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Found 232 results
  1. Content Article
  2. Content Article
    Key findings The maternal deaths and incidents were not the result of deficiencies of care. Standards of care when a woman is admitted to the delivery suite are well above average. Incident reporting and investigation systems are of a high quality. There are examples of excellent practice which should be widely disseminated. Governance systems are fit for purpose and generally well applied. Recommendations The review panel made the following essential recommendations to further reduce risks for the large proportion of vulnerable and high risk women atte
  3. Content Article
    At Patient Safety Learning we believe that to reduce avoidable harm in healthcare we need a transformation in our approach to patient safety. Patient safety should not be treated as one of several strategic priorities, but instead as a core purpose of health and social care. This requires us not just to respond to, and mitigate the risk of, harm, but also to design healthcare to be safe for patients and the staff who work within it. This approach extends to how we source, supply and monitor the use of healthcare equipment and products. Procurement and supply chains can be complex and may
  4. News Article
    A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found
  5. Content Article
    How to use these cards You scan use these cards in any way that helps you and your colleagues to think and talk about safety culture. If you are using the cards in a group, one person may need to act as discussion facilitator. You can use as many or as few cards as you like. Four possibilities are described in the following cards: Option 1: Comparing views Compare similar and different views between groups. Option 2: Safety moments Discuss just one issue for 10-15 minutes. Option 3: Focus on… Discuss all of the cards in a particular element. Option 4: SWOT an
  6. News Article
    Some care homes have "no choice" but to allow workers who have Covid to deliver care, a public health official said. According to Public Health England cases are rising the fastest in Somerset. As a result, care homes in the county are struggling to safely staff their services and schools are seeing a rise in staff sickness. Somerset Council said ensuring vulnerable residents received care was "lower risk" than them being infected. Health officials advised care workers to continue working only if they wore PPE and felt well enough. Council public health consultant Alis
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    Key points Smoking, poor diet, physical inactivity and harmful alcohol use are leading risk factors driving the UK’s high burden of preventable ill health and premature mortality. All are socioeconomically patterned and contribute significantly to widening health inequalities. This report summarises recent trends for each of these risk factors and reviews national-level policies for England introduced or proposed by the UK government in England between 2016 and 2021 to address them. Based on our review, it assesses the government’s recent policy position and point towards policy
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    Coroner's Matters of Concern The concern in this case is that a vulnerable young person can be known to the County Council and Mental Health Trust and yet not receive the support they need pending substantive treatment. Danny was repeatedly assessed as not meeting the criteria for urgent intervention and yet the waiting list for psychological therapy was likely to be over a year from point of first presentation. That gap between urgent and non-urgent services is potentially dangerous for a vulnerable young person, where there is a chronic risk of an impulsive act. Although I unde
  12. News Article
    NHS England and the Care Quality Commission have asked systems with large numbers of ambulance handover delays to urgently hold a meeting to try to fix the problem by “balancing the risks” of long 999 waiting times. The request was made in an email to chief executives, which warned the service was “in a difficult position with all parts of the urgent and emergency care pathway under considerable strain… most acutely in ambulance response times which in turn is linked to challenges in handing patients over to emergency departments”. The NHSE headed letter was signed by its chief opera
  13. Event
    This one day masterclass will focus on Safety Management Systems (SMS) in healthcare. It will look at how other sectors and organisations have developed SMS to improve safety. SMS is a systematic and proactive approach to managing safety risks. A formal management system or framework can help you manage health and safety. Use of SMS can be generally interpreted as applying a quality management approach to control safety risks. Put simply, effective safety management systems use risk and quality management methods to achieve their safety goals. All Clinical Staff and Team Leads should attend.
  14. Content Article
    You can use a risk assessment template to help you keep a simple record of: who might be harmed and how what you're already doing to control the risks what further action you need to take to control the risks who needs to carry out the action when the action is needed by.
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    Following the recent House of Commons debate on the prevention of surgical fires in the NHS, the AfPP is calling for: the Expert Working Group to reconvene and produce guidance on the prevention of surgical fires for review by NHS England. the four recommendations made by the Expert Working Group in their 2020 report to be implemented in both the NHS and the independent sector: Professional associations to explore the value of a national awareness campaign for healthcare professionals. Mandating of surgical perioperative education and training syllabus on surgical
  19. News Article
    A watchdog found there were safety concerns at a south-east London care home weeks after a resident killed a woman in her bedroom, it has emerged. Alexander Rawson, 63, beat 93-year-old Eileen Dean to death at Fieldside Care Home in Catford on 3 January. Inspectors visited the care home on 26 January after the murder of the grandmother-of-five triggered alarm about patient safety. Inspectors concluded that the home failed to record dangers properly and residents "were not always safe". Mrs Dean suffered catastrophic injuries after she was attacked by Rawson with a walking stick
  20. Content Article
    Background A surgical fire is one that occurs in, on or around a patient undergoing a surgical procedure and is an internationally recognised patient safety issue. Although rare, these incidents can cause serious harm to both patients and healthcare professionals and, in some cases, result in life-changing injuries. House of Commons Debate Key points raised in this debate included: There is a discrepancy in how surgical fires are reported, which raises questions about the true numbers of how many of these incidents occur annually in the NHS. Training courses and educ
  21. Content Article
    The prevention of surgical fires (one that occurs in, on, or around a patient undergoing a surgical procedure) is an internationally recognised patient safety issue. Although rare, these incidents can cause serious harm to both patients and healthcare professionals and, in some cases, result in life-changing injuries. How frequently do surgical fires occur in the NHS? The Short Life Working Group for the prevention of surgical fires looked at this issue in their report published last year, A case for the prevention and management of surgical fires in the UK.[1] They found that: fr
  22. News Article
    A hospital trust has been told to "immediately improve" its maternity and surgical services. The Care Quality Commission (CQC) made unannounced inspections in September and October at four of the hospitals run by University Hospitals Sussex NHS Foundation Trust. Inspectors raised concerns about staff shortages, skills training and risk management. At the trust's four maternity services, inspectors found departments "did not have enough staff to keep women and babies safe" and staff were "not up to date" with training. Infection prevention measures in surgical services at th
  23. Content Article
  24. News Article
    An inspection at a failing hospital trust has identified "some progress" but its services are still inadequate. The Care Quality Commission (CQC) inspected the Shrewsbury and Telford Hospital NHS Trust (SaTH) in August. The Trust has been in special measures since 2018 and its maternity services are subject of a review following a high rate of baby and maternal deaths. The CQC said SaTH still had "significant work to do" to improve its patient care and safety standards. Inspectors highlighted particular concerns around risk management at the Trust which it said was "inconsistent
  25. Content Article
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