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Found 113 results
  1. News Article
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action. Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation. There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units. Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients. He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care. In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal. Read full story Source: The Independent, 16 July 2020
  2. Content Article
    This edited collection can be seen to facilitate global learning. This book will, hopefully, form a bridge for those countries seeking to enhance their patient safety policies. Contributors to this book challenge many supposed generalisations about human societies, including consideration of how medical care is mediated within those societies and how patient safety is assured or compromised. By introducing major theories from the developing world in the book, readers are encouraged to reflect on their impact on the patient safety and the health quality debate. The development of practical patient safety policies for wider use is also encouraged. The volume presents a ground-breaking perspective by exploring fundamental issues relating to patient safety through different academic disciplines. It develops the possibility of a new patient safety and health quality synthesis and discourse relevant to all concerned with patient safety and health quality in a global context.
  3. Content Article
    The results, published in BMJ Safety & Quality, found that fewer moderate-severe IMG-related errors occurred with the user-tested guidelines compared with current guidelines, but this difference was not statistically significant. Significantly more simulations were completed without any IMG-related errors with the user-tested guidelines compared with current guidelines. Participants who used user-tested guidelines reported greater confidence. The authors conclude that user-testing injectable medicines guidelines reduces the number of errors and the time taken to prepare and administer intravenous medicines, while increasing staff confidence.
  4. News Article
    London’s Nightingale hospital recorded 144 patient safety incidents during its 29 days treating 54 patients, it has emerged. There were two serious incidents at the field hospital, a doctor told a Royal Society of Medicine webinar. Dr Andrew Wragg, consultant cardiologist and director of quality and safety at Barts Health NHS Trust, said a study of the long-term outcomes of the 54 patients was ongoing, as 20 of those treated at the ExCel conference centre site were still recovering in hospitals across London. Johanna Cade, a nurse at Guy’s and St Thomas’ NHS trust and who worked at the Nightingale, said: “We had quite high incident reporting at 144 incidents reported and I think that demonstrates that Nightingale really did well at building a no blame safety culture for resolution and learning. This system manifested itself and staff were really striving to make things better continually. We knew who to report to and how to escalate things.” She showed data revealing the largest number of safety incidents involved medical devices. There were 25 incidents that included the ventilators used to keep patients alive. Staffing issues and medication, as well as pressure ulcer and communication incidents, were also among the highest numbers. Read full story Source: The Independent, 27 June 2020
  5. News Article
    A High Court judge has ruled that an NHS trust was negligent in failing to consider early enough that a toddler with fever, lethargy, and vomiting might have had a serious bacterial infection and to give her intramuscular antibiotics. Mr Justice Johnson said that doctors from University Hospital Southampton NHS Foundation Trust should have ordered a lumbar puncture on the 15 month old girl on the day she was first seen or the next day. The girl, referred to in court as SC, was sent by her GP to the hospital by ambulance on 26 January 2006 with a note describing his findings on examination and ending “?meningitis.” The GP, Mark Dennison, had given her intramuscular penicillin. Read full story (paywalled) Source: BMJ, 22 June 2020
  6. News Article
    The NHS has kept secret dozens of external reviews of failings in local services – covering possible premature deaths, unnecessary and harmful operations, and rows among doctors putting patients at risk – an HSJ investigation has found. At least 70 external reviews by medical royal colleges were carried out from 2016 to 2019, across 47 trusts, according to information provided by NHS trusts, but more than 60 of these have never been published – contrary to national guidance – while several have not even been shared with the Care Quality Commission (CQC) and other regulators. These include reviews which uncovered serious failings. Bill Kirkup’s review into the Morecambe Bay scandal in 2015 recommended trusts should “report openly” all external investigations into clinical services, governance or other aspects of their operations, including notifying the CQC. Since then the CQC has asked trusts for details of external reviews when it reviews evidence, and in July 2018 it began to ask for copies of their final reports, but HSJ’s research suggests this does not always happen. James Titcombe, the patient safety campaigner whose son’s death led to the inquiry by Bill Kirkup into the Morecambe Bay maternity care scandal, said a review was now needed of whether its recommendations had been implemented. “It is not acceptable that five years [on], there are still secretive royal college reports and patients are kept in the dark,” he said. Read full story Source: HSJ, 25 June 2020
  7. Content Article
    Practical guidance on the application of human factors in the investigation process is presented. Nine principles for incorporating human factors into learning investigations are identified: 1. Be prepared to accept a broad range of types and standards of evidence. 2. Seek opportunities for learning beyond actual loss events. 3. Avoid searching for blame. 4. Adopt a systems approach. 5. Identify and understand both the situational and contextual factors associated with the event. 6. Recognise the potential for difference between the way work is imagined and the way work is actually done. 7. Accept that learning means changing. 8. Understand that learning will only be enduring if change is embedded in a culture of learning and continuous improvement. 9. Do not confuse recommendations with solutions.
  8. Content Article
    This qualification is for anyone who wants to carry out incident investigations effectively. Employers, supervisors, SHE champions, union and safety representatives will benefit. Attending the course will enable you to: Independently investigate simple incidents. Gather evidence including conducting witness interviews. Produce an action plan to prevent a recurrence of an incident. Contribute to team investigations for large scale incidents Positively impact the safety culture in your organisation.
  9. News Article
    A hospital A&E department has been rated "inadequate" after inspectors found patients at "high risk of avoidable harm". The Care Quality Commission (CQC) reported a "range of regulation breaches" and a shortage of nurses at Stepping Hill hospital's A&E unit. It also criticised maternity and children's services. Stockport NHS Foundation Trust's chief executive said the trust had taken "immediate steps" to improve. The CQC inspected Stepping Hill Hospital in January and February and found A&E performance "had deteriorated significantly" since its last inspection in 2018. Inspectors found shortcomings "relating to patient-centred care, dignity and respect, safe care and treatment, environment and equipment, good governance, and staffing". Their report said the service "could not assure itself that staff were competent for their roles" and patient outcomes "were not always positive or met expectations in line with national standards". Read full story Source: BBC News, 19 May 2020
  10. News Article
    The Care Quality Commission (CQC) has suspended its routine inspections due to the coronavirus outbreak following pressure from system leaders and NHS bosses. The decision to suspend inspections where there are no immediate safety concerns is understood to have been taken by the CQC’s executive team this morning, senior sources told HSJ. Both the NHS Confederation and The Royal College of GPs said the decision had been made. NHS Confederation called the move a “sigh of relief” for front-line staff, while the RCGPs said it would enable GPs to dedicate their time to providing care. NHS Confederation chief executive Niall Dickson said: “Front-line staff will breathe a sigh of relief that CQC has responded to our concerns and will now postpone its inspections where there is no immediate safety concern so that they can gear themselves up to prepare for the huge task ahead in dealing with the coronavirus pandemic.” Read full story Source: HSJ, 16 March 2020
  11. Content Article
    Working with early adopters To test the PSIRF, NHS Improvement are first working with a small number of early adopters who are using an introductory version of the framework in their organisations. This testing phase will be used to inform the creation of a final version of the PSIRF which is anticipated to be published in Spring 2021. At that point, other providers of NHS funded care in England who are not early adopters will also begin adopting the new framework. All NHS organisations are expected to have transitioned to using the new framework from Autumn 2021. Introductory version of the PSIRF While NHS Improvement are not asking organisations other than the early adopters to transition to the PSIRF, they will help providers outside of the early adopter areas to plan for this change. They have therefore published below the introductory version of the framework that is being tested. Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2021. Until instructed to change to the PSIRF (likely from Spring 2021), non-early adopter organisations must continue to use the existing Serious Incident Framework.
  12. Content Article

    Marking your own homework

    Anonymous
    I read the recent blog from a fellow nurse, ‘Silent witness’, and I too am frustrated with the current system of ‘datixing’. Reporting is a good thing. We must report incidents; we do report incidents to try to keep our patients and staff safe. Many of us, I think, feel comfortable in reporting incidents. However, the frustration with me is different. Yes, the feedback and the way that the reporter gets ‘missed out’ of inquiries is wrong, but the outcomes and the ‘learning’… that is where my frustration lies. I should point out at this stage of my blog; I am raging. I am so angry and frustrated at this system I could scream. I have been a nurse now for over 20 years. I have probably filed hundreds of Datixes over the years. Some I have received feedback on, some I have not. I want to give you an insight on what I see. Not how it should be, not how you think it should be, this is how I see the system working where I am and how it makes me feel. At present I am angry in what I see. Organisational structure Where I work (in an NHS Trust) we have divisions: Medicine, Women and Children, Surgery, etc. Each one of these divisions has a head of nursing who is responsible for the safety and quality of their area, then, moving down the hierarchy, there are the matrons and then the ward managers – these are the people who would ‘investigate’ the incident that has happened, overseen by the safety and quality team (who are non-clinical). Competition time These divisions have meetings. The frontline staff – nurses, doctors, AHPs and support staff – are not invited to these meetings. From being curious, I have determined what goes on in these meetings by shadowing my manager. In these meetings they discuss how many falls, how many acquired infections, how many serious incidents, pitching against each other to see who has performed best or better than last time. So, by investigating the incidents that happen in your division while attempting to keep your numbers for falls, acquired infections and serious incidents low, by untrained investigators, how can these investigations be rigorous and unbiased? In come the safety team. I’ve never met anyone from our safety team. I don’t know where their office is. I wouldn’t know them if they walked past me in the corridor. I have no idea if they have a clinical background, but what I do know is that they do not have experience in what it is like to work in the department where I work. They don’t know the nuances, the culture, the normal deviance of behaviours or the workarounds that we use to get the work done. Perhaps if they understood... Real life examples I would like to share with you a few events to demonstrate how this safety process is not set up to keep patients safe; it's set up to keep the numbers of serious incidents low in that area. As I mentioned earlier, this is how it looks from my lens. Incident 1 – Tracheostomy and laryngectomy patients Looking after patients with tracheostomies or laryngectomies are sometimes tricky. They are high risk patients and require staff to have specialist training to care for them safely. These patients are cared for on specific wards so that patients are cohorted and cared for by staff who look after them on a regular basis. One of these wards was a surgical ward – the ward where I work. There was an incident on this ward with a patient with a tracheostomy. The patient received significant harm and ended up on the intensive care ward as a result. One of the outcomes from this incident was not to have laryngectomy or tracheostomy patients on this ward. At no point was learning from the incident disseminated to staff about the causes of the incident – just remove this cohort of patients from this ward. I don’t know what we did wrong. If the situation arose again, could we do anything different? We will never know as we don’t care for these patients here now. Incident 2 – Swallowed foreign object An incidental finding on a chest X-ray showed that an elderly lady had swallowed her wedding ring. It was stuck in her throat. This finding was found at 23:00 at night. It was removed at 12:00 midday the following day. A Datix report was filed as a concern was raised about the process of out of hours ENT services at my hospital. The investigation was completed. The response was that the incident was downgraded to low and that this lady was not compromised and that the ring was removed safely. This did not address the system failure. If this was a child in our hospital, what is the provision for removing a foreign object from the throat? Opportunity for changing and improving the current system/process was overlooked. Incident 3 – Dehydration death and downgrade A patient undergoing palliative bladder surgery died of dehydration on a ward less that 24 hours post-operation. The patient was not written up for any fluids, was not on a fluid balance chart and was not correctly monitored. Despite gallant efforts to rehydrate the man over the course of the night, the patient had a cardiac arrest and died. This Datix was graded as catastrophic by the reporter, but down graded to low by investigators. When questioned about this, the response was "his surgery was for comfort, he was going to die anyway". Surely anyone post-operation should have fluids written up and be monitored – otherwise what is the point? Again, system failure has been overlooked and opportunities for future learning quashed. The work we do as clinicians is complex. There needs to be an understanding of what we do and why we do it, or, sometimes, why we don’t do it. Investigating harm from an office about procedures and processes you don’t understand is ludicrous. For my friends and family, I will not recommend this hospital I work in. It’s not a case of we don’t learn from mistakes, it’s a case of we don’t want to learn from our mistakes – it's too much effort. I don’t trust them to do the right thing.
  13. Content Article
    The complaints included in the report are not thematic or related to a specific incident or body. Instead, these new annual Ombudsman Casework Reports will share some of the most significant findings from cases completed over the year, including complaints against: NHS in England Mental Health Care. The report offers valuable lessons about the importance of good complaint handling and how complaints can be used to drive improvements.
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