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Patient safety

The latest patient safety related news

Highlighting learning from practitioners and research from human factors in health care.

Follow this theme to discover what patient safety means as a practice. We share learning from practitioners, and researchers and findings from the developing field of human factors in health care.

Patient safety

Action against Medical Accidents

Regulating the duty of candour: requires improvement

This research shows that the Care Quality Commission “requires improvement” in how it regulates the statutory duty of candour, despite significant improvements since a previous report published in 2016.

BBC News

NHS Weekend: Action demanded over death risk

The case for improving hospital care at weekends in England is "simply unassailable", medical chiefs say, as new figures on deaths are published. NHS England medical director Sir Bruce Keogh called for action as research by him and others linked the "weekend effect" to 11,000 excess deaths.

BMJ

RCGP members: CQC-style inspections don’t raise standards or improve patient safety

Inspections such as those carried out by the Care Quality Commission are not effective in raising standards or ensuring patient safety, delegates at the Royal College of General Practitioners’ annual conference have argued. The conference hosted a debate on the merits of inspection.

Diabetes UK

Making hospitals safe for people with diabetes

This report has been developed through conversations with people with diabetes, diabetes inpatient teams, healthcare professionals working in hospitals and hospital managers. It highlights the challenges facing diabetes inpatient services and shows what should be in place in all hospitals.

Digital Health Age

The healthtech company using barcoding in the fight to improve patient safety

With the NHS set to receive close to half a billion to fund innovative technology in hospitals to make it safer for patients, and allow clinicians to spend more time on the frontline, secretary for health and social care, Matt Hancock, earlier this year stressed the importance of government healthcare initiatives to encourage this; Scan4Safety, GS1 and e-procurements are key ones.

Guardian

Newly discharged mental health patients at much higher risk of death

People with mental health problems are at a hugely increased risk of dying from unnatural causes, including suicide, soon after they have been discharged from hospital, new research by Manchester University’s centre for mental health and safety reveals.

Guardian

More than 260,000 diabetes inpatients had hospital medication errors in 2017

More than a quarter of a million diabetes inpatients experienced a medication error at hospital last year, putting them at risk of serious harm or death. Diabetes UK said more than 260,000 people with the condition had encountered errors during a hospital stay in 2017.

National Health Executive

Wake-up call’ for NHS: a quarter of million diabetes patients suffered medication error

Research from Diabetes UK said that more than 260,000 people with diabetes experienced errors during their hospital stay in 2017, of which 9,600 suffered a serious and potentially life-threatening hypoglycaemic attack due to poor insulin management.

NHS Improvement

Improving safety critical spoken communication

Every 36 hours the NHS deals with over a million patients and each of these contacts probably generates discussion between staff about a patient’s care. It is known from serious incident investigations that communication failure is a common finding. This research examines the issues surrounding both good and poor spoken communication of safety critical information. It identifies six key areas that present challenges to spoken communication.

NHS Improvement

Provisional publication of Never Events reported as occurring between 1 April and 31 August 2018

209 serious incidents appeared to meet definition of a Never Event including 7 relating to administration of medication by the wrong route, 6 to overdose of insulin due to abbreviations or incorrect device, and 2 of overdose of methotrexate for non-cancer treatment.

NIHR Signal

Inducing labour at or after 41 weeks reduces risks to infants

Inducing labour after the due date slightly lowers the risk of stillbirth or infant death soon after birth compared with watchful waiting. But the overall risk is very low. Induced deliveries may reduce admissions to the neonatal intensive care unit.

Public Health England

UK public health antimicrobial resistance alerts

Public Health England will issue antimicrobial resistance alerts to inform microbiologists of emerging antimicrobial-resistant pathogen strains which could spread in the UK health service. If there is suspicion of a resistant circulating strain, isolates should be sent for testing.

Public Health England

Inactivated influenza vaccine: information for healthcare practitioners

For inadvertent administration of inappropriate flu vaccine type, updated guidance now recommends that if an individual wishes to receive the vaccine that they should have been given, this can be offered following a discussion of the benefits and risks.

Pulse

CQC: GP practices 'improve patient safety' despite 'increasingly stretched' workforce

The overall safety of GP practices in England is improving, although there is a concern about the ‘stretched’ GP workforce going forward, the CQC has said. But the CQC went on to express concern regarding the GP workforce going forward, linking this to the ‘national drive to provide seven-day services’.

Royal College of Physicians

National Mortality Case Record Review (NMCRR): Annual report 2018

This report reveals that hospitals are using a standardised review approach to learn from adult acute deaths and improve patient care. It cites a number of case studies where the structured judgement review process has made positive contributions to improving healthcare for patients.

Wales Online

Independent review to be carried out into stillbirths and baby deaths at Cwm Taf health board

The deaths of 26 babies over nearly three years at Cwm Taf health board are to be the subject of an independent external review ordered by the Welsh Government's Health Secretary. Vaughan Gething said a full review needed to be carried out to ensure such services are safe for mothers and their babies in the region.

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