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News Article
Leak reveals trust omitting two-year waits from reported figures
Patient Safety Learning posted a news article in News
A hospital trust has been breaching national guidance by excluding some long waiters from its reported waiting list figures, in a move experts warned could put patient safety at serious risk. The practice appears to have helped Sandwell and West Birmingham Hospitals report zero patients waiting more than two years for treatment during most of last year. Its policy means cases that unexpectedly “pop up” as two-year waits in its datasets are temporarily removed. The trust will then review whether the cases are data errors or genuine two-year waits, and if genuine, aim to provide treatment within a month. If not treated within a month, the cases would be added back to the reported waiting list the following month. Rob Findlay, an expert on RTT waiting lists, said the implications of the SWBH policy are far more serious than simply reporting incomplete numbers for a month. He said allowing a month to deal with the pop-up without declaring it “relieves them of pressure to solve the problems that are causing patients to be lost in the first place”. He added: “Some patients – the hospital would never know – might never pop up and be lost from the waiting list forever. “[This is] a serious patient safety issue which could potentially have a significant impact on how long patients are waiting for treatment.” Read full story (paywalled) Source: HSJ, 19 January 2024 -
Content ArticleError management is a systematic approach aimed at identifying and learning from critical incidents by reporting, documenting and analysing them. However, almost nothing is known about the incidents doctors in outpatient care consider to be critical and how they deal with them. This interview study aimed to to explore outpatient doctors’ views on error management, discover what they regard as critical incidents and find out how error management is put into practice in ambulatory care.
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Content Article
A complex adaptive systems approach to patient safety
Kumar posted an article in Improving patient safety
Hospitals are complex adaptive systems. They are industrial environments where it isn't always possible to expect predictable responses to inputs. Patient safety management practices need to adapt to align with the environment in which events occur. It is time to reimagine safety event reporting and management solutions that guide, not prescribe, investigations and improvement actions.- Posted
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Content ArticlePatients treated and transported by Helicopter Emergency Medical Services (HEMS) are prone to both flight and medical hazards, but incident reporting differs substantially between flight organisations and healthcare, and the extent of patient safety incidents is still unclear. This study in the Journal of Patient Safety is based on in-depth interviews with eight experienced Norwegian HEMS physicians from four different bases from February to July 2020. The study aimed to explore the physicians’ experience with incident reporting and their perceived areas of risk in HEMS. The authors concluded that sparse, informal and fragmented incident reporting provides a poor overview of patient safety risks in HEMS. A focus on organisational factors and system responsibility is needed to further improve patient safety in HEMS, alongside research on environmental and contextual factors.
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Content ArticleReporting behaviour associated with safety-related accidents, incidents and hazards is a concern for many managers, regulators, safety specialists, operational staff and patients. In this blog, Stephen Shorrock looks at the many influences on reporting behaviour and how these influences are interrelated.
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Content ArticleNHS organisations are able to record patient safety events to the Learning From Patient Safety Events (LFPSE) system via the online recording form or via LFPSE service compliant risk management software. This web page provides details on which organisations have connected to the LFPSE service via their local risk management system.
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Content ArticleIn this opinion piece for the BMJ, Scarlett McNally looks at the issue of sexual assault and harassment by and against NHS staff. She argues that rather than focusing solely on reporting mechanisms, there needs to be more emphasis on prevention. In order to change the culture in NHS workplaces, all members of the team need to consider how they may contribute to a culture that allows sexual misconduct to happen.
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Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. Homerton University Hospital have shared a presentation on how they are going to implement LFPSE into Datix, a quick reference guide and a screen saver they are using to introduce it to staff. Others may find the resources useful and can adopt/adapt them in their own organisations. They can be downloaded from the attachments below. Additional resources on the hub: CSH Surrey share their presentation slides on LFPSE and Datix.
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Content ArticleIn her latest blog, Patient Safety Commissioner Henrietta Hughes discusses MHRA's Yellow Card reporting system and why, until we have mandatory reporting, including for devices that are working as designed, we will continue to see avoidable harm occurring to patients. She stresses that it is vital that the voices and views of patients, clinicians, manufacturer, and health providers participate in the design and delivery of devices.
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Content Article
Thirlwall Inquiry
Mark Hughes posted an article in Other reports and inquiries
The Thirlwall Inquiry has been set up to examine events at the Countess of Chester Hospital and their implications following the trial, and subsequent convictions, of former neonatal nurse Lucy Letby of murder and attempted murder of babies at the hospital. This website provides information about inquiry team, terms of reference and publications relating to this. -
Content ArticleA BMJ investigation has raised concerns that the Vaccine Adverse Event Reporting System (VAERS) isn’t operating as intended and that signals are being missed. VAERS is supposed to be user friendly, responsive, and transparent. However, investigations by The BMJ have uncovered that it’s not meeting its own standards. Not only have staffing levels failed to keep pace with the unprecedented number of reports since the rollout of covid vaccines but there are signs that the system is overwhelmed, reports aren’t being followed up, and signals are being missed. The BMJ has spoken to more than a dozen people, including physicians and a state medical examiner, who have filed VAERS reports of a serious nature on behalf of themselves or patients and were never contacted by clinical reviewers or were contacted months later.
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Content ArticleLearn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. LFPSE introduces improved capabilities for the analysis of patient safety events occurring across healthcare, and enables better use of the latest technology, such as machine learning, to create outputs that offer a greater depth of insight and learning that are more relevant to the current NHS environment. LFPSE fields can now integrated into Datix incident form, and the information is uploaded to the national database upon the completion of an incident report. After the reviewing manager’s and Patient Safety Team review, any changes are automatically re-uploaded and the information updated in the national database. CSH Surrey share their presentation slides on LFPSE and Datix.
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Content ArticleThrough a data sharing agreement, the Faculty of Intensive Care Medicine can access a record of incidents reported to the National Reporting and Learning System (NRLS). Available information is limited and from a single source; all that is know about these incidents is presented in this report. The safety bulletin aims to highlight incidents that are rare or important, and those where the risk is perhaps something we just accept in our usual practice. It is hoped that the reader will approach these incidents by asking whether they could occur in their own practice or on their unit. If so, is there anything that can be done to reduce the risk?
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News Article
Indigestible and illegible: the sorry state of board safety reports
Patient Safety Learning posted a news article in News
A report highlights that maternity and neonatal services are often regular agenda items at board meetings, but the quality and quantity of information that is presented and the subsequent discussion (or lack thereof) doesn’t lead to effective oversight. The shocking and distressing stories emerging from the Lucy Letby case in August 2023 shone a light on the “cover-up culture” in the NHS. Although deliberate harming of babies is thankfully exceedingly rare, some of the issues raised in this case echo concerns that trusts are failing to react to signs of poor performance in maternity and neonatal services. Responsibility ultimately lies with trust boards which have a statutory duty to ensure the safety of care. However, the actions (or inactions) of leadership have come up frequently in inquiries and reviews. Read full story (paywalled) Source: HSJ, 7 November 2023 -
Content ArticleTrust boards’ regular oversight of the quality and safety of maternity and neonatal services has been the subject of successive inquiries and reviews. In this report, the Sands and Tommy’s Joint Policy Unit review publicly available board papers and minutes for seven NHS Trusts in England. They analyse whether the information presented to boards, the process for review, and actions taken enabled boards to deliver effective oversight over the safety and quality of maternity and neonatal services.
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Content Article
UKCVFamily was set up in November 2021 to support patients in the UK who have had an adverse reaction to a Covid-19 vaccination. The group provides help and advocacy as well as raising awareness amongst healthcare professionals, the media and the Government. In this video, founder of UKCVFamily Charlet Crichton talks to us about the side effects she experienced after having the AstraZeneca Covid vaccine. She outlines why she established the group and describes the support it offers to patients. She outlines some of the issues people face when trying to access diagnosis and treatment, and discusses the limitations of the MHRA's Yellow Card scheme in collecting data about adverse reactions. She also describes how healthcare professionals can support people with adverse reactions by taking their concerns seriously and investigating symptoms thoroughly. -
News Article
Families dismay at interim report plans despite review ‘chaos’
Patient Safety Learning posted a news article in News
Families involved in a major review into maternity failings at Nottingham University Hospitals Trust (NUH) have criticised the decision of the review team to press ahead with the publication of an interim report, despite serious concerns about its terms of reference and methodology. A “thematic review” into NUH was first announced last year after reports that dozens of babies died or were brain damaged after errors were made at the trust over the last decade. More than 460 families have since contacted the review team. The review has been overseen by NHS England and local commissioners, but, in April, the families called for an independent inquiry and asked for it to be carried out by Donna Ockenden, the senior midwife who chaired the high-profile review of Shropshire maternity services, which reported in March. Last month, NHSE chief operating officer Sir David Sloman wrote to families and said former strategic health authority chair Julie Dent would be brought in to chair the review. However, Ms Dent stepped down from the role weeks later, citing “personal reasons”. A new chair is yet to be appointed. Despite these uncertainties, families have been told by the review team that an interim report will be issued shortly. Gary Andrews, whose daughter Wynter died after being delivered by caesarean section at NUH’s Queens Medical Centre in 2019, said to issue an interim report “seems at odds with the current situation” and risked causing “significant distress” to families. He added: “We need government to get to grips with this review. Put the brakes on, ensure its structure and design and objectives are fully supported by families, before any interim report can be issued.” Read full story (paywalled) Source: HSJ, 19 May 2022 -
News Article
Trust heavily criticised by coroner for delays to death investigations
Patient Safety Learning posted a news article in News
A coroner has strongly criticised a mental health trust for failing to investigate serious incidents promptly. Tees Esk and Wear Valleys Foundation Trust has been told that delays in probing serious incidents may “compromise the quality” of these investigations and hence “their value in preventing deaths”. The warnings, from Jeremy Chipperfield, senior coroner for County Durham and Darlington, come amid an ongoing inquest into the death of TEWV patient Ian Darwin. Mr Darwin died aged 42 in March, and the serious incident review into his death is still ongoing. A recently published prevention of future deaths report relating to Mr Darwin’s death said TEWV’s serious incident death investigations, “at all levels of seriousness, are routinely (if not invariably) significantly delayed and I understand there is no expectation of immediate, or any timetable for eventual rectification”. “In permitting delay of ‘serious incident’ investigations, TEWV may permit lethal hazard to persist for longer than necessary, and compromise the quality of such investigations and hence their value in preventing avoidable deaths.” -
News Article
Global COVID-19 data gap grows as countries stop reporting to WHO
Patient Safety Learning posted a news article in News
Fewer than 20 countries worldwide still report COVID-19 hospitalisation and ICU data to the World Health Organization (WHO), leaving the UN health body blind to the impact and evolution of the virus in most of the world, agency leaders have said. The decline in data reporting is a major setback for the WHO’s efforts to track the pandemic. Without reliable data, the WHO cannot accurately assess the burden of disease, identify new variants, or target its resources where they are most needed. “We don’t have good visibility of the impact of COVID-19 around the world,” said Dr. Maria Van Kerkhove, who leads the WHO’s COVID-19 task force. “It is really important that surveillance continues, and this is on the shoulders of governments right now.” “While we are certainly not in the same situation that we were in a year ago or two years ago, SARS-Cov-2 circulates in all countries right now,” said Van Kerkhove. “It is still causing a large number of infections, hospitalisations, admissions to the ICU and deaths.” The current set of dominant COVID-19 variants can still cause the “full spectrum” of disease, from asymptomatic infections to severe disease and death, Kerkhove said. Read full story Source: Health Policy Watch, 25 August 2023 -
News Article
Norfolk and Suffolk NHS trust deaths report 'watered down to spare bosses'
Patient Safety Learning posted a news article in News
A critical report into how a mental health trust mismanaged its mortality figures was edited to remove criticism of its leadership, the BBC has found. In June, auditors Grant Thornton revealed how the Norfolk and Suffolk NHS Foundation Trust (NSFT) had lost track of patient deaths. But earlier drafts included language around governance failures that were missing in the final version. NSFT and Grant Thornton said the changes were due to fact-checking. A number of drafts of the report were produced, with the first dated 23 February this year. The first version described "poor governance" in the way deaths data was managed, with governance also being called "weak" and "inadequate". But many of these critical words were missing from the report released to the public, with "governance" also being replaced with "controls", according to leaked documents. After losing her son Tim in 2014, Caroline Aldridge has been highlighting what she and others claimed had been the trust's undercounting of deaths. "I think people need to know what was removed and what was changed, because I suspect that the first report is a lot nearer to the truth," she said. Ms Aldridge added: "It takes all responsibility from governance, removing the words 'inadequate', 'poor', 'weak' governance, removing significant pieces of information that's not factual accuracy. "We cannot have people watering it [the report] down when it's about deaths." Read full story Source: BBC News, 29 August 2023 -
News Article
NHSE and government reprimanded for ‘selective reporting’ of cancer performance
Patient Safety Learning posted a news article in News
NHS England and the government have been criticised for “selective reporting” of statistics by an influential Westminster committee. The chair of the Public Accounts Committee Meg Hillier wrote to NHS England CEO Amanda Pritchard requesting “greater realism about the scale of the challenge” on cancer services. It follows the government and NHSE claiming in a government response to the committee that they had “implemented” one of its earlier recommendations, to “bring cancer treatment back to an acceptable standard”. In their February report on backlogs and waiting times, MPs said cancer delays were “unacceptable” and services should be recovered “as a matter of urgency”. The report also criticised NHSE for “over-optimism” when drawing up cancer and elective recovery plans. Read full story (paywalled) Source: HSJ, 4 July 2023 -
News Article
Hundreds died on same day as being discharged, trust review finds
Patient Safety Learning posted a news article in News
An independent review has raised concerns about a mental health trust’s reporting systems and has highlighted a significant number of patient deaths shortly after leaving the trust’s care, including almost 300 who died on the same day they were discharged. However, the review into how Norfolk and Suffolk Foundation Trust collects, processes and reports mortality data made no conclusions on the number of avoidable deaths – the issue which had originally prompted the probe. Local NHS leaders argued the review’s purpose was focused on auditing the trust’s processes, and this had been delivered. But a local MP, Clive Lewis, accused it of “explicitly dodg[ing] the big questions”. The report, which looked at data from between April 2019 and October 2022, has however raised concerns about the number of patients dying soon after being discharged. Read full story (paywalled) Source: HSJ, 28 June 2023 -
News Article
Multiple reporting systems undermine patient safety, says watchdog
Patient Safety Learning posted a news article in News
A single system to report patient safety concerns would “keep people safer”, a newly appointed NHS watchdog has told HSJ. Henrietta Hughes – who will take up the post of patient safety commissioner in September – said both clinicians and patients faced a bewildering choice when looking to raise a safety concern, and that there was a need for a “report once” system. She said that when ”exhausted” clinicians “come to the end of a 12-hour shift, they don’t want to have to do a Datix report and a yellow card report, and if they’ve got a safeguarding concern or a concern about an individual condition, [to have to] send that somewhere else”. Dr Hughes added: ”Wouldn’t it be better if we had one report that you do, and all the information that comes from that report just gets sent to the appropriate authority? That’s the type of change that I think we’d like to see. I know, as a GP myself, that’s what I would rather do as a professional. But also, I think, for all the organisations, we could get so much more richness of information, we would get more reporting, and we’d keep people safer as a result of it.” She added that if a patient “wanted to report an individual clinician” they often ended getting bounced around the system, like a pinball. They get sent from pillar to post.” Read full story (paywalled) Source: HSJ, 8 August 2022 -
News ArticleFresh concerns have been raised about the launch of the national incident reporting system, despite Steve Barclay taking a ‘personal interest’ in hitting the tight timetable, HSJ has learned. NHS England already delayed the launch of the “learning from patient safety events” database by six months, to September this year. It is due to replace the existing national reporting and learning system (NRLS) which is considered to be outdated and at risk of failing. But serious concerns are now being raised again by trust safety managers about whether the revised launch date can be met, HSJ has been told, with calls for it to be extended again until next year. HSJ has heard concerns from several managers that an upgrade due in July to the RLDatix risk management system – which is used by the majority of trusts – will cause knock-on problems implementing LFPSE in September. They said the timeframe was too short for testing and delivering the upgrade in time to make the transition and decommission the old NRLS. The creation of LFPSE is a key part of NHSE’s safety strategy, along with replacing the serious incident reporting system, with an aim of making it easier for staff to record safety events across all services, including primary care, which is excluded from NRLS. Read full story (paywalled) Source: HSJ, 3 May 2023
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Content ArticleIncomplete or inaccurate recording of ethnicity will undermine attempts to address health inequalities and improve access, experience and outcomes for Black, Asian and minority ethnic communities. This report by the Race Equality Foundation and the Office for National Statistics (ONS) looks at different aspects of the recording of ethnicity in healthcare. The authors interviewed people from a range of communities across England, as well as healthcare workers from different areas and settings to understand both sides of the process of collecting ethnicity data.
