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Found 359 results
  1. Content Article
  2. News Article
    A woman who had her ovaries removed by mistake was one victim of the hundreds of “never events” that occurred in the NHS over the past year. Between April 2021 and March 2022 more than 400 patients in England’s hospitals suffered errors so serious that they should never have happened according to data released by NHS England. They include the wrong hips, legs, eyes and knees being operated on, and diabetic patients being given too much insulin. Foreign objects were left inside 98 patients after operations, including gauzes, swabs, drill guides, scalpel blades and needles. Vaginal swa
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    Never Events 1 April 2021 – 31 March 2022 by type of incident: Wrong site surgery – 171 Retained foreign object post procedure – 98 Wrong implant/prosthesis – 47 Misplaced naso or oro gastric tubes and feed administered – 31 Administration of medication by the wrong route – 21 Unintentional connection of a patient requiring oxygen to an air flowmeter – 13 Overdose of insulin due to abbreviations or incorrect device – 11 Transfusion or transplantation of ABO incompatible blood components or organs – 7 Falls from poorly restricted windows –
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    Findings Twenty-five per cent of Medicare patients experienced patient harm during their hospital stays in October 2018. Patient harm includes adverse events and temporary harm events. Twelve per cent of patients experienced adverse events, which are events that led to longer hospital stays, permanent harm, life-saving intervention, or death. In addition to the patients who experienced adverse events, 13% of patients experienced temporary harm events, which required intervention but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures. Temporary harm
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    The number of notified “extreme” and “major” incidents involving serious harm to patients and others in hospital has risen significantly in the Republic of Ireland in recent years, new figures reveal. Reported “extreme” incidents, which can involve death or permanent incapacity, rose from 373 in 2017 to 579 last year. The number of cases classified as “major”, where there is long-term disability or incapacity, climbed from 46 to 82 in the same period. “Moderate” incidents, when there is a patient injury involving medical treatment, also increased from 9,219 in 2017 to 13,563 las
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    Ambulance trusts are seeing rising numbers of serious incidents resulting from delays in reaching patients, research by HSJ has uncovered. Serious incidents are defined by the NHS as a patient safety failure “where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified.” East Midlands Ambulance Service Trust saw 71 serious incidents in 2021-22 compared with 38 in the financial year before. The trust’s board papers attribute the increase in SIs related to d
  15. News Article
    Patients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prev
  16. News Article
    A nurse has been suspended for three months by the Nursing and Midwifery Council (NMC) after forcing medication into a person with dementia's mouth. An NMC Fitness to Practise (FtP) panel found Reni Kirilova had forced medicine into the patient’s mouth, held her mouth closed and shouted ‘take your tablets’ while working at the Chocolate Quarter Care Home in Bristol, run by the St Monica Trust. Patient was reportedly distressed, waving her hands and shouting The incident occurred on 30 May 2019, seven days after Ms Kirilova began working at the care home on 23 May. She was suspen
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    On the 30 March 2022 the NHS published the results of its annual staff survey for 2021. 648,594 staff from 280 organisations took part in this, providing a snapshot of their experiences of working in the NHS.[1] This survey provides an important insight into attitudes and feelings towards reporting and acting on patient safety concerns in the NHS and how safe staff feel to speak up on these issues. At Patient Safety Learning we’ve previously highlighted the survey’s results in this regard in 2020 and 2021 and here we consider the most recent results and what they tell us about the safety
  21. Content Article
    Thirty-seven employees described sixty-six adaptations in their transfusion practices, showing clear differences between what has been characterised as work-as-imagined (WAI) and work-as-done (WAD). An analysis of the adaptations using the Systems Engineering Initiative for Patient Safety 2.0 (SEIPS 2.0) shows that triggers for adaptations were mostly staff-related or driven by poor information technology systems, but the resultant adaptations were usually amendments to tasks and processes. The majority of adaptations (83%) were forced – ideal solutions are not possible, so workarounds an
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  23. News Article
    The Care Quality Commission is to prosecute an acute trust after a patient was injured when allegedly exposed to “avoidable harm”. United Lincolnshire Hospitals Trust is due to appear tomorrow afternoon at Boston Magistrates’ Court. The alleged incident took place at Lincoln County Hospital, the CQC said. Although the CQC declined to comment further, Lincolnshire Live reported the alleged incident involved 91-year-old Iris Longmate and relates to a failure to provide safe care and treatment on or before 3 March 2019. The local publication added court papers claimed “at the same
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    A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using. An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous. The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre. The process saw a Care Q
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