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Content ArticleOn the 22 January 2024 Assistant Coroner Sarah Bourke began an investigation into the death of Anoush Summers who died aged 77, on the 14 January 2024 at Homerton University Hospital. The deceased was a frail lady who was prone to falls. She lived at home, alone, with carers who visited her twice a day. She had a wrist alarm. The wrist alarm was reported as broken and not working on the 6 January 2024, but it was not repaired or replaced. Sometime after 4.45pm on 11 January 2024 the deceased fell at home. She was found the next day by a carer, wearing her wrist alarm and taken to hospital where she died on 14 January 2024 of hypothermia. The absence of a working wrist alarm prevented her from being found sooner that she was and probably contributed to her death.
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News Article
Council warned over broken alarm after woman dies
Patient Safety Learning posted a news article in News
An assistant coroner has warned an east London council more people may die if it does not take action, after a "frail lady who was prone to falls" died of hypothermia at her home. Anoush Summers, 77, died in hospital in January after a fall days earlier. In a prevention of future deaths report, external, assistant coroner Edwin Buckett said Ms Summers' inquest concluded "the absence of a working wrist alarm prevented her from being found sooner than she was and probably contributed to her death". Ms Summers lived alone but received help from two carers from Supreme Care Services, and she was visited twice a day. After falling at home on 11 January, she was found the next day at 09:00 GMT wearing her wrist alarm and was taken to hospital. She died of hypothermia at Homerton University Hospital on 14 January. The assistant coroner said among issues he identified in her case "giving rise to concern" were: Her wrist alarm had been reported as broken and not working on 6 January, but "this was not replaced or repaired by the company engaged by the local authority", which meant Ms Summers could not call for help as "it did not work" None of the carers who attended her home after the wrist alarm broke on 6 January "ensured that steps were taken to replace the alarm" or reported the matter to the local authority The last carer to see her, who visited on 11 January, "was not aware that the wrist alarm did not work as she had not read the care notes", and "no clear instruction was given" about the extent to which carers should read these notes "None of the carers had been given any training, instruction or guidance on the testing of wrist alarms to ensure they worked properly when attending" There was not a "clear system identified between the company providing carers and the local authority as to the duties and responsibilities of each in the reporting of faults with wrist alarms" Read full story Source: BBC News, 26 June 2024 -
Content ArticleFalls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures. This study reviewed interventions to reduce falls.
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News Article
Hip breaks more deadly than some cancers in elderly, study finds
Patient-Safety-Learning posted a news article in News
A recent analysis found poor survival rates after bone fractures in older adults, with fewer than a third of men and half of women surviving five years after a fracture. Published in JBMR Plus, the study looked at a cohort of 98,474 Ontario residents age 66 and older who suffered fractures to parts of the body associated with osteoporosis between January 2011 and March 2015. The patients were grouped into sets based on the fracture site and matched to patients with a similar demographic profile but no bone breaks during the study period. The fracture cohort was mostly female (73 percent), and the median age at fracture was 80. In the year before the fracture, up to 45 percent of the women and 14 percent of the men had been treated for osteoporosis. The analysis revealed that those within a year of a hip, vertebral or proximal non-hip, non-vertebral fracture were at the highest risk of death. The survival probability was lower for the oldest patients. “Survival most dramatically declined within one month after most types of fracture, with a five-year survival being similar to or worse than some common cancers,” the paper’s lead author, Laval University department of medicine professor Jacques Brown, said Read full story (paywalled) Source: Washington Post, 12 May 2024 -
Content ArticleThis annual report from ECRI and the Institute for Safe Medication Practices (ISMP) presents the top 10 patient safety concerns currently confronting the healthcare industry. It is a guide for a systems approach to adopting proactive strategies and solutions to mitigate risks, improve healthcare outcomes and enhance the well-being of patients and the healthcare workforce. Drawing on ECRI and ISMP’s evidence-based research, data and insights, this report sheds light on issues that leaders should evaluate within their own institutions as potential opportunities to reduce preventable harm. Some of the concerns represent emerging risks, some are well known but still unresolved, but all of them pertain to areas where organisations can make meaningful change.
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Content ArticleThe Falls and Fragility Fractures Audit Programme (FFFAP) is looking to recruit new members to their award-winning Patient and Carer Panel. FFFAP is a national clinical audit run by the Royal College of Physicians (RCP) and commissioned by the Healthcare Quality Improvement Partnership on behalf of NHS England and the Welsh Government. Their work aims to improve the care that patients with fragility fractures receive in hospital and after discharge and to reduce inpatient falls.
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Content ArticleThis article outlines a recent improvement put in place by a ward at Sir Robert Peel Community Hospital, part of University Hospitals of Derby and Burton NHS Foundation Trust. The team won an award for implementing learning following a patient fall to help drastically reduce the frequency of incidents and improving patient safety.
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Content ArticleIn 2021 in New South Wales (NSW) there were 41,619 people over 65 who were hospitalised due to a fall at home or in the community. This number increased by 60% in a decade from 25,982 in 2010 and the incidence of falls is set to increase further as the population ages. In 2021 the cost to the NSW health system from falls by older people in the community was around $752 million. These costs are projected to grow to $1.09 billion by 2041 – the result of around 60,300 hospitalised falls projected for that year. There is robust evidence that falls can be prevented. Fall prevention is a complex area as there are multiple risk factors that may contribute as to why a person may fall. A systems thinking approach acknowledges the complexity of fall prevention, seeks to understand the interactions between components, and identifies what interventions work best.
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Event
Patient safety in hospices
Patient Safety Learning posted an event in Community Calendar
This conference focuses on improving safety for hospice patients. The day will highlight best practice in improving safety in hospices, highlight new developments such as the implications of the new Patient Safety Incident Response Framework (PSIRF), and the new CQC Inspection Framework, and will focus on key clinical safety areas such as falls prevention, medication safety, reduction and management of pressure ulcers, nutrition and hydration, improving the response and investigation of incidents, preparing for onsite inspections and developing a compassionate culture in hospices. Register at https://www.healthcareconferencesuk.co.uk/virtual-online-courses/patient-safety-hospices or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow the conference on Twitter @HCUK_Clare #PSHospices -
Content ArticleThis report published by the National Audit of Inpatient Falls (NAIF) includes information on multi-factorial risk assessments and post fall management, and contains five recommendations as well as resources to support improvement.
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Content Article
Fundamental Care podcasts
Patient Safety Learning posted an article in Recommended video and audio resources
Throughout this series of Fundamental Care podcasts, a panel of key opinion leaders and passionate healthcare staff from the UK will discuss and debate evidence based best practices at the core of the day-to-day challenges faced in healthcare, not only for patients but also for healthcare workers themselves. -
News Article
Woman waits six hours for ambulance after fall on her 100th birthday
Patient Safety Learning posted a news article in News
A woman has described how she spent more than six hours of her 100th birthday waiting in agony for an ambulance after slipping and fracturing her pelvis while getting ready for a family lunch. Irene Silsby was due to be picked up by her niece, Lynne Taylor, for a celebration to mark her centenary on 9 April. But she fell in the windowless bathroom of her care home in Greetham, Rutland, and staff called an ambulance at 9am after she managed to summon help. “All I remember is I was in terrible pain,” said Silsby from her hospital bed on Saturday. When asked of the ambulance delay, she said: “It’s disgusting. I don’t know how I stood it so long, the pain was so severe.” Taylor expected to meet the ambulance as she arrived 45 minutes later. But when she reached the care home, the manager said it would be a 10-hour wait, she said. What was to be her aunt’s first trip outside the care home in more than five months turned into her lying on a cold floor surrounded by pillows and blankets to keep her warm and quell some of the discomfort. Taylor, 60, recalled her aunt saying: “They’re not coming to me because they know I’m 100 and I’m not really worth it any more.” Taylor said she had never felt so scared, frustrated and worried. After calling 999 and expressing her outrage, she was told that life-threatening conditions were being prioritised. “I thought she was going to die,” she said. “I didn’t think that any frail, tiny, 100-year-old body could put up with that level of pain on the floor.” Read full story Source: The Guardian, 20 April 2022 -
News Article
Lincolnshire Trust fined after patient suffered serious avoidable harm
Patient Safety Learning posted a news article in News
United Lincolnshire Hospitals NHS Trust has been ordered to pay a total of £111,204 in fines and legal costs after pleading guilty to failing to provide safe care and treatment to an elderly patient, causing them avoidable harm, following a sentencing hearing on Friday, 25 March at Boston Magistrates’ Court. The case was taken by the Care Quality Commission (CQC) under regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The case against United Lincolnshire Hospitals NHS Trust involved the care of an elderly patient, Iris Longmate, who was admitted to the Greetwell Ward at Lincoln County Hospital on 20 February 2019. On March 3, 2019 Iris fainted and fell unsupervised from a commode, and was found face down on the floor in her room. Iris sustained spinal injuries and a cut to the head as a result of the fall, but then also suffered significant burns to her thigh and left arm as a result of being pressed against a radiator whilst being assessed by staff following the fall. Iris was subsequently transferred to Queens Medical Centre for assessment and treatment. She sadly contracted pneumonia in hospital and died on March 14, 2019. United Lincolnshire Hospitals NHS Trust pleaded guilty to a single offence of failure to provide safe care and treatment causing avoidable harm to Iris, for which the trust was fined £100,000. The court also ordered the trust to pay £170 victim surcharge and £11,034 costs to the CQC. The trust was found to not have taken all reasonable steps to ensure that safe care and treatment was provided, resulting in avoidable harm to Iris. In pleading guilty to the offence of causing avoidable harm to Iris, the trust also acknowledged that other patients on the Greetwell Ward had also been exposed to a significant risk of avoidable harm. Fiona Allinson, CQC’s deputy chief inspector of hospitals, said: "This death is a tragedy. My thoughts are with the family and others grieving for their loss." "People have the right to safe care and treatment, so it’s unacceptable that patient safety was not well managed by United Lincolnshire Hospitals NHS Trust," she said. "Had the trust addressed the issues with the exposed heating pipes before Iris fell, she wouldn’t have suffered such awful burns injuries." Read full story Source: Medscape, 2 April 2022 -
News Article
We need to find alternatives to 999 for care homes and falls
Patient Safety Learning posted a news article in News
The NHS needs to do more to support care homes and people who have fallen with alternatives to ambulance calls and hospital admissions, the NHS England chief executive has said. Speaking at the Ambulance Leadership Forum, Amanda Pritchard acknowledged this winter would be a difficult one for the health service, saying: “The scale of the current and potential challenge mean that we do need to continue to look further for what else we can do… We need to pull out all the stops to make sure that they [patients] get that treatment as safely as possible and as quickly as possible.” She added one area of focus should be making sure certain patient groups can access other – more appropriate – forms of care, rather than calling an ambulance by default and often resulting in hospital admission. On care homes, she said: “Can we wrap around even more care for these care homes so they get to the point where they don’t need to call for help at all or, if they do, there are alternatives pathways [to the emergency department]?” She suggested another area where responses could be made more consistent was for patients who had fallen but without serious injuries, which she said made up a “really significant part of activity”. These patients took a long time to reach and, if admitted to hospital, risked long admissions, she said. Some areas were working to find other ways of responding to non-injury falls patients and trying to keep them away from hospital, she said. Read full story (paywalled) Source: HSJ, 6 September 2022 -
News Article
NHS Wales: Falls project avoids 50 needless ambulance callouts
Patient Safety Learning posted a news article in News
A new scheme in Wales to help people who have suffered falls has prevented 50 ambulances being unnecessarily sent this year. St John Ambulance works with Hywel Dda health board in Pembrokeshire to send its people when someone calls 999. The pilot has been used 96 times since January but it needs more health board funding to continue after March. Ageing Well in Wales estimates that between 230,000 and 460,000 over 60s fall each year. When people dial 999, it can be directed to the St John Ambulance falls response team, who are sent to perform an assessment and identify whether the person can stay home or needs an ambulance to take them to hospital. St John Ambulance operational team leader Robert James said in 60% of cases, the person was well enough to stay at home. "You can imagine if you were sending an ambulance crew out and it has wasted 60% of the crew's time, well it's a big saving towards the NHS and the ambulance service in itself," he added. "Provided there are no injuries, or reason for them to go to hospital, they can be discharged on the scene." Read full story Source: BBC News, 10 March 2023 -
News Article
NHS fined £180,000 after vulnerable patient’s death
Patient-Safety-Learning posted a news article in News
A health board has been fined £180,000 for failing to protect a vulnerable pensioner who died after repeatedly falling in hospital. Colin Lloyd, 78, was assessed as posing a high risk of falling and required one-to-one care after being admitted to Raigmore Hospital in Inverness. Despite repeated requests for more nursing staff none were made available and the pensioner suffered falls on the ward, which caused fatal injuries. Fiona Hogg, NHS Highland’s director of people and culture, said: “We are deeply sorry for the failures identified in our care. Our internal review following the incident identified several areas of improvement and we have made a number of changes to our practice.” Read full story (paywalled) Source: The Times, 15 February 2023 -
News ArticleTwo years ago, administrators and caregivers at St. Bernard Hospital in Chicago were stunned when they flunked a basic standard for patient safety. "It was a real jolt," said Charles Holland, the hospital's president and CEO. "We thought we were doing patient safety and we thought we were doing it well." But the Leapfrog Group, a nonprofit health care watchdog organisation, found the hospital fell short on documenting and having comprehensive approaches to hand-washing, medication safety systems and fall and infection prevention. The wake-up call led Holland to hire a Patient Safety and Quality Officer and to use Leapfrog's criteria as a roadmap for improving patient safety. It worked. In its latest annual review of hospital safety, released Wednesday, Leapfrog awarded the century-old charity hospital an A. The fact that St. Bernard could turn around so quickly and so effectively without spending a fortune in the process shows that patient safety is an attainable goal, said Leah Binder, Leapfrog's president and CEO. Read full story Source: USA Today, 3 May 2023
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Content ArticleThis study in JAMA Health Forum aimed to assess the costs of inpatient falls and cost benefits associated with the Fall TIPS (Tailoring Interventions for Patient Safety) Program. The authors carried out an economic evaluation across a large cohort of 900,635 patients. The average total cost of a fall was $62 521 ($35 365 direct costs), and injury was not significantly associated with increased costs. The Fall TIPS Program was associated with $22 million in savings at study sites across the five year study period. The findings of this study indicate that implementation of cost-effective, evidence-based safety programs was associated with lower cost and care burdens associated with inpatient falls and are a step toward safer, more affordable patient care.
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Content ArticleThe Fracture Liaison Service Database (FLS-DB) collects, measures and reports on the care provided by Fracture Liaison Services (FLSs). This annual report presents the results of secondary fracture prevention care received by patients aged 50 and older following a fragility fracture between January and December 2021. Based on 70,384 patient records in 2021 (compared with 70,614 in 2019), it found that there has been a reduction in both case identification and assessment performance, but an improvement in treatment recommendation, monitoring and follow up, when comparing national data from 2021 with 2019.
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Content ArticleIn the UK, the focus of osteoporosis care in the NHS has been on people who have sustained a fragility fracture as a result of their underlying condition. Not much has been done to try and prevent the first fracture by promoting good bone health and proactively identifying people at higher risk. This report by the APPG on Osteoporosis and Bone Health presents the results of its inquiry into primary care provision for people with osteoporosis and those at high risk of fracture, launched in March 2022. The inquiry aimed to establish the current quality of care being offered to patients.
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Content ArticleThis video by the NHS England National Patient Safety Team provides tips for patients on keeping safe during a hospital stay. It highlights simple things you can do as a patient to help keep yourself safe during a hospital stay, such as asking for help when needed, protecting yourself from slips and falls and helping to prevent blood clots. A British Sign Language (BSL) version of the video is also available, as well as a leaflet translated into these languages: English Arabic Cantonese French Gujarati Mandarin Polish Portuguese Punjabi Romanian Spanish Urdu
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Content ArticleThis Canadian study in the Journal of Patient Safety describes an initiative that introduced system-wide changes to practice and patient safety culture in a rapid time frame. it looks at the implementation of a 'zero harm' approach to eliminate preventable harm across a wide variety of clinical areas. In less than a year, the intervention increased patient safety incident reporting by 37% while decreasing falls with injury by 39%, pressure injury rates by 37% and central line–associated blood stream infections by 34%.
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News Article
NHS boss Amanda Pritchard vows that victims of falls won’t wait hours in agony
Patient Safety Learning posted a news article in News
Elderly people who call for help after a fall at home will no longer be left waiting for hours on the floor, the head of the NHS has said, as she bids to keep patients out of hospital and stop the service being overwhelmed this winter. Amanda Pritchard said she would start a new national service within weeks under which community teams would offer immediate help to people who had had an accident but had avoided serious injury. Pritchard, who took over as chief executive of NHS England last year, said a quarter of less severe 999 calls in January involved falls. The new teams could stop 55,000 elderly people a year being taken to hospital, she said. All NHS areas will be told this week to establish the service before a “very, very, very challenging winter” for the health service. Read full story (paywalled) Source: The Times, 16 October 2022 -
Content ArticleThis report is the Falls and Fragility Fractures Audit Programme's (FFFAP's) State of the Nation Report 2022 for Wales. It examines how the care of inpatient falls and fragility fractures has changed since 2020, highlighting what the audit reveals about the quality of patient care and the impact of the Covid-19 pandemic. The report used three sources of data and concludes with a number of recommendations around the care of people with hip fracture, preventing inpatient falls, and preventing future fractures.
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Content ArticleA repository of resources aimed at patients and carers which have been co-produced by the Falls and Fragility Fracture Audit Programme (FFFAP) patient and carer panel.
