Understanding failings in patient safety: lessons from the case of surgeon Ian Paterson.

While rare, incidents of inappropriate and/or unnecessary surgery do occur, so effective surveillance of surgical practice is required to ensure patient safety. This article explores the case of Ian Paterson, a consultant surgeon who was sentenced to 20 years in prison in 2017 for wounding with intent and unlawful wounding, primarily by undertaking inappropriate or unnecessary mastectomies. The article details the main points of the Paterson case, with reference to the subsequent government-commissioned inquiry and its recommendations. It also outlines various strategies for enhancing patient safety, including applying human factors theory, improving auditing, and rationalising NHS and private healthcare. The author concludes that nurses have a crucial role in the surveillance of surgical practice and that combined reporting of surgeons' practice across NHS and private healthcare organisations is required.

"Supporting nursing, midwifery and allied health professional students to raise concerns with the quality of care: A review of the research literature".

BACKGROUND: This article reports aspects of a systematic literature review commissioned by the UK Council of Deans of Health. The review collated and analysed UK and international literature on pre-registration healthcare students raising concerns with poor quality care. The research found in that review is summarised here. OBJECTIVE: To review research on healthcare students raising concerns with regard to the quality of practice published from 2009 to the present. DATA SOURCES: In addition to grey literature and Google Scholar a search was completed of the CINAHL, Medline, ERIC, BEI, ASSIA, PsychInfo, British Nursing Index, Education Research Complete databases. REVIEW METHOD: Sandelowski and Barroso's (2007) method of metasynthesis was used to screen and analyse the research literature. The review covered students from nursing, midwifery, health visiting, paramedic science, operating department practice, physiotherapy, chiropody, podiatry, speech and language therapy, orthoptist, occupational therapy, orthotist, prosthetist, radiography, dietitian, and music and art therapy. RESULTS: Twenty three research studies were analysed. Most of the research relates to nursing students with physiotherapy being the next most studied group. Students often express a desire to report concerns, but factors such as the potential negative impact on assessment of their practice hinders reporting. There was a lack of evidence on how, when and to whom students should report. The most commonly used research approach found utilised vignettes asking students to anticipate how they would report. CONCLUSIONS: Raising a concern with the quality of practice carries an emotional burden for the student as it may lead to sanctions from staff. Further research is required into the experiences of students to further understand the mechanisms that would enhance reporting and support them in the reporting process.

Development of a language identification tool.

Service improvement is an important aspect of healthcare practice. Practitioners need to identify improvements in processes to free up time and resources for patient care. The obligation to do this falls to all staff, from students to chief executives. The project described in this article was led by a nursing student at the University of Bedfordshire, Luton, as part of the final-year assessment requirement of the pre-registration nursing degree programme. The project involved the development of a language identification tool to address communication barriers in the emergency department.

Diabetes medication incidents in the care home setting.

This article analyses data received from a Freedom of Information Act 2000 request made to the National Patient Safety Agency in June 2010. Information was requested about adverse drug event reports in relation to insulin therapy and oral glucose-lowering agents in the care home setting. Data identified were reported to the National Patient Safety Agency between January 12005 and December 312009 and were processed through the National Reporting and Learning Service. There were 684 reports related to insulin and 84 incidents related to oral glucose-lowering agents. The most common error involved wrong or unclear dose: 173 reports for insulin, including one death, and 20 reports for oral glucose-lowering agents. Evidence shows that residents with diabetes in care homes are at risk of harm from adverse drug events involving insulin and oral glucose-lowering agents.

Establishing a culture for patient safety - the role of education.

This paper argues that the process of making significant moves towards a patient safety culture requires changes in healthcare education. Improvements in patient safety are a shared international priority as too many errors and other forms of unnecessary harm are currently occurring in the process of caring for and treating patients. A description of the patient safety agenda is given followed by a brief analysis of human factors theory and its use in other safety critical industries, most notably aviation. The all too common problem of drug administration errors is used to illustrate the relevance of human factors theory to healthcare education with specific mention made of the Human Factors Analysis and Classification System (HFACS).

Implementing solutions to prevent patient harm.

This article is the last in this series based on the Seven Steps to Patient Safety. Each article analyses one of the seven steps and offers a resource for healthcare staff to enhance knowledge, skills and attitudes relating to patient safety. This article identifies solutions and actions that healthcare staff can take to improve patient safety.

Improving patient safety and incident reporting.

Patient safety is currently an international priority in health care, as it is widely accepted that the quality of healthcare provision, in terms of reducing errors and other forms of unnecessary patient harm, needs to be improved significantly. This article describes the work and position of the National Patient Safety Agency (NPSA) in NHS-funded care. It outlines the contribution made by two nurses who, as clinical specialty advisers (CSAs) in the organisation, are charged with helping to ensure that nursing issues are considered as an integral part of developing solutions to patient safety issues.

Adverse health-care events: Part 4. Challenge of a blame-free culture.

This, the final paper in this series analysing the significance of adverse health-care events and near-miss reporting, explores the requirement of a shift towards a 'blame-free' culture and the potential contribution such a change could bring to health care in terms of reducing risk for patients. Barriers to achieving a blame-free, or 'blame-fair', culture are also examined.

Adverse health-care events: Part 3. Learning the lessons.

If the NHS is to achieve its goal of developing a safety culture, active learning from adverse events and near misses is crucial. This paper, the third in the series, will discuss how learning from adverse events is informing practice and promoting the development of a safety culture. It also discusses a number of case studies where learning has occurred from adverse events.

Adverse health-care events: Part 2. Incident reporting systems.

This paper, the second in a series of four on adverse health events, outlines the process for reporting, investigating and learning from clinical incidents. It outlines the nursing contribution and nurses' responsibility with regards to effective clinical risk management in order to achieve a major cornerstone of clinical governance--making the NHS safer for patients.

Adverse health-care events: Part 1. The nature of the problem.

Adverse events are a significant cause of unnecessary harm in health care and can lead to both physical and psychological injury and, in some cases, death. This paper, the first in a series of four, outlines the nature and extent of the problem. The overall aim of the series is to enhance knowledge levels among nurses in an attempt to reduce the number of adverse events.