A recent report for the patient safety and justice charity, AvMA (Action against Medical Accidents) identifies some short comings in the way the NHS statutory duty of candor is regulated. The report is not all doom and gloom, however. Some improvements are also noted. Read More
Earlier this month, health law scholar and frequent Bill of Health contributor John Tingle visited Western New England University, School of Law for their CLASON Speaker Series to give a talk titled “Global Patient Safety Law, Policy, and Practice — With Particular Focus on Developing and Transitioning Countries.”
The NHS (National Health Service) in England is in very deep water when it comes to the increasing costs of clinical negligence claims made against it. NHS litigation compensation damage awards and costs over recent years have shot upwards to reach record heights threatening some would argue the very sustainability and fabric of the NHS. The increase in litigation against the NHS is well documented in terms of levels and trends over time. However, what is less clear is the motivation behind patients suing. Read More
Matt Hancock, the recently appointed Government, Health and Social Care Secretary, made a keynote speech on patient safety in London recently. The speech spelled out the future direction of NHS (National Health Service) patient safety policy development in England and also contained some very useful observations and policy which have relevance to patient safety policy developers globally, as well as in England.
Good communication is an essential prerequisite for good and safe patient care. To effectively communicate is an everyday life skill and it’s one of the most basic that we all must master in some way.
From a patient safety context, poor health carer communication practices are a worldwide problem which continues to cause global patient harm. The WHO states that communication failures are the leading cause of inadvertent patient harm.
Successive Health Service Ombudsman in England have maintained that communication failures are a leading cause of patient complaints. In 2014-2015 poor communication, including quality and accuracy of information, was a factor in one third of all health care complaints.
By John Tingle
“Medical errors are the third leading cause of death in the United States,” says a new report by the World Health Organization. And in the United Kingdom, “recent estimations show that on average, one incident of patient harm is reported every 35 seconds.”
Patient safety remains an issue of concern for all countries across the globe. But by observing what other countries do and report about patient safety we can avoid the costly mistake of trying to reinvent the wheel when information is already available about important trends.
The Minnesota Department of Health (MDH) have recently published their 14th Annual Public Report on Adverse Health Events in Minnesota. The report contains a lot of detailed patient safety information, analysis, and trends which will be of use to health carers and patient safety policy developers everywhere.
By John Tingle
Our National Health Service turns 70 in July and has made remarkable achievements since its inception on July 5, 1948. The NHS is quite rightly an institution to be proud of, and it is envied across the world. Admittedly, the NHS does have its problems, but these should not detract from an overall appreciation of its core value to our society.
In 70 years a lot has happened. Nursing and medicine have evolved, new treatments, and medicines have been developed to cope with new diseases, and our concept of health has also changed.
Health is no longer just the absence of disease; it’s a far more holistic concept today.
Since its inception, the NHS has had to deal with clinical negligence claims. Today there is mounting concern that the high level and costs of clinical negligence claims threaten the very existence and fabric of the NHS.
Exactly what must be done to reduce levels and costs remains a topic of intense speculation and conjecture.
By John Tingle
A common theme found in patient safety reports in England going back as far as the year 2000 is that the NHS (National Health Service) is poor at learning lessons from previous adverse health incident reports and of changing practice. The seminal report on patient safety in England, Organisation with a memory in 2000 stated:
“There is no single focal point for NHS information on adverse events, and at present it is spread across nearly 1,000 different organisations. The NHS record in implementing the recommendations that emerge from these various systems is patchy. Too often lessons are identiﬁed but true ‘active’ learning does not take place because the necessary changes are not properly embedded in practice.” (x-xi).
In late 2003 our NRLS (National Reporting and Learning System) was established.This is our central database of patient safety incident reporting. Can we say today that the NHS is actively learning from the adverse patient safety incidents of the past and changing practice? That the NRLS has been a great success? Or is the jury still out on these questions? Unfortunately the jury is still out. Sadly, there is no shortage of contemporary reports saying that the NHS still needs to improve its lesson learning capacity from adverse events.
By John Tingle
In tort law we have a very well-known Latin phrase, ‘Res Ipsa Loquitur’ (the thing speaks for itself). An inference of negligence can be raised by the events that occurred. In the National Health Service (NHS) in England there is a similar concept,‘the Never Event’. The Never Event concept is a USA import into the NHS and was introduced from April 2009. The list of what is to be regarded as a Never Event has been revised over the years in the NHS and is currently set out by NHS Improvement.
Never events include, wrong site surgery, wrong implant/prosthesis, retained foreign object post procedure, mis-selection of a strong potassium solution, administration of medication by the wrong route and so on. Never Events are defined in NHS policy documentation as:
“…patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event.” (p.6) Read More
By John Tingle
The House of Commons Committee of Public Accounts (Committee of Public Accounts) has recently considered the issue of managing the increasing clinical negligence costs in NHS (National Health Service) hospitals in a report. They make a number of important recommendations as well as putting into the spotlight a number of developing trends and themes. The report is linked to a report recently published by the National Audit Office on managing clinical negligence costs.This report is closely examined by the Committee with witnesses giving oral and written evidence.
The high cost of clinical negligence litigation
The report begins with a statement on the high and increasing cost of clinical negligence which sets the scene and tone for the rest of the report The Committee has raised concerns about the rising costs of clinical negligence on a number of previous occasions going back as far as 2002. The questions and answers of witnesses called by the Committee do reveal some very interesting and telling insights into the issues and the problems faced. Read More