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Wrexham Maelor Hospital patients 'waiting on trolleys for hours'

Inspectors have demanded action over patients facing long waits on trolleys at Wrexham Maelor Hospital's A&E unit.

Healthcare Inspectorate Wales (HIW) said officials found some people waiting eight hours during an unannounced visit in August. It wants Betsi Cadwaladr University Health Board (BCUHB) to make rapid improvements.

In a statement, it said some of HIW's recommendations had already been addressed.

In its report, HIW acknowledged efforts made by emergency department staff to look after those in need, the Local Democracy Reporting Service reported.

"It was identified that patients who were waiting on trolleys in the corridor were not receiving appropriate and timely care," said HIW. "We had to alert the nurse responsible for the patients in the emergency department corridor to a patient who was experiencing increased chest pain."

"During the inspection, we found that there were no pressure relieving mattresses available for any patients who were waiting on trolleys within the emergency department."

"We considered the above practices to be unsafe and increased the risk of harm to patients."

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Source: BBC News, 9 November 2019

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World Pharmacists Day

Today millions of pharmacists worldwide will celebrate World Pharmacists Day, this year themed “safe and effective medicines for all.”

The annual day is used to highlight the value of the pharmacy profession to stakeholders and to celebrate pharmacy globally. It was originally adopted in 2009 at the World Congress of Pharmacy and Pharmaceutical Sciences.

The theme for 2019 aims to promote pharmacists’ crucial role in safeguarding patient safety through improving medicines use and reducing medication errors.

“Pharmacists use their broad knowledge and unique expertise to ensure that people get the best from their medicines. We ensure access to medicines and their appropriate use, improve adherence, coordinate care transitions and so much more. Today, more than ever, pharmacists are charged with the responsibility to ensure that when a patient uses a medicine, it will not cause harm”, says International Pharmaceutical Federation (FIP) President Dominique Jordan.

Watch Dominique Jordan's video

Source: FIP, 25 September 2019

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World Mental Health Day 2019

Today is World Mental Health Day. An opportunity for all of us to raise awareness of mental health issues and advocate against social stigma. This year's theme, set by the World Federation for Mental Health, is suicide prevention. 

Every year close to 800,000 people globally take their own life and there are many more people who attempt suicide. Every suicide is a tragedy that affects families, communities and has long-lasting effects on the people left behind. It's the leading cause of death among young people aged 20-34 years in the UK and is the second leading cause of death among 15-29 year-olds globally.

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Source: Mental Health Foundation, 10 October 2019

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World Antibiotic Awareness Week: Letter from senior NHS and health system leaders

The World Health Organization's (WHO) World Antibiotic Awareness Week (WAAW) aims to increase awareness of antibiotic resistance as a global problem, and to promote best practices among the general public, health workers and policy-makers to avoid the further emergence and spread of antibiotic resistance.

Since their discovery, antibiotics have served as the cornerstone of modern medicine. However, the persistent overuse and misuse of antibiotics in human and animal health have encouraged the emergence and spread of antibiotic resistance, which occurs when microbes, such as bacteria, become resistant to the drugs used to treat them.

As part of preparations for the 2019 Awareness Week this November, a group of senior leaders from across the health system, including NHS England and Improvement, have co-signed a letter, coordinated by Public Health England, that reminds commissioners and providers alike of their responsibility to contribute to this important agenda. The letter also reminds colleagues that this year’s WAAW campaign is the first of a new five-year UK National Action Plan for antimicrobial resistance, which contains stretching ambitions for reducing inappropriate prescriptions; as well as controlling and preventing infections.

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Women take legal action over breast implant cancer link

Twenty UK women are taking legal action after developing a rare form of cancer linked to their breast implants. More than 50 women have been diagnosed with the same condition in the UK, and hundreds more worldwide. A top surgeon said there were gaps in implant information and people were almost being "used as guinea pigs".

One manufacturer has issued a worldwide recall of some textured implants, which have been linked to most cases of breast implant-associated lymphoma. The Medicines and Healthcare products Regulatory Agency (MHRA), which regulates medical devices in the UK, is currently collecting data on women affected by breast implant associated-anaplastic large cell lymphoma (BIA-ALCL).

Tens of thousands of breast implant surgeries are thought to take place each year in the UK, mostly in private clinics.

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Source: BBC News, 16 August 2019

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Women needlessly having their appendix out in almost one in three cases

Women are having their appendixes removed wrongly in nearly a third of cases, British research suggests.

Researchers said too many female patients were being put under the knife when they should have undergone investigations for period pain, ovarian cysts or urinary tract infections. They said the study, which compared practices in 154 UK hospitals with those of 120 in Europe, suggests that Britain may have the highest rate of needless appendectomies in the world. 

Surgeons said they were particularly concerned by the high rates among women, with 28% of operations found to be unnecessary. 

They said the NHS was too quick to book patients in for surgery, when further scans and investigations should have been ordered. 

Researchers warned that such operations put patients at risk of complications, as well as fuelling NHS costs.

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Source: The Telegraph, 4 December 2019

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Woman with anorexia 'faced delays' before death

A woman described as a "high risk" anorexia patient faced delays in treatment after moving to university, an inquest has heard.

Madeline Wallace, 18, from Cambridgeshire, was told there could be a six-week delay in her seeing a specialist after moving to Edinburgh.

The student "struggled" while at university and a coroner said there appeared to be a "gap" in her care. Ms Wallace died on 9 January 2018 due to complications from sepsis.

A parliamentary health service ombudsman report into her death was being written at the time of Ms Wallace's treatment in 2017 and issues raised included moving from one provider to another and higher education.

Coroner Sean Horstead said Ms Wallace only had one dietician meeting in three months, despite meal preparation and planning being an area of anxiety she had raised.

Dr Hazel said she had tried to make arrangements with the Cullen Centre in Edinburgh in April 2017 but had been told to call back in August. The Cullen Centre said it could only accept her as a patient after she registered with a GP and that an appointment could take up to six weeks from that point.

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Source: BBC News, 10 February 2020

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Woman dies after being set on fire during surgery in Romania

A woman has died after being set on fire during surgery in Romania, the country’s health ministry has said, in a case that has cast a spotlight on the ailing Romanian health system.

The patient, who had pancreatic cancer, died on Sunday after suffering burns to 40% of her body when surgeons used an electric scalpel despite her being treated with an alcohol-based disinfectant.

Contact with the flammable disinfectant caused combustion and the patient “ignited like a torch”, Emanuel Ungureanu, a Romanian politician, said.

A nurse threw a bucket of water on the 66-year-old woman to prevent the fire from spreading. The health ministry said it would investigate the “unfortunate incident”, which took place on 22 December.

“The surgeons should have been aware that it is prohibited to use an alcohol-based disinfectant during surgical procedures performed with an electric scalpel,” the Deputy Minister, Horatiu Moldovan, said.

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Source: The Guardian, 30 December 2019

the hub has a number of posts on preventing surgical fires:



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Woman awarded £8m after doctors left sponge inside her during surgery

A woman has been awarded $10.5 million (£8m) in damages after medical staff left a sponge inside her body.

The sponge – which measured 18-by-18 inches and was left behind during surgery – was inside the woman's body for years before she realised.

It had been left in her body after she underwent heart surgery at a Kentucky hospital in 2011. The bypass surgery is said to have gone wrong, leaving a mess – and as nurses rushed to deal with the problems, the sponge was left inside her body. 

It was not discovered for four years, until she had a CT scan in 2015. In the meantime, the sponge had moved around the woman's body, shifting around her intestines and causing pain as it did so. She had her leg amputated and was left with gastrointestinal issues after the sponge eroded into her intestine.

The patient's lawyers said the case should be a reminder to hospitals to ensure that objects such as needles and other sharp objects, as well as sponges, are removed from patients after surgery.

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Source: The Independent, 1 January 2020

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Why women are more likely to have dodgy hip implants or other medical devices

The past year has seen wide concern about the safety of medical implants. Some of the worst scandals have involved devices for women, such as textured breast implants with links to cancer, and transvaginal mesh implants, which were the subject of the asenate inquiry. But women are harmed not only by 'women's devices' such as breast implants and vaginal mesh. Women are also more likely to be harmed by apparently gender-neutral devices, like joint replacements and heart implants according to Katrina Hutchison in a recent MENAFN article.

Bias starts with design and then lab testing: biological and social factors can affect how women present when injured or ill, and how well treatments work. Often, device designers do not take these differences into account. The lab tests used to make sure implants are safe often ignore the possibility women could have different reactions to materials, or their activities could place different loads on implants.

Bias continues with clinical trials. And then there's the doctor-patient relationship; the gender of the doctor and patient can make a difference to what women learn about their implant. 

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Source: MENAFN, 11 August 2019

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Whorlton Hall: Care regulator ‘was wrong’ to bury whistleblower’s report into failings at hospital where patients were abused

The Care Quality Commission (CQC) missed multiple opportunities to identify abuse of patients at a privately run hospital and did not act on the concerns of its own members, an independent review has found.

Bosses at the CQC have been criticised in an independent report by David Noble into why the regulator buried a critical report into Whorlton Hall hospital, in County Durham, in 2015.

His report published today said the CQC was wrong not to make public concerns from one of its inspection teams in 2015.

“The decision not to publish was wrong,” his report said, adding: “This was a missed opportunity to record a poorly performing independent mental health institution which CQC as the regulator, with the information available to it, should have identified at that time.”

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Source: The Independent, 22 January 2020

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WHO calls for urgent action to reduce patient harm in healthcare

Millions of patients are harmed each year due to unsafe health care worldwide resulting in 2.6 million deaths annually in low-and middle-income countries alone.  Most of these deaths are avoidable. The personal, social and economic impact of patient harm leads to losses of trillions of US dollars worldwide. The World Health Organization (WHO) is focusing global attention on the issue of patient safety and launching a campaign in solidarity with patients on the very first World Patient Safety Day on 17 September.

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Source: WHO, 13 September 2019

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Whistleblowing district nurse 'different person' after unfair dismissal

A senior district nurse who was unfairly dismissed after blowing the whistle over valid safety concerns has told how the ordeal has left her life in "chaos" and she feels forced to quit the profession for good. 

Linda Fairhall, who had worked at North Tees and Hartlepool NHS Foundation Trust for 38 years, has spoken to Nursing Times about her experiences after she successfully challenged her employer's decision to sack her. Between December 2015 to October 2016, Ms Fairhall raised 13 concerns to the trust regarding staff and patient safety. At the time, she was managing a team of around 50 district nurses in her role of clinical care co-ordinator.

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Source: Nursing Times, 17 February 2020

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When parents of sick children don't get to decide

The parents of five-year-old Tafida Raqeeb, who is on life support, are going to the High Court to challenge an NHS decision which is preventing them from taking her abroad. 

Tafida Raqeeb suffered a traumatic brain injury in February as a result of a rare condition, arteriovenous malformation, where a tangle of blood vessels causes blood to bypass the brain tissue. Tafida's mother and father want to seek treatment in Italy. But the Royal London Hospital, which is caring for their daughter, says releasing her is not in her best interests.

A spokesperson for Barts Health NHS Trust, which runs the hospital, said that its clinicians and independent medical experts had found "further medical treatment would not improve her condition".

In England and Wales the concept of parental responsibility is set out in law, in the Children Act 1989. This gives parents the responsibility broadly to decide what happens to their child, including the right to consent to medical treatment. But this right is not absolute. If a public body considers that a parent's choices are not in the best interests of their child, and an agreement cannot be reached, it can challenge these choices by going to court. It comes down to a judge to make the final decision, based on the evidence available.

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Source: BBC News, 2 September

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What was found in the FDA’s "hidden" device database?

After two decades of keeping the public in the dark about millions of medical device malfunctions and injuries, the US Food and Drug Administration (FDA) has published the once hidden database online, revealing 5.7 million incidents publicly for the first time.

The newfound transparency follows a Kaiser Health News investigation that revealed device manufacturers, for the past two decades, had been sending reports of injuries or malfunctions to the little-known database, bypassing the public FDA database that’s pored over by doctors, researchers and patients. Millions of reports, related to everything from breast implants to surgical staplers, were sent to the agency as “alternative summary” reports instead.

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Source: Kaiser Health News, June 27 2019

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What the US government should be doing – but isn’t – to guard against unsafe prescription drugs

Documents released in an Ohio court case last month, in a landmark, multi-district opioid lawsuit, gave new insight into an unparalleled opioid epidemic in the United States. It revealed that between 2006 and 2012, some 76 billion opioid pills were distributed in the United States — more than 200 pills for every man, woman and child.

It paints a damning picture of the tension between drug company profits and patient safety during the time opioid sales were climbing dramatically. In one 2009 exchange, a pharmaceutical company representative emailed a colleague at another company to alert him to a pill shipment. “Keep ’em comin’!” was the response. “Flyin’ out of there. It’s like people are addicted to these things or something. Oh, wait, people are.”

According to Charles L. Bennett et al. in an editorial published in the Los Angeles Times, the failings are at every point in the system, starting with drug approvals. But the authors believe there is a particularly serious problem with the mechanisms for identifying, monitoring and disseminating information about issues with a drug after its release.

They suggest a good starting point for reforming the system would be increased transparency about drugs already recognised as particularly dangerous. These drugs, currently numbering about 70 (including opioids), carry the FDA’s so-called 'black box warning,' intended to alert patients and their doctors to the high risks associated with the drugs. But that is not enough. The authors propose a 'black box' database or 'registry,' publicly available and simple to use, that would contain extensive information about where, by whom and for what purpose black box drugs are prescribed, as well as where and in what quantities such drugs are being distributed and sold. Information about adverse side effects, culled from the myriad of government databases that now collect them, would also be consolidated in an open form and format.

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Source: Los Angeles Times, 8 August 2019

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Weston General A&E rated 'inadequate' after warnings

A hospital A&E department has been rated "inadequate" after warnings over urgent and emergency care.

The Care Quality Commission (CQC) reported a lack of support for staff and safety concerns in Weston General hospital's A&E department.

Dr Nigel Acheson, deputy chief inspector of hospitals for the South NHS , said it was "disappointing". Weston Area Health NHS Trust "fully recognises that while improvements have been made... further work is required."

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Source: BBC News, 17 December 2019

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Western Sussex Hospitals Foundation Trust rated "outstanding"

Western Sussex Hospitals Foundation Trust has become the first non-specialist trust to be rated “outstanding” in all five Care Quality Commission (CQC) domains.

The latest CQC report means the trust has not only retained its overall “outstanding” rating from its December 2015 inspection, but also improved its rating in the safe domain from “good” and in the responsiveness domain from “requires improvement”. The trust was also rated “outstanding” for critical care, improving from “requires improvement”. It was also rated outstanding for use of resources.

Read CQC report

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Source: HSJ, 22 October 2019

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West Suffolk Hospital's maternity services 'needs improvements'

The Care Quality Commission (CQC) issued a warning notice to the West Suffolk Hospital in Bury St Edmunds, which must improve by 31 January.

It has not released details but the hospital said inspectors flagged up how it recorded observations and monitored women in its care.

A hospital spokeswoman said: "We have taken this feedback seriously and are acting accordingly."

She added: "Concerns have been raised about how we record patient observations after we have taken them, which are currently not in line with national guidance". "The CQC also identified that we should make changes to the way we monitor women in our care, again to bring us in line with national guidance".

"We are making the necessary changes and the CQC is satisfied with the plans we have in place to make the improvements required."

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Source: BBC News, 21 November 2019

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West Lane Hospital patients 'at high risk of avoidable harm'

A mental health unit for young people where two girls died in two months is not safe. The Care Quality Commission (CQC) rated West Lane Hospital in Middlesbrough inadequate and said patients were at high risk of "avoidable harm". It found staff did not store medicines safely, out-of-date medicines were still in use, and staff used non-approved restraint techniques.

Tees, Esk and Wear Valleys NHS Trust said it was taking "urgent action".

The inspection in June uncovered a catalogue of failings, including "substantial and frequent staff shortages" and employees not always "adequately assessing, monitoring or managing risks to patients".

The report said staff did not feel supported or valued, with morale low, and some told inspectors not all incidents were reported.

CQC report

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Source: BBC News, 21 August 2019

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We need to rethink our approach to patient safety

Dr Suzette Woodward describes in her latest book a more positive approach to patient safety that seeks to learn how things normally happen in order to understand why they failed in that instance.

"The book aims to provide a significantly more positive approach to patient safety because it moves people away from focusing people on their shortcomings, which doesn’t enable learning, it in fact impairs it.  It also moves us away from spending all of our time identifying failure as we see it and giving people feedback about how to avoid it, telling them to stop making mistakes."

"The book also provides examples of how we can move from the rhetoric to action including the extremely useful methods for how we can study work-as-done and the adjustments and adaptions people make every day."

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Source: HSJ, 7 October 2019

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Ways to identify EHR usability issues and reduce patient harm

An electronic health record (EHR) bug that transmits and medication order for 25 mg of a drug – not the prescribed 2.5 mg – could be the difference between life and death. And it’s that seemingly impossible reality that’s bringing more industry stakeholders to the table working to better understand EHR usability and its effects on patient safety.

“Often times when people think about usability, they think about design and then they think about the EHR vendor,” Raj Ratwani, PhD, Director of MedStar Health Human Factors Center, said in an interview with EHRIntelligence.

“In reality, it's a very complex space. The products that are being used by frontline clinicians are shaped by the vendor. But they are also shaped by how that product is implemented at that provider site, how it's customized, and how it’s configured. All of those things shape usability.”

EHR usability issues are an exceptionally common issue, Ratwani reported in a recent JAMA article. About 40% EHRs reported having an issue that can potentially lead to patient harm and about 786 hospitals and 37,365 individual providers may have used EHRs with potential safety issues based on required product use reporting.

Direct safety challenges typically come from EHR products that are sub-optimally designed, developed, or implemented. Usability issues stem from a very cluttered interface or a complex medication list. Seeing a cluttered list can lead to a clinician selecting the wrong medication.  

A major usability issue also comes from data entry. EHR users want that process to be as clean as possible. Consistency in the way information is entered is also key, Ratwani explained.

Ratwani also wants to ensure that certification testing is as realistic as possible.

He compared it to when a vehicle is certified to meet certain safety standards each year. This type of mechanism does not exist when it comes to EHRs because right when the product is certified, it then gets implemented, and there is no further certification of safety done at all after the initial testing.

“One way to do that, at least for hospitals, is to have that process be something that the Joint Commission looks to do as part of their accreditation standards,” Ratwani said.

“They could introduce some very basic accreditation standards that promote hospitals to do some very basic safety testing.”

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Source: EHR Intelligence, 13 January 2020

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Warrington cancer patient died after "unacceptable delay"

Serious failings have been found at an NHS trust which performed "unacceptably delayed" and unnecessary surgery on a bladder cancer patient.

Denis Harrison, 62, died in August 2017 after waiting six months for surgery at Warrington and Halton Hospitals NHS Foundation Trust. The Parliamentary and Health Service Ombudsman (PHSO) said the trust had "failed to act with any urgency".

Mr Harrison's wife said the couple faced "severe mental anguish" waiting.

The PHSO said it was not possible to know whether earlier surgery would have saved his life, but he "was not given the best possible chance of survival".

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Source: BBC News, 25 September 2019

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