Coming up in the April issue (volume 16 issue 5) of Health Care Risk Report :

• The National Audit Office’s reports on stroke and dementia care, by John Tingle
• NHS Western Cheshire’s work on patient safety, plus an overview of work by primary care trusts from the Patient Safety First Campaign
• The launch of the Patient Safety Section of the Royal Society of Medicine
• Steve Morgan concludes his series on taking a positive attitude towards risk in mental health care
• Andrew Hogan explains the review of civil litigation costs
• Case reviews and more

March issue (volume 16 issue 4):

• Registration with the Care Quality Commission – why it is welcome and what the implications are for NHS organisations
• Taking a positive attitude towards risk in mental health care
• The Public Accounts Committee’s report on healthcare-associated infection
• How the 1000 Lives campaign in Wales is bringing together care sectors
• Application of the “theory of constraints” to healthcare
• An interview with a researcher who aims to find the “cause of safety”
• Plus case reviews, news and resources

February issue (volume 16 issue 3):

• Legal expert Hannah Taylor asks whether the Liverpool Care Pathway is up to scratch in terms of meeting requirements for consent, capacity and confidentiality.
• John Tingle discusses the report on death in hospital, "Caring to the end?", from the National Confidential Enquiry on Patient Outcome and Death.
• In the news, fire safety experts cricitise a Department of Health move to farm out fire safety guidance to strategic health authorities.
• Susan Burnett looks at "organisational readiness" which may help to explain why some trusts successfully implement guidance and others do not.
• Edwina Rawson breaks down exactly how clinical negligence payouts are made with an update on how much cases settled for in 2009.
• we interview the Health and Safety Executive finding out what it plans to do to help organisations improve health and safety.
• Sara Melville from Alder Hey hospital describes a critical care intervention designed to improve safety for children.
• Wendy Rayner outlines new Environment Agency guidance on clinical waste.
• Case reviews cover a payout for eye damage sustained in intensive care; compensation for undiagnosed wrist fracture; a claim for impotence resulting from antipsychotic treatment; and two mental health homicide reviews from Wales.

December issue (volume 16 issue 2):
In this issue we cover health and safety prosecutions for reasons including exposure of patients to Legionella and failing to remove ligature points - leading in this case to the suicide of a patient. HCRR will be interviewing the Health and Safety Executive soon so will hope to give you more insight into its approach to health services. Also in this issue:

• Scotland's health secretary writes for HCRR explaining its review of no-fault compensation for clinical negligence
• How one intensive care unit has brought down its ventilator-associated pneumonia rates dramatically thanks to a critical care "bundle", by Diane Campbell and colleagues
• The highs and lows of implementing surgical safety checklists at NHS trusts, by Sandra Iskander and colleagues
• Learning from incident investigations, by Donna Forsyth and Martin Fletcher from the National Patient Safety Agency
• Patient safety progress in Northern Ireland and in Spain
• The Care Quality Commission's verdict on how well trusts handle patient informatio
• What the guidance on assisted suicide prosecutions means to you.

November issue (volume 16 issue 1):
The Productive Ward initiative has been a runaway success, with ward managers, nurses and auxiliary staff all embracing it enthusiastically. This issue of Health Care Risk Report focuses on how those involved feel the safety of patients has been affected for the better. Also in this issue:

• Getting boards on board with patient safety to stop the “fish rotting from the head”, by Stuart Emslie
• Learning from the Safer Patients Initiative, by Susan Burnett from Imperial College
• A claimant lawyer’s perspective on NHS claims, by Edwina Rawson
• Learning from National Patient Safety Agency data on adverse incidents connected to medication, by John Tingle
• The George Eliot Hospital’s dramatic patient safety story
• Mental capacity advocacy in acute care
• Standardisation and fire safety.

October issue (volume 15 issue 10):
Swine flu is continuously on the NHS agenda at the moment, and Health Care Risk Report presents a different view this month. Professor Hilary Pickles, a public health and risk expert, points out that lessons can be learned from the rush to set up antiviral distribution centres over the summer - not least that the distraction it caused posed a risk to normal NHS business. Also in this issue:

• how GPs reacted to using the Primary Care Trigger Tool to identify harm in their practices, by Dr Richard Jenkins and colleagues from the NHS Institute for Innovation and Improvement
• whether "Seven steps to patient safety" is too far for GPs to climb, by Dr Tayza Aung
• how the NPSA plans to take forward learning from serious incidents, by chief executive Martin Fletcher
• patient safety in the Netherlands and Pennsylvania, USA
• the Department of Health's new consent guidance and changes to Lasting Power of Attorney forms.

September issue (volume 15 issue 9):

• Why questions remain in spite of an internal inquiry, complaint, and claim following a baby's death, by Nicola Wainwright from Leigh Day & Co
• The effect of budgetary pressures on pressure sores and staff sickness absence at an NHS trust, by Helen Jones and colleagues from Loughborough University
• How an aviation manual on risk management could usefully be adapted for the NHS
• How lives have been saved through "Operation Life" in Denmark, and what named trusts in the English patient safety campaign are doing
• What the National Patient Safety Agency can tell us about healthcare-associated harm to children
• Why record-keeping is of vital importance even at the busiest times
• What the Parliamentary health committee's report on patient safety recommends and how the NHS has responded
  

July issue (volume 15 issue 8):

• Many of us look "across the water" for patient safety expertise, but as John Tingle explains in this month's edition of HCRR, all is not well in the USA. The US Government has said that patient safety is declining, while consumers have given healthcare a "failing grade" on patient safety. Do we have a chance to do better over here?The case of a young boy who was left disabled by meningitis and whose family secured for him a £5.5m payout;
• The failure of an attempted prosecution of the owners of a care home where 14 elderly residents died in a fire;
• How the National Patient Safety Agency plans to improve the way the NHS picks up and deals with serious incidents, by its chief executive Martin Fletcher;
• How airline pilot Martin Bromiley is helping the NHS to change its ways following the death of his wife during an attempted operation;
• The role that the Care Quality Commission is going to play in your working life;
• Risk management and "positive risk-taking" in mental healthcare;
• The difficulties of training staff to evacuate patients in an emergency; and
• Staff absenteeism levels in a flu pandemic.
  
  

June issue (volume 15 issue 7):

• we look at another gap between aspiration and reality – that of being open with patients and relatives following an adverse event. As Professor Louise M Wallace and Susan Marshall describe, attempts to be more open strike at the very heart of healthcare professionals’ relationships with patients, so there is a lot more work to do.
• we look at the experience of “early adopter” sites for complaints reform, and the successes and challenges they relate
• Part 2 of our essential guide to writing investigation reports, by Maria Dineen, director of Consequence UK
• an analysis of the “refocused” Care Programme Approach, by freelance risk trainer Andrew Wetherell
• how the Healthcare Commission performed during its lifespan, by John Tingle
• what the “great and good” told the health committee about patient safety (again)
• our case reviews cover a surgical complication that went unnoticed because the patient was on the wrong ward (leading to her death), falls from unsafe windows, and the case of the men who lost the chance to use their frozen sperm samples.

May issue (volume 15 issue 6):

• patient safety continues to be a focus at the highest level, with Parliament's health committee grilling the great and good over care failings at the Mid Staffordshire Foundation NHS Trust. The Healthcare Commission's report on this trust - one of the last that it produced before becoming part of the Care Quality Commission - shows that the NHS still far to go to achieve a true patient safety culture.
• clinicians and managers throughout the NHS are putting a lot of hard work into patient safety and it is to be hoped that as time goes on this work will bring results. However, improved safety has been hard to demonstrate in the USA, as John Tingle points out in this issue, in spite of their having started work on this issue earlier than us.
• investigation expert Maria Dineen provides some useful pointers on report writing
• Josephine Ocloo talks about the expertise and knowledge that patients and relatives have to offer patient safety work in the NHS.
• an analysis of the Healthcare Commission's report on NHS boards and patient safety, by Stuart Emslie
• the success of the Speedy Resolution Pilot in Wale
• professional evidence to the health committee
• medication safety and pharmacists' new professional body
• expert comment on "failure to refer" in general practice, the care and treatment of mental health service user Daniel Gonzales and a fatal fall from a hoist in a care home.

April issue (volume 15 issue 5):

• `As MPs' scrutiny of patient safety at the health committee goes on, the patient perspective has been brought to light. This issue of HCRR brings you an account of the powerful stories told by relatives of those who have lost their loved ones because of adverse incidents in healthcare. Coverage in future editions will aim to reflect what clinicians, managers and those at the top of public bodies have told the committee.
  
• Dr Tayza Aung argues that pursuing patient safety in general practice is still at the discretion of individual GPs and practices
• Sarah Head calls for serious complaints to be pursued even when doctors have moved on to employment elsewhere
• In the wake of the "baby P" case, Charles Hancock and Katrina Denton offer points for discussion about employees' competence to pick up abuse
• Andrew Alonzi and Nathalie Bailey-Flitter offer guidance on research among people who lack the capacity to make decisions
• John Tingle discusses the Health Commission's final report on complaints.
• Our case reviews include the latest ruling on Savage, successful defence of an obstetric claim, and the case of a man left paralysed by surgery.

March issue (volume 15 issue 4):

• the question of how risk management and patient safety do (or do not) fit together, with articles on this topic by three experts in the field - Pat O'Connor, Stuart Emslie and Dr Jeff McIlwain.
• Our case reviews in this issue include a payout for a failed kidney transplant, and a successful defence of two NHS radiologists' standard of care.
• a look by general practitioner Dr Tayza Aung at whether structures designed to improve clinical quality have actually done so
• a round-up of structures and processes to preserve the safety of patients involved in NHS research by Nathalie Bailey-Flitter and Gill Sarre
• a briefing on NHS trusts' obligations towards the victims of offenders who are unrestricted patients
• part one of a two-part guide by Andrew Alonzi on decision-making under the Mental Capacity Act.
  

February issue (volume 15 issue 3):

• 2009 will be a year of further developments in patient safety, with a revision on the cards for the National Patient Safety Agency's advice - Being open - which gives staff guidance on how to deal with patients and relatives following an incident where a patient has been harmed as a result of their healthcare'.
• Peter Walsh, chief executive of Action against Medical Accidents, explains how in the NHS, openness is still lacking. He shows that failure to provide a true apology, where responsibility is taken for what has happened, can cause additional distress to traumatised patients and families
• Case reviews on the death of a premature baby, failure to lift patients safely in hoists leading to two deaths, and a protracted complaint to the health service ombudsman
• How the NHS needs to deal better with the deteriorating patient, by John Tingle
• A report from the National Patient Safety Agency's national conference on patient safety in mental health
• Why the English national patient safety campaign wants you to "measure to improve" - and how it will help you do so
• Improving falls management in a local authority using "healthcare failure modes and effects analysis", by Charles Hancock and Melanie Sturman-Floyd
• New guidance from NHS Employers bringing together all the occupational health and safety standards, legal requirements and good practice examples - introduced by Julian Topping
• What the latest health and safety legislation means to you, by Phil Gifford
• Plus news, editorial view and resources.

December/January issue (volume 15 issue 2):

• consent, with a case review of Birch v University College London Hospital NHS Foundation Trust, and a related article by Dr Jeff McIlwain on how the pendulum has swung in the patient's favour in modern consent cases. In Birch, the trust was ordered to pay damages for negligently performing a diagnostic test without proper consent, because it had not explained the comparative risks of two diagnostic procedures to the patient concerned;
• independent mental capacity advocacy, which is at present under-used by the NHS but which can enrich clinical decisions and provide clear benefits for patients who lack capacity. Andrew Alonzi and Don Cattell highlight the role of independent mental capacity advocates, while a further short article looks at their role where patients are deprived of their liberty;
• bed rails, which are a cause of accidents and deaths in the NHS every year. Health and safety expert Phil Gifford offers lessons from three deaths, along with advice on appropriate use and management of bed rails in hospitals and care homes;
• general practice, where patient safety work includes development of a "trigger tool" similar to that used in hospitals, pointing GPs towards potential patient harm in their practices;
• violence and aggression towards staff, with solicitor Claire Bentley looking at guidance relating to mental health services as well as other NHS settings;
• preventing data losses in hospitals and other care settings; and
• complaints. John Tingle draws together findings from three sources - the National Audit Office, Patients Association, and the health service ombudsman - in the "never ending story" of NHS complaints system reform.

November issue (volume 15 issue 1):

• new-look 'Cases and comment' section, offering claims, complaints, reviews and patient stories drawn from a wide variety of sources and accompanied by expert comment. The aim of this section is to promote learning from individual cases, which often have lessons of relevance to the wider NHS.
• How to close the learning loop, using your patient safety newsletter, as explained by Coventry University researcher Professor Louise M Wallace;
• What the NHS must do to improve the service it offers to people with learning disabilities, by Sir Jonathan Michael and Anne Richardson;
• Stuart Emslie on why you should read the Government of Ireland's patient safety document;
• How NHS trusts in Scotland have implemented Lean Six Sigma and their successes so far, by Professor Jiju Antony;
• Why nurses need better fire training, by Charles Hancock from Loughborough University;
• An analysis of two key reports on the good, the bad and the risky in general practice, by John Tingle and
• A guide to the deprivation of liberty safeguards code of conduct by Andrew Alonzi.

October issue (volume 14 issue 10):

• How useful is your patient safety newsletter to staff? A research analysis comparing 90 trust newsletters to the ideal
• Why the English national patient safety campaign needs you
• Consent: ticking boxes or a process that really involves patients?
• Ethical dilemmas in fire safety - what should staff do if a patient cannot be evacuated?
• How NHS bodies in London are working together on fire safety
• Lean Six Sigma and error reduction in healthcare
• The Mental Capacity Act's deprivation of liberty safeguards plus all our regular case reviews, news, opinion, and resources pages

September issue (volume 14 issue 9):

• a peer-reviewed article on purchasing for safety in injectable medicines, containing previously unpublished information for NHS trusts
• a precis of newly-released, Department of Health-backed guidance for nurses and others, entitled Guidance for adult community services staff on the Mental Capacity Act 2005. Readers can download the full guidance here
• expert comment on litigation related to healthcare-associated infections
• critical analysis of the concept of governance between organisations
• guidance on the Care Quality Commission, which will have the power to de-register poorly-performing organisations
• discussion of the Health Service Ombudsman's report on 12 representative complaints against the NHS
• A special HCRR bite size summary on the Mental Health Act 2007 which comes into force this Autumn.

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Health Care Risk Report (ISSN: 1356-0611) is edited by Pat Anderson and published by Chamberlain Dunn.


This leading journal is produced 10 times a year.