which support safety. Drawing upon a rich seam of archival material, as well as a distinctive methodology, it makes timely contribution to historical understandings of the NHS. The project asks the following key questions: 1. What defines the ‘safety culture’ of NHS hospitals? How can these ‘safety cultures’ vary? 2. How was safety in hospitals assessed, and in what ways did it come to the attention of NHS managers and policymakers after 1960? 3. How did NHS managers promote safety among their staff? 4. What role did groups such as patient organisations, safety campaigners and the press play in depicting, challenging and promoting reform of hospital ‘safety cultures’? The project will directly engage individuals and organisations involved in promoting or campaigning for safety in the NHS. Interviews will also be conducted with a wide range of individuals. If you are interested in participating in the project, please see the ‘Participate‘ page for more information. You can follow the project via @hazardhospitals or, for more information follow the link below.
  14. News Article
    A damning new report has exposed numerous lapses in nursing care on wards at Shrewsbury and Telford Hospital Trust amid a culture which left patients at risk of “unsafe and uncaring” treatment, the care watchdog has said. Inspectors from the Care Quality Commission (CQC) cited multiple examples of nurses at the scandal-hit trust lacking the knowledge to look after patients safely and failing to record key information needed to keep patients safe during an inspection of medical wards in June this year. The inspectors found poorly completed nursing records, equipment unavailable and nurses not following procedures. This meant some patients developed pressure sores, fell from their beds and were injured or suffered pain at the end of their life. Other patients were at risk of suffering similar harm. Inspectors ruled the trust, which was rated inadequate and put into special measures in 2018, was unsafe and criticised the hospital leadership for what it said was a “collective failure” that was perpetuating the problems at the hospital. Read full story Source: The Independent, 14 August 2020
  15. News Article
    A cosmetic surgeon who did not have adequate insurance for operations that went wrong has been struck off. Dr Arnaldo Paganelli worked privately for The Hospital Group in Birmingham. The Medical Practitioners' Tribunal Service ruled his actions constituted misconduct. Four women took their case to the body and the tribunal heard evidence about his time at Birmingham's Dolan Park Hospital where he made regular trips from Italy to work. Lead campaigner Dawn Knight, from Stanley, County Durham, said too much skin was removed from her eyes during an eyelift in 2012 and they became "constantly sore". She told BBC Radio 4's You and Yours programme she felt relieved Dr Paganelli "cannot injure anyone else on UK soil" and called for the government to tighten regulation around cosmetic procedures to protect the public. "The process has been long, emotional and exhausting. This situation must never be repeated. After all, when are you more vulnerable than when under aesthetic at the hands of a surgeon who has no insurance?" Read full story Source: BBC News, 12 August 2020
  16. News Article
    Like most women affected by incontinence, 43-year-old Luce Brett has her horror stories. As a 30-year-old first time mum she recalls wetting herself and bursting into tears in the “Mothercare aisle of shame”, where maternity pads and adult nappies sit alongside the baby nappies, wipes and potties. But, she adds, these isolated anecdotes don’t really do justice to what living with incontinence is really like. “It’s every day, it’s all day. People talk about leaking when you sneeze or when you laugh, but for me it was also when I stood up, or walked upstairs. It was always having two different outfits every time I left the house to go to the shops. Incontinence robbed me of my thirties; it made me suicidally depressed,” Luce explains. “Everyone kept telling me it was normal to be leaky after a vaginal birth. It took quite a long time for me to find the courage or the words to stop them and say: ‘Everybody in my NCT (National Childbirth Trust) class can walk around with a sling on, and I can’t do that without wetting myself constantly’,” she adds. Read full article here.
  17. News Article
    The mother of a former patient at a north Wales mental health unit has said she "couldn't let" her daughter "go back there" as new details about people being "neglected" there have emerged. ITV News has seen a leaked copy of the Robin Holden report from 2014. It was commissioned by Betsi Cadwaladr Health Board after staff on the Hergest mental health unit, which is situated within Ysbyty Gwynedd in Bangor, blew the whistle over management and patient safety concerns. It reveals details never before made public, about how staff struggled to care for patients. The document, which the health board has fought for six years to keep out of public view, gives an account of the death of a patient while no doctor was available because of rota gaps, another of a patient who tried to take their own life, again when no doctor was available, and inadequate staffing affecting patient care. Read full story Source: ITN News, 31 August 2020
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