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Found 82 results
  1. Content Article
    People with kidney failure or chronic kidney disease, whose kidneys have stopped working properly, may need dialysis. This therapy takes over the normal function of the kidneys and removes waste products and excess fluid from the blood. Many people have regular dialysis in hospital, where fluids are filtered by a machine (haemodialysis). In peritoneal dialysis, often carried out at home, a catheter is inserted in the abdomen and left there permanently. A catheter can be inserted under general anaesthetic by a surgeon, or without a general anaesthetic by a physician using a needle (medical insertion). Medical insertions have become more common in recent years due to a lack of access to surgeons and theatre space; they have the advantage of being possible in people who are not well enough to have a general anaesthetic. However, evidence on the safety and efficacy of medical insertions is lacking. This study assessed the number of safety events following catheter insertions for peritoneal dialysis via the medical and surgical route. Researchers explored the reasons for choosing medical, versus surgical catheter insertions.
  2. News Article
    An integrated care board (ICB) has found its handling of whistleblowing “not fit for purpose”, after a complaint about safety incidents not being properly investigated. A report by North West London ICB, obtained by HSJ, states: “The whistleblowing policy is not fit for purpose and requires immediate updating. The [Freedom to Speak Up] Guardian has been left blank and the policy does not include key components of best practice.” It also found the “whistleblower should have been provided with a substantive response to their concerns within 28 days” but in fact waited 98 working days, “due to delays with starting the whistleblowing component of the grievance”. The ICB reviewed its processes after a complaint from a staff member who raised concerns early last year about “a lack of, or poor, response” to reported patient safety incidents in the system, which are meant to be routinely reviewed by ICBs “prior to closure”. Read full story (paywalled) Source: HSJ, 15 February 2024
  3. Content Article
    Appropriate care escalation requires the detection and communication of in-hospital patient deterioration. Although deterioration in the ward environment is common, there continue to be patient deaths where problems escalating care have occurred. Learning from the everyday work of health care professionals (work-as-done) and identifying performance variability may provide a greater understanding of the escalation challenges and how they overcome these. The aims of this study from Ede et al. were to i) develop a representative model detailing escalation of care ii) identify performance variability that may negatively or positively affect this process and iii) examine linkages between steps in the escalation process.
  4. Content Article
    In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk.  In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. 
  5. Content Article
    This is the protocol for a Campbell systematic review. The main aim of this systematic review was to identify whether hospital leadership styles predict patient safety as measured through several indicators over time. The second aim was to assess the extent to which the prediction of hospital leadership styles on patient safety indicators varies as a function of the leader's hierarchy level in the organisation.
  6. News Article
    A London hospital has launched an investigation after a woman whose baby died in the womb had to deliver her son at home due to lack of beds and keep his remains in her fridge when A&E staff said they could not store them safely. Laura Brody and her partner, Lawrence, said they were “tipped into hell” after being sent home by university hospital Lewisham to await a bed when told their baby no longer had a heartbeat but no beds were immediately available to give birth, the BBC reported. Two days later, after waking up in severe pain, Brody, who was four months into her pregnancy, gave birth in agony on the toilet in their bathroom. “And it was then,” she told the broadcaster, “I saw it was a boy”. The couple, who wanted investigative tests to be carried out at a later time, dialled 999 but were told it was not an emergency. They wrapped their baby’s remains in a wet cloth, placed him in a Tupperware box, and went to A&E where they were told to wait in the general waiting room, they said. She was eventually taken into a bay and told she would require surgery to remove the placenta. But, with the waiting room hot and stuffy and staff refusing to store the remains or even look inside the Tupperware box, they decided as it got to midnight they had no option but for her partner to take their baby’s remains home. Brody said the whole experience “felt so grotesque”. “When things go wrong with pregnancy there are not the systems in place to help you, even with all the staff and their experts – and they are working really hard – the process is so flawed that it just felt like we had been tipped into hell,” she told Radio 4’s Today programme. The case is said to have raised wider concerns among campaigners who argue that miscarriage care needs to be properly prioritised within hospitals including A&E. Read full story Source: The Guardian, 30 May 2022
  7. News Article
    Hundreds of organisations, including drug companies, private healthcare providers and universities, have breached patient data sharing agreements but not had their access to patient data withdrawn, a report reveals. “High risk” breaches were revealed to have occurred at healthcare groups, pharmaceutical giants and educational institutions including Virgin Care, GlaxoSmithKline (GSK) and Imperial College London, during audits by NHS Digital, according to an investigation by the BMJ. This means these organisations were handling information outside the remit agreed in data contracts and may be failing to protect confidentiality, the journal said. In one instance, local NHS commissioners allowed sensitive, identifiable patient data to be released to Virgin Care without permission from NHS Digital. When auditors tried to get access to Virgin Care to check their compliance, they were denied access for several weeks and the company refused to delete the patient data, the BMJ reported. Records about mental health, including children and young people, those with learning disabilities, diagnostic imaging and other confidential patient data was being processed outside the scope of objectives agreed with NHS Digital, at an address that had not been agreed, and without a data sharing contract. A spokesperson for Virgin Care said it had “robust data protection in place”. “It is outrageous that private companies and university research teams are failing to comply,” said Kingsley Manning, the former chair of NHS Digital. “How is it that these organisations can be so lax with data?” Read full story Source: The Guardian, 11 May 2022
  8. Content Article
    Outpatient and daycase hysteroscopy and polypectomy (OPHP) are widely recognised methods for the treatment of endometrial polyps. There have been concerns regarding pain affecting satisfaction and tolerability of the outpatient procedure. Dr Bhawana Purwar and colleagues from the Royal Wolverhampton Hospitals NHS Trust conducted a service evaluation of their outpatient hysteroscopy and polypectomy (OPHP) and compared it with their daycase procedures. They concluded that the OPHP is cost-effective and efficient method with reasonable acceptability. It is well tolerated with remarkable success rates and excellent patient satisfaction. As compared to daycase group, it requires less time for recovery and sooner returns to work.
  9. News Article
    The health secretary Matt Hancock has been threatened with a judicial review amid fears patients’ human rights are at risk from the incorrect use of controversial do not resuscitate orders during the coronavirus pandemic. Ministers have been told they should use emergency powers to issue a direction to doctors and nurses in the NHS requiring them to comply with the law on do not attempt resuscitation orders (DNARS) and to ensure patients are properly consulted. In recent weeks there have been a number of reports of patients having DNARs put in place without their knowledge or in GPs imposing blanket decisions, prompting a warning letter from NHS England’s chief nurse last month. The legal action is being brought by Kate Masters, the daughter of Janet Tracey, who died at Addenbrooke's hospital in 2011 after a DNAR was put in place without her knowledge. In 2014, Tracey's husband David won a landmark victory at the Court of Appeal which gave patients a new legal right to be consulted by doctors when DNARS were being considered. Not consulting a patient was a breach of their human rights, the court ruled. Read full story Source: The Independent, 6 May 2020
  10. News Article
    All NHS hospitals in England have been ordered to create secure areas for coronavirus testing to “avoid a surge in emergency departments”, according to a leaked NHS letter. Hospitals have been told to create “coronavirus priority assessment pods”, where people will be checked for the virus, which will need to be decontaminated each time they are used. The letter, seen by The Independent and dated 31 January, instructs all chief executives and medical directors to have the pods up and running no later than Friday 7 February. It comes as the global death toll from the virus has reached 565 with around 28,000 infected. One hospital chief executive told The Independent he believed the requirement was “an overreaction”, adding: “I think we should be sending teams out to swab in patients homes as the advice is to stay at home and self-manage as with any other flu". In the letter, Professor Keith Willett, who is leading the NHS’s response to coronavirus, told NHS bosses: “Plans have been developed to avoid a surge in emergency departments due to coronavirus. “Although the risk level in this country remains moderate, and so far there have been only two confirmed cases, the NHS is putting in place appropriate measures to ensure business as usual services remain unaffected by any further cases or tests of coronavirus.” Read full story Source: 5 February 2020
  11. News Article
    Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed. Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved. Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospitals ignoring the deadlines. National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes. NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt. Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.” He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.” Read full story Source: The Independent, 30 December 2019
  12. Content Article
    This webpage provides links to all recent NHS England national Patient Safety Alerts and sets out the criteria for issuing a Patient Safety Alert.
  13. Content Article
    NHS healthcare providers are under constant pressure to make costs savings. There does not appear to be a way to account for the costs of errors, harms and inefficiencies in patient care. If we could account for these costs, then medium to long term plans could be created in order to reduce the costs lost in the consequences of errors, harm and delayed or low-quality care of patients. If we get ‘Care Correct First Time’ then these wasted costs will fall, which could well achieve the 5% savings target within 5 years. Dr Gordon Caldwell proposes a conceptual framework, which would account for these costs wasted on the consequences of error, harm or delays caused by opportunity costs in the inefficient way that frontline staff have to provide patient care.
  14. Content Article
    A paper from Sidney Dekker et al. describing a previously unlabelled and under-theorised problem in safety management – ‘safety clutter’.
  15. Content Article
    Double-checking the administration of medications has been standard practice in paediatric hospitals around the world for decades, but there is little evidence of its effectiveness in reducing errors or harm. This study in BMJ Quality & Safety measures the association between double-checking and the occurrence and potential severity of medication administration errors. The authors found that: most nurses complied with mandated double-checking, but the process was rarely independent when not carried out independently, double-checking resulted in little difference to the occurrence and severity of errors compared with single-checking where double-checking was not mandated, but was performed, errors were less likely to occur and were less serious. They raise a question about whether the current approach to double-checking is a good use of time and resources, given the limited impact it has on medication administration errors.
  16. Content Article
    Government guidance on the changes to care home visits.
  17. Content Article
    The use of graded exercise therapy and cognitive behavioural therapy for myalgic encephalomyelitis/chronic fatigue syndrome has attracted considerable controversy. This controversy relates not only to the disputed evidence for treatment efficacy but also to widespread reports from patients that graded exercise therapy, in particular, has caused them harm. The authors of this study surveyed the NHS–affiliated myalgic encephalomyelitis/chronic fatigue syndrome specialist clinics in England to assess how harms following treatment are detected and to examine how patients are warned about the potential for harms. The study found that clinics were highly inconsistent in their approaches to the issue of treatment-related harm. They placed little or no focus on the potential for treatment-related harm in their written information for patients and for staff. Furthermore, no clinic reported any cases of treatment-related harm, despite acknowledging that many patients dropped out of treatment. The authors recommend that clinics develop standardised protocols for anticipating, recording, and remedying harms, and that these protocols allow for therapies to be discontinued immediately whenever harm is identified.
  18. Content Article
    The aim of the study was to create a core outcome set (COS), an agreed set of outcomes that could be measured, and report in all studies an evaluation of the introduction and evaluation of novel surgical techniques. The authors used data from several different sources such as innovation-specific literature, policy/regulatory body documents, and surgeon interviews. The results included 7,972 verbatim outcomes that were identified which were categorized into 32 domains. The researchers conclude the COS could be used to help encourage safer surgical innovation.
  19. Content Article
    This document describes how the Surveillance of Surgical Site Infection: Surgical Site Infection Surveillance Service aims to better patient care by asking hospitals to use data obtained from surveillance and compare rates of surgical site infections over time and against a benchmark rate. The aim is also to encourage the use of this information to help guide clinical practice.
  20. Community Post
    NHS hospital staff spend countless hours capturing data in electronic prescribing and medicines administration systems. Yet that data remains difficult to access and use to support patient care. This is a tremendous opportunity to improve patient safety, drive efficiencies and save time for frontline staff. I have just published a post about this challenge and Triscribe's solution. I would love to hear any comments or feedback on the topic... How could we use this information better? What are hospitals already doing? Where are the gaps? Thanks
  21. Community Post
    Overview Human error (HE) in global medicine kills 2.6 million annually placing patient safety on the G20 Summit (1). Solutions available (a) more staff training dominated by a HE-rate of about one error in 200 tasks and (b) a simple computer system used by high reliability organisations such as Banking with zero HE. With 70% of adverse events occurring on wards, patients should electronically acknowledge each intervention with their wristband-data. Missed interventions now detectable are compellingly alarmed reducing the consequences of HE 10,000 fold. Problem: The Healthcare sector have no “HE Recovery Protocols” on their wards (2a) This massive management error is punishable with fines and imprisonment across every other sector including Nuclear Rail Shipping etc. by the CPS here in the U.K. HE recovery protocol for ward-patient safety The patient is placed in a computerised quality-loop enabling them to acknowledge received MDT interventions by tagging their personal wristband-data back to the computer care plan. Missed interventions easily detected by the software-checklist now compellingly alarmed on-screen in front of health worker and patient. Nigh impossible to ignore, missed interventions are corrected, reducing the consequences of HE by more than a factor of ten thousand (104) (2b). Example: Opioid overdose prevention Software analyses patient's analgesic ladder. Their previously tagged opioid consumption displayed with opioid headroom warning. The patient tags acknowledging and updating the new opioid volume correctly administered. The system would have saved 450 Gosport patients 30-years ago, and currently under live investigation by Police (Operation Magenta). Conclusion Placing the ward patient in a computer driven tagged quality loop significantly reduces HE-consequences improving compliance lowering death rates adverse events bed-days and litigation. The tag system has a long-standing pedigree too. U.K. Bank customers have electronically tagged 30 million times a day, keeping accounts healthy and error free for decades. Please could colleagues on the hub help the NHS/CQC understand this established Industrial H&S concept with a view to trialling it. (Sums: 2.6m/10,000=2600 saving 2,597,400 annually?) References: [1] The cost of patient safety inaction: Why doing more of the … A .M. Alhawsawi. Patient Safety Hub 2020. [2a] The Blame Machine. R B Whittingham. ISBN 0-7506-5510-0. Industrial H&S. https://books.google.co.uk/then type “5.3 error recovery ” (page 74-75). [2b] https://books.google.co.uk/ then type “1. compelling feedback ” (page 78-79). Compelling feedback reduces HE by a factor of 10,000. Foot note: Sometimes whole industries become unwilling to look too closely at system faults and the blame machine swings into action. Pity the individual health worker not protected by management HE recovery protocols. https://books.google.co.uk/ type “The blame machine preface xii” last two paragraphs and xiii. Derek Malyon. 24.11.2020. Ward-Patient eQMS with Error Recovery Protocols.3 pdf.pdf
  22. Community Post
    Hi there, I represent a team of researchers in Reading, who are submitting ethical approval for a project investigating pain research and knee surgery. Part of this process is receiving feedback from an NHS ethics committee and addressing this for the benefit of the science, patients and clinicians involved. One suggestion they have made is that we involve patients within the review of our information sheets, which detail the procedures (both medical & research) that they may consent to. There is no requirement of expertise or experience from any patient who wishes to be involved, we are just very eager to make sure our information is clear, free of jargon and doesn't come across as confusing or intimidating. The committee have indicated this is an optional recommendation, but it is one that I am very keen to engage with. As it's optional, we are unable to shift our deadline for this, and I would unfortunately need the documents reviewed and submitted by Thursday 26th November. If this is something that anybody would be willing to help us with, I'd be very grateful. One information sheet is 2 pages, and the other is 7 pages, if this offers a good idea of how much time it may require. My hope it it would take no more than 30 minutes. If you are able to volunteer your time, please contact me on rich.harrison@reading.ac.uk, and I will forward you the documents for your review. Once again, thank you in advance! Richard
  23. Community Post
    Healthcare staff have had to adapt their way of working as a result of the pandemic, which has made pre-Covid guidance obsolete. Different Trusts are doing different things. What’s the solution?
  24. News Article
    The NHS has been returned to the highest level of risk on its emergency preparedness framework, a move which allows national leaders tighter control over local resources and decision making. NHS England chief executive Sir Simon Stevens announced the decision at a press conference this morning. He said: “Unfortunately, again we are facing a serious situation [due to rising coronavirus infections and hospital admissions]. That is the reason why at midnight tonight the health service in England will be returning to its highest level of emergency preparedness, EPPR level 4, which of course we had to be at from the end of January to the end of July.” Placing the NHS on level 4 of Emergency Preparedness Reslience and Response framework allows system leaders to take control of decisions over mutual aid and other local priorities. Sir Simon was joined by NHSE/I medical director Steve Powis and Alison Pittard, dean of the Faculty of Intensive Care Medicine. They used the press conference to stress the threat the NHS faced from the second covid peak, but also set out more positive news on the covid vaccine programme. Read full story Source: HSJ, 4 November 2020
  25. News Article
    The unlawful or inappropriate use of “do not attempt cardiopulmonary resuscitation” (DNACPR) orders by some clinicians risks undermining the care of terminally ill patients, almost 40 leading doctors, nurses and charities have warned. During the coronavirus pandemic repeated examples of unlawful decisions have emerged including widespread blanket orders on care home residents and patients with learning disabilities. Now the charity Compassion in Dying along with Marie Curie, Hospice UK and Sue Ryder, as well as more than 30 GPs, nurses and doctors, are warning more must be done to listen to patients and their families. In a joint statement, signed by more than 30 clinicians, they warn: “There have been examples of poor practice in relation to DNACPR decision-making during the pandemic, and the distressing impact this has had on patients and families cannot be underestimated. It is essential to thoroughly understand and learn from these cases to ensure that they do not happen again." “We are aware that the benefits of DNACPR decisions can be easily undone if they are not accompanied by honest, open and sensitive communication with a person’s healthcare team. To ensure that everybody who encounters a DNACPR discussion has a positive experience, we need to do more to listen to individuals and their families; their wishes must be sought and documented, their questions answered and their feelings acknowledged. “A DNACPR decision must always involve the person, or those close to them, and should be part of a wider conversation about what matters to that individual.” Read full story Source: The Independent, 8 March 2021
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