Patient Safety Awards 2016


Patient Safety Awards 2016

Now in their 8th year, the Patient Safety Awards continue to recognise and reward outstanding practice within the NHS and independent healthcare organisations. Joining forces this year with the Patient Safety Congress, there is even more opportunity to showcase your practice standards, hear best practice from your peers and neighbouring trusts and collect your trophy in a room full of health professionals. The Awards will take the place on 5 July 2016.

Entry deadline is Friday 18 March 2016.

For more details and to enter please see:

This information was taken from the rather good CHAIN mailing list, and it was shared among 1,711 UK folk who’ve expressed an interest in hearing about patient safety information. If you like hearing about patient safety ‘stuff’ or want to share yours with an interested group then CHAIN might be worth investigating, more here: (list of sub-groups:

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Button batteries can kill if swallowed

If a child has swallowed a battery take them immediately to A&E / the Emergency Room.

Button batteries can kill if swallowed.png

Click picture for safety-advice

Button batteries can kill if swallowed.

The potential harm from small “button” batteries has recently made the news. There have been some awful cases involving children who’ve swallowed one and who’ve died or been seriously harmed.

These batteries can be found in a variety of situations – toys are an obvious category, or musical greeting cards that play a melody when opened. They’re also in everyday medical devices like hearing aids and blood glucose meters.


You can see how much damage can be done from this time-lapse video which shows batteries placed between two layers of ham (to mimic an oesophagus, for example).

Recent news articles

(1) Doctor’s warning over ‘killer’ button batteries (29 December 2015) Leicester Mercury
– this aricle highlights the frequency of these batteries being swallowed (or put in noses) as seen by one hospital, including the recent death of a very young child.

Dr Rachel Rowlands, quoted in the article, is campaigning for better awareness of battery harms and noted that even if the child survives it may suffer long-term consequences:

“If the battery gets stuck in the windpipe or stomach it can make a electrical circuit and the battery produces caustic soda.

“This can not only kill but it can leave children with burns and they need to keep having operations.”

See Rachel’s talk (video) for NHS England at the end of this post.

(2) Toddler’s death puts spotlight on battery dangers (31 December 2015) The Oklahoman
– this article reports on the death of a child who happened this Christmas after swallowing a battery (note that the child’s autopsy is pending so an official cause of death is not known).

“Normally the battery passes through the digestive system” [Randy Badillo, Oklahoma Poison Control Center senior specialist] said.

But, if the battery lodges in the esophagus or digestive tract, it can open and release an alkaline substance that can cause corrosive or burning injuries.”

(3) Boy swallows small battery and is saved by grandmother (date not given) Reshareworthy

“It happened to 4-year-old Hunter, a young boy with natural curiosity, after he swallowed a button battery. Luckily, his grandmother rushed him to hospital. Doctors had to work fast to remove it from his windpipe before it caused damage.”

Chitra Acharya, from Swansea University, co-wrote an article for the British Academy of Audiology after she found problems in the way a case was handled where a young child appeared to have swallowed the battery from a hearing aid (the child’s own). Although this case was a near-miss requests for a replacement hearing aid with a tamper-proof battery compartment were not consistently followed-up and there seemed to be no coherent response to battery risks in audiology departments, despite an awareness of the problem.

What can be done?

Keep batteries out of children’s reach – even ‘dead’ ones
Used batteries can still cause great harm if swallowed. If you have multipacks of button batteries these are usually in segmented blister packs and children may be able to open them.

Raise awareness – it is a potential medical emergency
Parents and carers need to be aware – even if a child seems fine if there is a battery missing from something they were playing with and it is worth getting them checked.

Hopefully doctors and nurses understand the seriousness of the situation but awareness is important here too, because:

Incident reports suggested that when ingestion was reported, healthcare staff did not recognise the need for this to be treated as a medical emergency.

Consumer action
Put pressure on manufacturers and designers to include locked or otherwise tamper-proof compartments in their designs to make it much harder for children to get at the batteries. Chitra’s paper also suggests liaising with any professional bodies (in her case audiologists, raising awareness by publishing in the British Academy of Audiology’s journal).

Alternative solutions
In addition to locked compartments people are also looking at ways of preventing harm when a battery is swallowed by adding a protective coating that prevents them from creating an electrical current. One example is from MIT: New way to make batteries safer (3 November 2014)

CHI+MED’s recommendations

Awareness of the risks and their seriousness is needed among many different people.

  • Parents, carers and healthcare staff need to know that battery ingestion is a medical emergency and that follow-up care may be needed for several weeks. Unexplained symptoms of coughing up or vomiting blood and respiratory difficulties may indicate battery ingestion (perhaps unwitnessed).
  • Mistaken beliefs about battery ingestion needs to be challenged: some healthcare professionals have considered that “battery ingestion would be harmless unless the battery was damaged or leaking” (NHS England 2014) however it is the electrolytic effects that can cause catastrophic damage.
  • Near-miss incidents with batteries need to be systematically recorded with an opportunity to learn from these and share learning across departments (audiology, gastroenterology, A&E) as well as with manufacturers.
  • Information needs to be communicated, by parents and healthcare professionals, to hearing aid designers so that they can ‘design out’ this risk by fitting locks.
  • Regulators need to incentivise marketing of products which have tamper-proof battery locks.


Further reading, viewing

For parents

What should I do if I think my child has swallowed a button battery? – document from Leicester Safeguarding Children Board (also linked in picture above)

For healthcare and other professionals

NHS England (19 December 2014) Stage One: Warning Risk of death and serious harm from delays in recognising and treating ingestion of button batteries – advice for emergency healthcare professionals – “share any learning from local investigations or locally developed good practice resources by emailing

Acharya, C, Manchaiah, VKC, Lewis, A and Thimbleby H (2015) Hearing aid battery ingestion: medical error or poor design – CHI+MED paper based on a case study of a near-miss with a button battery from a hearing aid worn by a young child with learning difficulties.





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Aviation and its contribution to healthcare (free talk in London, 25 Nov)

Via the Interesting Talks in London Twitter feed.

Aviation and its contribution to healthcare
Wednesday 25 November 2015, 6-7pm
Museum of London, Barbican
London EC2Y

FREE – no booking, just turn up (first come first served)

Talk by Professor Martin Elliott who is Gresham Professor of Physic and Co-Medical Director at The Great Ormond Street Hospital for Children, London (GOSH).

“There are surprising similarities between the aviation (and especially airline) industries and healthcare; especially cardiac surgery. Both involve highly trained and skilled people working in teams over unusual hours and in stressful circumstances whilst being responsible for the lives of others. How airlines mitigate its risks and investigates its disasters has important lessons for healthcare.

This lecture will explore these lessons, with examples from both camps, and concentrate on the human factors which govern the performance of high reliability organisations.”

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[Free, London] The magic of {Christmas} Computer Science – magic show for secondary schools

Thanks to support from the IET, CHI+MEDics Profs Paul Curzon and Peter McOwan will be hosting a magic show for secondary school-aged children and teenagers (and their brothers & sisters, parents & grandparents, guardians, friends, teachers etc) in the Great Hall of the People’s Palace on Mile End Road on Wednesday 2 December 2015. It’s free.

Both Peter and Paul have used magic in talks to illustrate CHI+MED themes, drawing parallels between algorithms and magic tricks but also highlighting user / audience experience. A magician wants their audience to get something wrong or fail to spot something, so that the trick will fool them. By contrast medical device designers need to make sure that their audience (device users) don’t miss a thing, to keep their patients safe.

Come and enjoy a free talk about the hidden magic behind computer science. There’ll be mince pies too.

The magic of {Christmas} Computer Science

The Magic of {Christmas} Computer Science – click for a free ticket
Peter McOwan and Paul Curzon
The Great Hall at The People’s Palace, QMUL, Mile End Road (bus stop D, short walk from Stepney Green tube station)
Doors 5pm, lecture starts at 5.30
[More information] [Event flyer] [Free tickets]

magic of computer science flyer

Here’s a picture of the Engineering Building (next door to the People’s Palace) looking very pleased to be promoting the event.

2015-11-10 20.05.06

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Workshop at #OzCHI – SmartHealth: 7th International Workshop on Technologies for Health and Wellbeing

There’s a call for papers (submission date 28 August 2015) for the SmartHealth workshop that’s taking place on 7 December as part of OzCHI 2015, Australia’s annual conference on Human-Computer Interaction, to be held in Melbourne between 7th and 10th December 2015.

“An abundance of health-oriented technologies is becoming available to the public. Yet researchers suspect that many may be medically ineffective, poor in usability, or insufficiently engaging to maintain use over time. Thus to create effective health technologies, it is claimed that collaboration between health and technology researchers is essential. But how should this collaboration proceed? Researchers and practitioners working at the intersection of HCI and health are invited to join this one-day workshop where attendees will share experiences and attempt to articulate how a cross-disciplinary collaboration can best proceed.”

For more details see the link above, and the full workshop proposal.

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Can Standards and Regulations Keep Up With Health Technologies? – new Viewpoint article in JMIR mHealth uHealth

Following the publication of their Viewpoint article (Open Access) in the Journal of Medical Internet Research, JMIR mHealth uHealth, CHI+MED researchers Chris Vincent and Katarzyna Stawarz from UCL’s Interaction Centre have written the blog post below to introduce it. The JMIR article was jointly written with their colleagues Gerrit Niezen from Swansea University’s FIT Lab and UCLIC’s Aisling O’Kane.

The article looks at the tension between patient benefit from and regulatory oversight for newer, innovative technologies using as examples 3D printing, customisable medical devices and smartphone apps.

The full paper can be read freely at the journal’s website, which also keeps a record of its popularity on Twitter, with a ‘Tweetations‘ (Twitter citations) tab.

Screen Shot 2015-08-03 at 13.07.43

© UCL Creative Media Services

New Viewpoint: Can Standards and Regulations Keep Up With Health Technologies?
3D printing, customisable medical devices, and smartphone apps are creating new opportunities for personalised healthcare and changing the ways people manage their health. Some of these new technologies are supporting a move away from hospital-centred care towards the home, increasing patients’ independence and helping to control the burden on healthcare providers.

Health related technologies: Brave new world?
There are many benefits to the above technologies, but changes in health management also create challenges in balancing the need for regulation (ensuring safety and performance) with the need to innovate flexibly. On one hand, putting in place checks to make sure that solutions work seems obvious. We all get annoyed when software fails to work in the way we need it to or gives the wrong results. In healthcare, the consequences can be serious, for example an app might incorrectly detect a cancerous mole which can cause unnecessary stress.

Although such accounts can be concerning, no one wants to delay the introduction of new technologies when people are likely to find benefits. It could be wrong to get in the way of new processes or technologies that are suitable but don’t yet fit in with existing approaches to regulation.

In our latest viewpoint article, Can Standards and Regulations Keep Up With Health Technology?, we discuss some of the challenges to regulating new types of health technologies. We give three examples of novel medical technologies (3D printed medical technologies, customisable medical devices and smartphone apps) that illustrate the types of issues that can arise and suggest opportunities for improvement.

Below we highlight some of the main points, but invite you to read the whole article.

Open hardware and 3D printed devices
Open source hardware is an increasingly popular way to create medical devices within the maker community. Although existing mechanisms of control might not fit well with the rapid turnaround that 3D printing technology provides, the benefit in allowing for a customisable prosthesis or bespoke medical devices is huge. By opening up the design documentation, and making it publicly available, not only can others benefit from a solution but they can also help to review it.


© UCL Creative Media Services

Medical devices and social interactions
Our article also examines the way that medical technology is evaluated in terms of social needs. Allowing customisation of a medical device can improve its fit with people and their surroundings. For example, changing the exterior shell of a device so that it looks less like a piece of hospital equipment and more like a consumer product, or adapting appearance to be discrete (or indiscrete, depending on circumstances) can make people feel more comfortable and at ease during many social situations. Usability evaluation processes don’t always accommodate these aspects and we discuss what could be done to address this.

Regulating smartphone apps
Finally, we discuss issues with regulating smartphone apps. As the number of available health apps is increasing, it becomes more difficult to decide which ones are suitable and what sort of evaluation is required. Although regulatory guidance has been updated to address this, using medication adherence technology as an example, it can be tricky to know when the device regulations do and don’t apply. As a result, such apps are more or less unregulated. We outline the confusion that can arise when following classification schemes and highlight the fact that developers often side-step the process through use of disclaimers. This makes this topic a difficult one to address and we give suggestions regarding an increasing need for in situ monitoring.

These are just some of the challenges that are introduced by new medical technologies. We hope our article is a starting point to bigger discussion.

Further reading
Can Standards and Regulations Keep Up With Health Technology? by Chris Vincent, Gerrit Niezen, Aisling O’Kane and Katarzyna Stawarz

Cite this paper as
Vincent CJ, Niezen G, O’Kane AA, Stawarz K
JMIR mHealth uHealth 2015;3(2):e64
DOI: 10.2196/mhealth.3918
The paper’s record on PubMed – PMID: 26041730

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FDA warns about cybersecurity re: hacking risk for hospital infusion pump

From the FDA’s Safety Communication updates (click to subscribe)

“Today [31 July 2015] the FDA issued a Safety Communication on cybersecurity vulnerabilities of the Hospira Symbiq Infusion System.

Hospira and an independent researcher confirmed that it is possible to access the Symbiq Infusion System remotely through a hospital’s network. This could allow unauthorized users to control the infusion pump and change the dosage it delivers, potentially leading to over- or under-infusion of critical patient therapies.

The FDA and Hospira are not aware of any patient adverse events or unauthorized access of a Symbiq Infusion System in a health care setting. Health care facilities can reduce the risk of unauthorized access by transitioning to an alternative infusion pump and implementing recommendations from the FDA Safety Communication.”

“The Food and Drug Administration said Friday it’s the first time it has warned caregivers to stop using a product because of a cybersecurity risk.” Modern Healthcare article

Further reading

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