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- This week’s cut from Cowper: Just like déjà vu all over again
- Today’s covid breakdown by region: Most hospital admissions now in North East and Yorkshire
Patient safety alerts are meant to prompt action from trusts to ensure that issues which arise in one organisation are not repeated elsewhere. But sometimes compliance with them is lacking – telling staff not to do something or even offering training does not always give the results it should.
And as one trust has found out, sometimes the same problem can occur several times. Over a year, staff at Calderdale and Huddersfield Foundation Trust connected four patients to air rather than oxygen – a “never event” – before calling in the Royal College of Physicians to carry out an invited review. It says no patient came to “significant harm” but in one case a baby’s oxygen saturation level fell to 75 per cent.
What went wrong? Partly, it seems the trust did not adequately block off the air outlets after receiving the patient safety alert several years previously and thereby left a route open for human error to play a part.
But a newly installed electronic patient record was also seen as causing issues by overriding nurses’ desire to follow their instincts and limiting their face-to-face contact with doctors.
Whatever the ultimate cause, Calderdale is not the only trust in this position – in just five months in 2018, there were 32 incidents, according to the Healthcare Safety Investigation Branch. Other trusts might want to brush off their implementation plans to ensure it does not happen in their hospitals.
HSIB investigates rise in stillbirths
A national rise in stillbirths during the first covid lockdown is being probed by safety investigators.
The Healthcare Safety Investigation Branch says it wants to understand the impact of “big decisions on care provision” by maternity services made in the first lockdown.
Between April and June this year, the HSIB has investigated 40 intrapartum stillbirths. It had investigated far fewer – 24 – in the previous year.
In an exclusive interview with HSJ, the watchdog revealed it has launched a thematic review which will investigate stillbirths in all settings across England in that period.