House of Commons Health Committee ‘Special Report’ on Patient Safety

The Health Committee has published a ‘special report’ on patient safety relating to the Committee’s patient safety report published in July 2009 (click here).

The Government responded to the patient safety report on 13 October (click here).

This special report sets out the responses to the patient safety report  by the Care Quality Commission and Monitor. It also contains a response by Professor Sir Ian Kennedy (formerly chair of the Healthcare Commission) and a reply to his response from the chairman of the Health Committee.

Of particular interest in the report is Monitor’s responses to various issues around boards highlighted in the original patient safety report.

Download the 27 page ‘special report’ Patient Safety: Care Quality Commission, Monitor, and Professor Sir Ian Kennedy’s Responses to the Committee’s Sixth Report of Session 2008-09 here.

Primary Care Trust fined £10,000 after patient falls 4 metres from a window

North East Essex Primary Care Trust has been fined £10,000 and ordered to pay costs of £4,972 after a vulnerable and partially-sighted patient it was responsible for fell 4.3 metres from a first floor window at Clacton & District Hospital.

The retired 68-year-old suffered a blow to the head and broke his pelvis, shoulder and coccyx in the fall in March last year. The court heard he was known to wander on the ward and had previously suffered four strokes, which had left him mentally and emotionally impaired.

The Health and Safety Executive (HSE) prosecuted the Primary Care Trust (PCT), based at Colchester Primary Care Centre, in Turner Road, Colchester, over the incident. Today representatives of the PCT appeared at Harwich Magistrates’ Court and admitted breaching Section 3(1) of the Health and Safety at Work etc. Act 1974.

The court heard that the patient was staying in the St Osyth Priory Ward at Clacton & District Hospital, in Tower Road, Clacton-on-Sea. At around 10.20pm on Tuesday 4 March 2008, he had wandered into the ward’s first floor day room and fell from an open window to the ground below.

The window was able to open 254mm, but since 1989 NHS standards have required such a window to only open to 100mm by fitting a window restrictor.

Shortly before the incident the PCT was required by the Department of Health to review its window restrictors and identify any that were missing, damaged or defective. This review was not carried out.

HSE Inspector Kim Wicks said:

“North East Essex Primary Care Trust failed in its duty to ensure the health and safety of this retired gentleman, who was left severely injured after his fall, which should never have happened.

“Today’s case should serve as an alarm bell, reminding all Primary Care Trusts how vitally important it is to carry out full risk assessments and act on the findings. The risk of vulnerable patients falling from windows above ground level is well known and there have been a number of similar cases. Equally, the control measures, in this case window restrictors, to prevent this risk are easy to fit and maintain.

“All PCTs must ensure they adhere to recognised NHS safety standards – they are there for a reason. If North East Essex PCT had done so this unfortunate incident could have been avoided.”

Patients at risk from mis-management of medicines

According to a new report by the Care Quality Commission (CQC), patients could be at risk unless the management of medicines between services such as GP practices and hospitals is improved.

The report – Managing patients’ medicines after discharge from hospital – looks at how well patients’ medication is managed after patients leave hospital.

The CQC visited 12 primary care trusts (PCTs), and surveyed 280 of their GP practices and found some evidence of good practice, but also found the following concerns:

• Information shared about patients moving between GPs and hospitals is often patchy, incomplete and not shared quickly enough
• GP patient records are not  always updated by clinical staff
• Too few patients are offered discussions with their GP about managing their medication
• GPs are not consistently reporting medication incidents and errors, and PCTs are not always monitoring them.

CQC Chief Executive Cynthia Bower says: “There needs to be a change of attitude in the NHS in recognising how important it is for clinicians to pass the baton smoothly between services in order to offer person-centred, integrated care.”

Download the report Managing patients’ medicines after discharge from hospital here.

NHSLA and NICE joint statement about NICE guidance and risk management

The NHS Litigation Authority (NHSLA) and the National Institute for health and Clinical Excellence (NICE) have issued a joint statement about how compliance with NICE guidance can help trusts manage risk and optimise their resources.

Compliance with NICE guidance is the focus of criterion 5.8 of the NHSLA risk management standards. This requires organisations to have in place approved documentation (Level 1) which describes the process for ensuring that agreed best practice as defined in NICE guidance is taken into account in the context of the clinical services provided by the organisation, that is implemented (Level 2) and monitored and, where monitoring has identified deficiencies, there is evidence that recommendations and action plans have been developed and changes made accordingly (Level 3).

For higher level assessments, every year NICE will provide the NHSLA risk management assessors with a revised list of manual-specific clinical guidelines that will be assessed against during the financial year. Topics will be selected by NICE based on its assessment of those that are current, relevant and could reasonably be expected to have been discussed and implemented within the organisation. The list of clinical guidelines will be included at the back of the specific manuals so that organisations and assessors are aware of the topics selected each year. The assessor will select one clinical guideline from the relevant list to test compliance with the requirements of Criterion 5.8. For interventional procedures the organisation will be asked to indicate the interventional procedures guidance that has been implemented and the assessor will select one from those to test compliance with the requirements of Criterion 5.8.

Download the full joint NHSLA/NICE statement here.

BMJ research paper adds to evidence of increased patient mortality associated with trainee doctors

A recent Healthcare Governance Review post focused on Dr Foster’s research into the association between increased patient mortality and the August intake of new junior doctors (click here).

The British Medical Journal (BMJ) has published a research paper describing a study that sought to determine whether an increase in the rate of undesirable events occurs after care provided by anaesthetic trainees at the beginning of the academic year.

The ‘retrospective cohort’ study was carried out at the Alfred Hospital, a University affiliated hospital in Melbourne, Australia. The study used administrative and patient record data and the participants involved 19,560 patients having an anaesthetic procedure carried out by first to fifth year trainees starting work for the first time at the hospital over a period of five years (1995-2000).

The study found that “The rate of undesirable events was greater among trainees at the beginning of the academic year regardless of their level of clinical experience. This suggests that several additional factors, such as knowledge of the working environment, teamwork, and communication, may contribute to the increase.”

The study concluded that “Strategies to minimise the rate of undesirable events at the beginning of the academic year should look at improving trainees’ orientation and integration during the first weeks, by developing, for example, mandatory introductory courses, hospital settings’ visits, and interprofessional meetings and, beyond all the rest, by avoiding residents’ involvement in clinical tasks from the first day. The orientation period could also include close one to one supervision, particularly when cross cover work is done in different hospital settings. The systematic use of written documentation of standard working practices should be encouraged to minimise the loss of tacit knowledge associated with staff turnover. Crew resource management programmes such as those developed in aviation and now increasingly introduced in the healthcare environment could be used to improve team coordination and interprofessional collaboration. Finally, early training sessions in simulators could be scheduled to favour rapid improvements in junior trainees’ technical skills.”

The full research paper Rate of undesirable events at beginning of academic year: retrospective cohort study can be freely downloaded here.

Survey of UK surgeons indicates patients are less safe with European Working Time Directive

The Royal College of Surgeons has published the results of its survey into the impact of the introduction of the European Working Time Regulations (EWTR) on surgeons. The results are based on responses by 900 surgeons across the UK and indicate that there is clear evidence that patients are much less safe in the NHS since the August introduction of the 48 hour working limits. The results included the following:

· 64 per cent of all respondents thought quality of care had worsened due to the EWTR.

· More than half of consultants believe compliance with EWTR has been achieved at the expense of patient safety (overall 44 per cent of respondents agreed).

· A third said handover arrangements are inadequate in their hospital and 23 per cent said they cannot stay involved in all stages of individual patients clinical care that require their expertise.

· 62 per cent of surgeons said they were not working a truly compliant 48 hour week with 70 per cent estimating they worked more than 48 hours – with these surgeons estimating they averaged between 55-60 hours a week.

· A quarter of respondents said that other professionals in the healthcare team are acting up to cover tasks previously done by surgeons and 43 per cent said they are covering rota gaps in other areas of their own hospital to keep services running.

Download the summary results here.

NPSA publishes latest organisational incident reports…..but still no learning

The National Patient Safety Agency (NPSA) has published ‘Organisational Patient Safety Incident Reports’ for NHS organisations across England and Wales. The reports summarise incidents reported by staff that have occurred between October 2008 and March 2009, and reported to the NPSA by 30 June 2009.

The figures show that across England, 92.5 per cent of all patient safety incidents result in low or no harm to the patient, 6.2 per cent of incidents are reported as moderate harm to patients, 0.8 per cent as severe harm to patients and 0.4 per cent as contributing to patient death.

The most commonly reported incident type overall is patient accident (32.8 per cent of reports), followed by treatment/procedure (10.1 per cent) and medication (9.4 per cent).

However, as the NPSA continues to fail to collect information on contributory factors and root causes, a principal reason for its establishment back in 2001, the potential for learning from the NPSA reports is limited (see Government response to the Health Select Committee Patient Safety Report here.).

Incident reports by organisation can be downloaded here.

The Government response to the Health Select Committee Report ‘Patient Safety’

The Department of Health has published the Government’s response to the Health Select Committee Report ‘Patient Safety.’

National Reporting and Learning System (NRLS)

The Health Select Committee stated that “After the expenditure of much effort and funding on the National Reporting and Learning System…….we are concerned that the NRLS is nevertheless still limited in its effectiveness.”

Healthcare Governance Review is particularly concerned that despite the ongoing failure of the NPSA to establish a national reporting system in line with Building a Safer NHS for patients, published in 2001, the Department of Health nevertheless contends that “The NRLS is one of the most comprehensive patient safety reporting and learning systems in the world.” We wonder how this statement can be justified given that the Health Committee states that “The [NRLS] currently amasses a good deal of summary data of doubtful usefulness [and] unlike reporting systems in other safety critical industries, and in other healthcare systems, it does not systematically gather in-depth (root-cause analysis) data on serious and sentinel events.”

Managers and Boards

Managers and boards came in for significant criticism from the Health Committee. In particular, the Committee felt that:

1. There was disturbing evidence of catastrophic failure on the part of some Boards in cases such as Maidstone and Tunbridge Wells Trust and Mid-Staffordshire Trust.
2. Boards too often address governance and regulatory issues, believing that they are thereby discharging their responsibilities in respect of patient safety—when what they should actually be doing is promoting tangible improvements in services.
3. Many managers and non-executive members of Boards with responsibility for patient safety seem to have little or no grounding in the subject.
4. Patient safety is not currently, but must become the top priority of Boards.
5. No Board in the NHS should always be meeting behind closed doors.

The Government appears to have largely accepted the Committee’s finding in relation to management and boards and their responses can be found in the Government’s response document at paras. 49-57, inclusive.

Download the Government response to the Health Committee report on Patient Safety, together with the original patient safety report, here.

South Tees FT needs Deputy Director of Healthcare Governance and Quality: Closing date 23 Oct 2009

Following a major Trust-wide review of their Governance structures, South Tees are looking for someone to provide the strategic leadership and corporate management of Clinical Governance within the Healthcare Governance Directorate. This will involve working closely with the Medical Director and Director of Nursing and Patient Safety. It will also involve working with the Head of Corporate Affairs and the Head of Financial Governance and Control to ensure that the Trust achieves integrated governance. The successful candidate will deputise for the Executive Directors on Governance issues and be part of the Trust’s senior management team. He/she will lead a team covering a comprehensive range of associated functions: NICE and NPSA guidance, Clinical Audit, NHSLA and CQC compliance.

Educated to Masters Degree level the successful candidate will need to have significant experience of working in a senior management position in a complex organisation. He/she will possess a comprehensive understanding of clinical governance and the requirements of the External Regulators and will need to be a dynamic and transformational leader with experience of developing corporate policy, strategy and preparing and presenting Board papers.

Successful candidates will be required to attend the selection process on Monday 16 November 2009.

The post is advertised as 37.5 Hours Per Week and Agenda for Change terms and conditions Band 8D with Salary Range: £63,833 – £79,031 pa plus Pension and Staff Benefits

For informal enquiries, or to arrange a visit, please contact Sue Wooding on (01642) 854697 or email Sue.wooding@stees.nhs.uk

Closing Date: 23 October 2009

Mid Staffs – “It is the job of boards and board members to make choices and balance priorities”

The Health Service Journal (HSJ – 8 October 2009) has reported on the publication by Mid Staffordshire Foundation Trust of a report into the conduct and performance of its previous chief executive Martin Yeates. Mr Yates resigned in May this year after the Mid Staffs board received the report.

According to the HSJ, the report says leadership and management of the trust had improved after Mr Yeates arrived, but confirms the massive failures reported by the Healthcare Commission.

It says: “….we have not seen or heard evidence to subvert the [Healthcare Commission’s] findings that there were significant failures in the leadership and management of the trust over the period of care, and these contributed to poor clinical care.”

The report further states that “Safety and quality of care are clearly of paramount importance in any NHS trust and would therefore need to be given priority in any consideration of the conduct and performance of a chief executive. They are not, however, the only measure of performance and the trust appears to have performed well against some other targets and priorities in recent years and we make reference to some of these later in the report. But performance in one area cannot be at the expense of performance in another, especially where patient care is concerned. It is the job of boards and board members to make choices and balance priorities.”

Readers can download the report on the HSJ’s website here.

Audit Commission ‘High Performing Board’ events for existing and aspirant foundation trusts

Following the success of their high performing board seminars in 2007 and 2008, the Audit Commission is holding a series of seminars between 22 October and 26 November dedicated to foundation trusts and aspiring foundation trusts across England.

Continuing the theme of the high performing board while focusing upon quality, the seminar will support executive and non-executive directors to enhance their understanding of the right level of information required to discharge their duties.

The seminar will focus on three themes:

Quality Improvement

This presentation will enable you to learn from others by sharing the experience of delivering quality improvements in patient care and re-shaping local health services to respond to the needs of the local community.

Quality and Costs

This presentation will explore how boards ensure that they can safely reduce costs and advance quality at the same time. It will also explore successful NHS productivity and efficiency schemes.

Quality NHS leadership

This presentation will discuss and explore the benefits of creating and embedding a quality leadership culture. The seminar will allow for presentations, time for discussion and reflection. It will enable you to meet and network with colleagues working in diverse roles across the health economy.

For further information, including dates, venues, speakers and booking form, click here.

Health Care Risk Report October 2009

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. 

Health Care Risk Report editor Pat Anderson has opened a new LinkedIn group for HCRR readers, contributors and editorial board members. Please take a look, join and consider contributing to the forum. Click here.

 Also in the October issue of Health Care Risk Report :

 - 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.

If your organisation does not currently subscribe to HCRR then please consider doing so. A subscription form can be downloaded here. You can also subscribe to the free ‘Health Care Risk Report e-zine’ newsletter.

Declaration of interest: Stuart Emslie, editor of Healthcare Governance Review, is on the editorial advisory board of, and is a regular contributor to, Health Care Risk Report.

Incidents that kill or harm patients may be subject to legal disclosure requirements

According to an article in the Guardian (27 September 2009) “The Department of Health is considering imposing a legally binding “duty of candour” on hospitals, surgeries and other healthcare providers, ensuring NHS managers admit to patients when an error has led to harm as well as explain exactly what has gone wrong and apologise.”

Read the full article here.

NPSA issues data quality standards for reporting patient safety incidents

The National Patient Safety Agency has released a ‘Data Quality Standards’ document, which they say is designed to improve the quality, accuracy and timeliness of patient safety incident data submitted to the Reporting and Learning System (RLS).

The document sets out the Data Quality Standards and provides guidance on their use. It is aimed at NHS staff (such as risk managers and governance managers) responsible for submitting their patient safety incidents to the RLS via local risk management systems (LRMS) or eform.

The National Reporting and Learning Service (NRLS), part of the National Patient Safety Agency (NPSA), recommends that all NHS healthcare organisations comply with these standards so that the NRLS receives the best quality information possible for issuing patient safety guidance.

According to the NPSA, evidence suggests that organisations that follow the Data Quality Standards, and have high reporting, also have a good safety culture and sound risk management processes (but see previous Healthcare Governance Review post here).

The NPSA asserts that the Data Quality Standards will also aid the improvement of data analysis for local organisations and ensure that they meet their obligations under the Data Protection Act (1998).

Download the new data quality standards here.

‘Healthcare boards should learn from banking leaders’

According to US physician, Charles R Denham MD, “Board members should learn from banking leaders who ignored risk and their responsibilities out of selfishness. Moral relativism and situational ethics are not going to cut it in the new world of transparency. The bankers’ governance issues are no different from ours in health care – this is about leadership, accountability, and values.”

In a paper published in the Journal of Patient Safety (Volume 5, Number 2, June 2009) Dr Denham asks “Is Your Hospital as Safe as Your Bank – Time to Ask Your Board.”

He suggests that “When we compare our financial collapse to our patient safety crisis, there are striking similarities.”

Dr Denham’s paper makes for interesting and though provoking reading, especially for boards members.

The paper can be freely downloaded here.

The paper

Call for better reporting of medical diagnosis errors

According to a recent BBC news article (20 September 2009 – see below) a review published recently in the American Journal of Medicine, about misdiagnosis in developed countries, suggested that up to 15% of all cases could be misdiagnosed.

Two of Britain’s leading authorities on misdiagnosis told BBC Scotland they believed this figure of 15% applied to the NHS, and much more needed to be done to reduce it.

Patient charity Action Against Medical Accidents (AAMA) has called for a change in the law to make reporting of misdiagnoses a mandatory requirement of doctors.

AAMA chief executive Peter Walsh said: “We have 4,000 inquiries a year and of those in primary care a large proportion, perhaps about 50% of cases, involve misdiagnosis of some sort.

“We see no reason why it shouldn’t be a legal requirement on healthcare organisations, including general practices, to report incidents that go wrong in healthcare, including incidents of misdiagnosis.

“It’s ridiculous that we get so few reports when we know there are significant numbers of this going on already.”

Read the full BBC news article here.

Patient Safety First week 21-27 September – plus new website

Patient Safety First week is seven focused days of local, regional and national activity to promote patient safety improvement as part of the national campaign for England.

Involving a wide range of activity the aim of the week is to raise awareness and celebrate the successes of more than 280 NHS Trusts in England who are now actively engaged in work to create measurable reductions in avoidable harm and death for patients.

Patient Safety First is calling upon everyone to work with colleagues and take just a few moments to look at their practice. By doing this, Patient Safety First believes that a real difference can be made to the safety of patients.

Get the full details of Patient Safety First week and see the re-vamped Patient Safety First website here.

Monitor publishes lessons learnt from Mid Staffordshire….and (re)defines clinical governance

Following the significant failings in quality of care at Mid Staffordshire NHS Foundation Trust, Monitor commissioned KPMG, its internal auditors, to consider how the way Monitor operates and works with others could be improved. The KPMG report and Monitor’s response has been published by Monitor (See below).

The KPMG report makes fourteen recommendations; all of these have been accepted by Monitor and, says Monitor, agood progress has already been made against many of these. There are two main themes:

1. The need for better sharing of information across the healthcare system. Monitor has already taken action in this area. We have agreed arrangements with the Care Quality Commission (CQC) to ensure that we are informed about concerns that they might have about the quality of care delivered by applicants to be foundation trusts and that these concerns are resolved before a decision is taken to authorise the applicant. Arrangements have also been agreed to share information about under-performing foundation trusts and to coordinate any action. These agreements are part of the Memorandum of Understanding which Monitor and the CQC have now signed and can be downloaded below.

2. The need for Monitor to focus on developing an approach to assuring itself that appropriate clinical governance is in place in applicant or existing foundation trusts. Monotor has (re)defined clinical governance as “the combination of structures and arrangements in place at, and immediately below, the Board level to manage and monitor clinical performance, plan and manage continuous improvement, identify performance that may be below standard or out of line, investigate it and take management action.”

Healthcare Governance Review feels the definition of clinical governance does nothing to bring clarity to the governance versus management debate.  The Monitor definition is a confusing ‘jumble’ of governance and management statements. Indeed, the majority of Monitor’s definition speaks to management rather than governance concerns. Monitor would have been better to adopt the Scottish definition of clinical governance, which is “Corporate accountability for clinical performance.”

Download the KPMG report, Monitor’s response and the Monitor/CQC Memorandum of Understanding here.

New book – Enhancing Patient Care: A practical guide to improving quality and safety in hospitals

This is, perhaps, THE most practical and useful book on patient safety and quality of care available today. Every hospital and anyone involved in patient care, clinical governance, quality, safety and/or risk management should have a copy. And any educational programme covering the subjects mentioned should commend this book as a key text.

Written by Australian clinicians, Associate Professor Alan Wolff, Director of Medical Services, and Sally Taylor, Clinical Risk Manager and former midwife (see photo), and formally launched by the Victoria Health Minister on 31 August 2009 (click here), this is a commonsense guide to quality improvement and risk management in hospitals. The book is based on their work, over many years, in the Wimmera Health Care Group in Victoria, Australia. Their experience at a regional hospital has led to a pragmatic framework that guides other health services through the relevant evidence and theory, down to finest details on practical quality, safety and risk management. 

Whilst the book has been described in terms of “help[ing] improve practices and patient outcomes in hospitals throughout Australia” there is little, if anything, in the book that cannot be applied internationally. Enhancing Patient Care will be of particular use to anyone who wants to set up or improve a quality improvement and risk management program, regardless of size and budget.

  

Assoc. Prof. Alan Wolff and Sally Taylor

The book contents include:

- Explanations of clinical governance, quality improvement and risk management
- How to detect adverse events and risks to patient safety
- A practical framework to prevent adverse events and reduce risks
- How to develop a quality improvement and patient safety culture
- A step-by-step guide to implementing a clinical risk management program in your health service
- How to develop a clinical risk management program in a small hospital

Interested readers can download a PDF preview of the book, which includes the detailed contents pages, a diagrammatic description of the Wimmera quality improvement and risk management model, and a Foreword by Profesor Bruce Barraclough, Chairman of the International Society of Quality in Healthcare (ISQua), here.

The book costs 50 Australian dollars (approx. 30 British pounds) and can be purchased from the bookshop of the Medical Journal of Australia, here.

Daily Telegraph reports on patient related serious untoward incidents and criticises NPSA

The Daily Telegraph (23 August 2009) carries an article on serious untoward incidents (SUIs) involving patient in the NHS. They allege that “last year there were a total of 336 serious incidents, 77 surgical mistakes, 41 equipment failures and a total of 218 drugs events. These include:

- Surgeons operated on the wrong patient after getting confused because two people with the same name were on the same ward
- Medics accidentally taking the eyes out of the wrong dead patient
- A woman who underwent surgery on her tearducts had the operation performed on the wrong eye while in a separate case a medic inserted the wrong lens during a cataract procedure
- Five times the correct dose of chemotherapy drug was given to a patient and an incorrect dose of ketamine led to a patient undergoing leg surgery suffering a heart attack
- Doctors had to remove a catheter from a patient’s leg artery after it snapped off inside him
- A patient who underwent a knee replacement had the wrong sized joint put in
- A patient who woke up from the operating theatre to find surgeons had ‘fixed’ the wrong kidney and he had to go back under the knife for the operation a second time”

Healthcare Governance Review recognises that that in the vast majority of cases, patients are treated without harm or dissatisfaction with care. However, in a small minority of instances, patients do suffer potentially preventable harm and/or dissatisfaction and ongoing improvement in the safety and quality of care should be underpinned by learning from things that have gone wrong.

The National Patient Safety Agency (NPSA) comes in for strong criticism in the article. According to the Daily Telegraph, “The National Patient Safety Agency costs 30 million a year, yet they have made no attempt to draw up reliable up to date figures. They admit that 7% of hospital trusts and 13% of primary care trusts report no incidents at all yet they take no action and patients continue to be put at risk.” Established in 2001, the NPSA has been widely criticised, including by the Public Accounts Committee, for failing to deliver a working national reporting and learning system for patient safety incidents in line with the Department of Health document Building a safer NHS for patients.

Read the Daily Telegraph article here.