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Archive - Volume 16 issue 2

  • Gifford, Phil. Inadequate control of Legionella. HCRR vol 16 no 2, p6
    Following the deaths of two patients, unsafe levels of legionella were found in a hospital’s water supply system. It was prosecuted under the Health and Safety at Work etc Act 1974 for putting employees and the public at risk, fined £35,000 and ordered to pay costs of £12,862.
  • Collier, Janine. Inappropriate size of bridge post. HCRR vol 16 no 2, p7
    A woman who attended her dentist for a bridge repair was fitted with a bridge post of the wrong size. A subsequent claim settled for £5,500.
  • Mullarkey, Paddy. Injury during keyhole surgery. HCRR vol 16 no 2, p8
    A claimant received £45,000 in compensation after sustaining a serious vascular injury during a laparoscopic procedure. A joint consultation between the parties led to a resolution of the case by way of settlement.
  • Gifford, Phil. Failure to remove ligature points. HCRR vol 16 no 2, p8
    Sylvan Money, an inpatient mental health service user, hanged herself from a curtain rail. A prosecution was taken under section 3(1) of the Health and Safety at Work etc Act 1974 for the local health board’s failure to remove such fixed ligature points. A fine of £30,000 was imposed by the Merthyr Tydfil Crown Court with £46,849.50 costs.
  • Tingle, John. Paying attention to detail in managing patient information. HCRR vol 16 no 2, pp10-11
    The quality of record-keeping reflects the quality of professional practice, and proper use of records is a prerequisite to good, safe and professional care. The Care Quality Commission (CQC) has produced an important report on handling patient information, looking at whether healthcare organisations are meeting basic standards on information governance. The report shows that while broad systems are be in place to manage patient information adequately, some of the detailed elements that help to deliver safe, high quality care are missing.
  • Sturgeon, Nicola. Scotland’s no-fault compensation review. HCRR vol 16 no 2, p12
    Patients in Scotland could benefit from a new simpler, less expensive and quicker system of medical compensation. An expert group was established by the Scottish Government, in June 2009, to consider the introduction of no-fault compensation north of the border. The group is chaired by Sheila Maclean, Director of the Institute of Law and Ethics in Medicine at Glasgow University. If introduced a system of no-fault compensation means that some patients would receive financial compensation without the need to go through the legal process.
  • Campbell, Diane; Crofts, Sally; and Watson, Catherine. The use of critical care bundles to improve patient outcomes. HCRR vol 16 no 2, pp13-15
    Preventing ventilator-associated pneumonia (VAP) is a substantial challenge for intensive care units (ICUs). Since implementing a Scottish Patient Safety Programme care bundle in 2008, including the use of chlorhexidine gel for oral hygiene, one ICU has achieved a 70 per cent reduction in VAP. Plan-do-study-act (PDSA) cycles have been central to this achievement, ensuring staff ownership of practice changes. A co-ordinated multi-disciplinary approach has resulted in improvements that are reliable and sustainable.
  • Forsyth, Donna; Fletcher, Martin. Improving incident investigation. HCRR vol 16 no 2, p16
    Patient safety cannot be improved without a range of valid reporting, analytical and investigative tools that identify sources and causes of risk in a way that leads to preventative action. In December 2008, the NPSA launched a new set of tools to assist NHS organisations to improve the credibility and thoroughness of root cause analysis (RCA) investigation reports. Overall, feedback from NHS staff using the tools has been positive and the NPSA will continue to review and develop them to promote learning.
  • Iskander, Sandra; Vats, Amit; and Burnett, Susan. Surgical safety briefings: the challenges of implementation. HCRR vol 16 no 2, pp17-18
    In the operating theatre, a significant number of adverse events are due to poor communication between members of the multi-disciplinary team. The introduction of surgical safety briefings, bringing structure to team communication, was a key element of the Health Foundation-funded Safer Patients Initiative in 24 NHS hospitals. Evaluation of the initiative has found that while briefings take time to implement, staff say they are beneficial and believe that they will improve patient safety.
  • Delgado, Pedro. Safety improvement in Northern Ireland’s health and social care services. HCRR vol 16 no 2, pp19-20
    Over the last five years, the patient and client safety improvement movement in Northern Ireland has seen unprecedented levels of planned and coordinated action. Front line staff have led efforts that reflect their own commitment to providing best care for patients and clients, as well as the commitment of trusts, commissioners, other health and social care agencies and the support of the Department of Health, Social Service and Public Safety (DHSSPS). Ultimately Northern Ireland’s vision is to become an exemplar for safety and quality improvement by 2020.
  • Cresswell, Jackie. A firm research foundation for patient safety work in Spain. HCRR vol 16 no 2, pp21-22
    Spain’s patient safety strategy has been developing since 2005, spearheaded by its Ministry of Health and Consumer Affairs (MCHA) and the Spanish NHS Quality Agency. Studies at a national level have established a baseline picture of patient safety in hospitals, intensive care units and primary care. Alongside work at a national level, regional initiatives are focusing on topics including medication safety, pressure ulcers, and patient identification.
  • Alonzi, A. Assisted suicide: what you need to know. HCRR vol 16 no 2, p23
    Following a House of Lords ruling, the Director of Public Prosecutions has issued interim guidance on whether someone who helps another person to commit suicide should be prosecuted. The guidance applies to healthcare practitioners as well as the public. It does not change the law, but lists factors weighing against prosecution, such as being motivated by compassion.
 
Archive

Abstracts from Health Care Risk Report, November 2009, Volume 16 no 1

  • Rimington, Gillian. Failure to recognise fracture. HCRR vol 16 no 1, p6
    A physician assistant working in accident and emergency failed to diagnose an ankle fracture in a 40-year old woman. She was left unable to work for seven months and following this, still experienced pain and inability to undertake activities such as hillwalking or cycling. The case settled for £125,000.

  • Gifford, Phil. Failure to reduce risk to employee. HCRR vol 16 no 1, p7
    A hospital employee was injured using a mechanical hoist to move a patient. The Court of Appeal unanimously held that the burden was on the employer to prove that it had taken appropriate steps to reduce risk to the employee. However, the employer was only liable for 50% of the damages.

  • Gifford, Phil. Inadequate Legionella surveys at care homes. HCRR vol 16 no 1, p8
    Deba UK Ltd, a Berkshire-based water treatment company, was prosecuted for carrying out inadequate and misleading surveys at nursing homes in Blaenau Gwent and Powys.

  • Tingle, John. A clearer picture of medication incidents and how to tackle them. HCRR vol 16 no 1, pp10-11
    The NHS is a very busy place and to some extent errors are an inevitable feature of professional practice, in a sense they are part of the cost of doing business. The National Patient Safety Agency (NPSA) has published an important review of medication incidents across England and Wales that offers safety advice and risk reduction strategies. The report addresses patterns of reporting, lessons from serious medication safety incidents, lessons to be learnt from incidents in clinical specialties including acute and primary care, and an overview of medication safety literature. Key features of the report include short reporting and learning system (RLS) case summaries which  reveal the essential nature of incidents involving medication errors, with patients dying in some instances.
  • Emslie, Stuart. Getting boards on board with patient safety: why and how. HCRR vol 16 no 1, pp12-13
    The tone of any organisation is set at the top – or “the fish rots from the head”. The Patient Safety First Campaign in England has based its own “Leadership for Safety” intervention on the  “Boards on Board” approach set out by the Institute for Healthcare Improvement in the USA. “Leadership for Safety” provides a list of key questions and actions or interventions needed in order to answer these questions so that boards can develop an appropriate action plan with clear priorities and timescales. More pressure on boards will help them to achieve better outcomes for patients.
  • Anderson, Pat. George Eliot’s patient safety story. HCRR vol 16 no 1, p15
    The George Eliot Hospital in Nuneaton, named after the novelist who was born and lived locally, has a dramatic patient safety story to tell. In 2005/6, its hospital standardised mortality ratio (HSMR) was 143 and the trust had high rates of C difficile infection and MRSA bacteraemia.  Now, the HSMR stands at 92 and there has been a 36% reduction in C diff infection and a “huge” reduction in MRSA rates. The trust calls this a “real success story for patients”.
  • Burnett, Susan. Improving patient safety: learning from the Safer Patients Initiative. HCRR vol 16 no 1, pp16-17
    The Health Foundation’s Safer Patients Initiative, launched in 2004, has helped 24 organisations to build a safer NHS. Researchers from Imperial College London were recruited to aid the capture and dissemination of lessons from the initiative. The programme’s aim was to improve safety through improved reliability of clinical practices, developing a safety culture, and ensuring safety was a strategic priority through involvement of the chief executives. Its design included collaboration between organisations, partnership between senior management and clinicians, and teaching improvement science and measurement techniques.
  • Anderson, Pat. The Productive Ward initiative and its effects on patient safety. HCRR vol 16 no 1, pp18-19
    The Productive Ward initiative, launched in January last year, has been enthusiastically embraced by NHS trusts. Nurses have been able to spend more time on direct patient care, with fewer interruptions, on wards where it has been introduced. There is anecdotal evidence that more time spent with patients, plus greater staff engagement in running of wards, is leading to safety improvements. Those involved with Productive Ward say that it is here to stay.
  • Rawson, Edwina. Litigation matters: a claimant lawyer’s perspective on NHS claims. HCRR vol 16 no 1, pp20-21
    It may be difficult for trust managers and medical practitioners to accept that there is a common goal between them and claimant litigation lawyers, but there is.  Nobody wants to be the subject of a claim for compensation, but litigation, and the threat of it, improve and maintain standards.  The steps involved in bringing a claim are simple to express although litigation can be complex. Swift resolution can keep costs down and help patients to move on.
  • Cattell, Don. MCA advocacy in acute care. HCRR vol 16 no 1, p22
    A study placed independent mental capacity advocates in two care of the elderly wards in an acute hospital for three hours a day over four weeks, to monitor admissions and advise staff unsure about their responsibilities under the Act. The presence of the advocate acted as a focus for the development of knowledge about IMCA and the MCA, and also highlighted training issues. Discharge co-ordinators came out of the study as particularly important individuals in that they liaise with all levels of staff, and are familiar with patients’ circumstances.
  • Hancock, Charles. Could standardisation improve fire safety? HCRR vol 16 no 1, p23
    A  wide variation in standards of preparation and training for the management of emergencies within health and social care can only increase the risk of emergencies being managed wrongly, with potentially disastrous consequences. This is especially true of fire safety.
 

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