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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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Pharmacist access to records is the key to even better patient care

The Royal Pharmaceutical Society (RPS) in Scotland has called on the Scottish Government to give all pharmacists read and write access to patient records.

Chair of the RPS in Scotland, Jonathan Burton, said: “World Pharmacists Day is an opportunity to celebrate the vital role of pharmacists at the forefront of healthcare.  Pharmacists across Scotland are already providing high-quality patient care, but the service could be even better if all pharmacists had access to the patient record."

Most community pharmacists do not have access to even basic information, despite performing an increasing role in providing NHS services both in and out of hours. Mr Burton continued: "It’s time the Scottish Government enabled all pharmacists to access patient health records so that, with patient consent and in appropriate circumstances, they have all the information they require to provide the safest and highest quality of care for patients in a timely and accessible manner.’’

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Source: Royal Pharmaceutical Society, 25 September 2019

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Repeat Caesareans 'often safer birth option'

Planned Caesarean delivery can be the safest option for women who have had a Caesarean in the past, according to new research in PLoS Medicine. Attempting a vaginal birth was linked with a small but increased chance of complications for mother and baby compared with repeat Caesareans.

The findings come from more than 74,000 births in Scotland.

Experts say mums-to-be should be offered a choice of how to deliver – natural or Caesarean – when possible.

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Source: BBC News, 25 September 2019

 

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A just culture for both staff and patients

"If we truly believe in a just culture for everyone and the benefits that can bring for patient safety, it has to give equal importance to being fair to patients and families as well as to staff, and inform practice and policy at every level," says James Titcombe, Peter Walsh and Cicely Cunningham in a recent commentary in HSJ. 

Although there is much to celebrate in the increased focus on 'just culture' – not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community – from the perspective of patients and families, the narrative to date can seem somewhat one sided. 

From the perspective of those affected, the current system of variable quality local investigations, inquests, litigation, complaints and interactions with a host of other regulatory bodies and organisations can feel designed in such a way that ensures further harm is inevitable.

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Source: HSJ, 17 September 2019

 

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Jeane Freeman launches partnership between Ireland and Scotland amid ongoing health crisis in NHS Scotland

Health Secretary Jeane Freeman announced the launch of a Joint Learning Fellowship programme between Ireland and Scotland, as the NHS in Scotland reels from one crisis to the next.

Ms Freeman and the Irish Health Minister, Simon Harris, announced the initiative, which will offer two three-month placements for Scottish and Irish senior policymakers or health service workers so they can learn more about what works in each system.

However, the move came on the same day The Times reported that Glasgow's 'super-hospital' was permitted to open despite the ventilation systems failing to meet the necessary safety standards.

Outbreaks of infection which are thought to have spread through the ventilation system at the Queen Elizabeth University Hospital (QEUH) have led to the deaths of two patients.

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Source: The Scotsman, 20 September 2019

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Investigation into insulin prescribing in hospitals starts

The Healthcare Safety Investigation Branch (HSIB) has started a national investigation looking into insulin prescribing and administration in hospitals.

It was launched after a patient was administered an overdose of concentrated insulin while under the care of an acute hospital. 

The investigation will focus on factors which compromise safety when health professionals administer concentrated insulin through insulin pen devices.

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Source: HSIB, 24 September 2019

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Patient safety at risk in England unless nurse numbers increase, RCN warns

The shortage of nursing staff in England is putting patient safety at risk, the Royal College of Nursing (RCN) has warned, as it launched a new campaign to encourage the public to speak out about the impact of England’s 40,000 nurse shortage. 

The RCN’s campaign calls for legislation to be brought forward in England to help address the nursing workforce crisis. Earlier this year, nurses and support workers in Scotland secured new legislation on safe staffing levels, and a nurse staffing law was introduced in Wales in 2016.

The 2013 Francis Report on failings of care at Stafford Hospital concluded that the main factor responsible was a significant shortage of nurses at the hospital.  Nurse numbers at NHS acute Trusts across England then increased as managers took steps to try to prevent similar scandals in the future. But a new analysis by the RCN shows that for every one extra nurse NHS acute Trusts in England have managed to recruit in the five years since 2013/14, there were 157 extra admissions to hospital as emergencies or for planned treatment. 

Commenting on the campaign launch, Dame Donna Kinnair, RCN Chief Executive and General Secretary, said: “Today we’re issuing a stark warning that patient safety is being endangered by nursing shortages.  Staffing shortfalls are never simply numbers on a spreadsheet – they affect real patients in real communities."

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Source: Ekklesia, 22 September 2019

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Nurses need to be kinder to each other or patients will be negatively affected, warns Senior Nurse

Teams that face rudeness experience a 12% drop in diagnostic and procedural performance.

University Hospital Southampton NHS Foundation Trust (UHS) has launched the “Reminder to be Kinder” project which was designed to recognise the importance of civility on patient care. The “Reminder to be Kinder” project encourages nurses and allied healthcare professions to be kinder to each other in order to improve patient safety.

Launched to coincide with World Patient Safety Day, the project will see the introduction of a range of action cards which include reminders to celebrate colleagues’ achievements, thank someone for their work and do something to make life easier for a colleague.

Juliet Pearce, Deputy Director of Nursing at UHS, said; “The way we interact with each other can have a surprising effect on patient safety,” 

“People who witness rudeness show reduced performance and are 50% less likely to help others. If a patient was to see this happen, you could understand why they would feel anxious dealing with staff and have less trust in the organisation.”

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Source: Nursing Notes, 19 September 2019

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Social media sites act on NHS call for greater online protection

The Chief Executive of NHS in England has called on all social media firms to crack down on potentially harmful material after two of the biggest sites confirm they plan to act on health service demands for action.

Facebook and Instagram have announced that they will remove posts promoting ‘miracle’ cures and get-slim-quick products, which are known to have limited benefits with possible damaging side-effects.

The move follows a series of requests from health service chiefs, including NHS Chief Executive Simon Stevens, to act responsibly and protect users from content that could cause physical or mental harm.

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Source: NHS England, 19 September 2019

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Thousands of US nurses tired of working with too many patients will walk out of hospitals in a four-state strike

Over 6,500 nurses in hospitals around California, Arizona, Florida, and Illinois will strike today. The strike will mark the first ever nurse strike in Arizona, and the first hospital registered nurse strike in Florida's history.

Nurses who are part of the National Nurses United union are asking for better nurse retention and nurse-to-patient ratios. 

"The strike is first and foremost about patient care and patient advocacy," Dominique Hamilton, a registered nurse at St. Mary's Hospital in Arizona, said. "We want the hospital to invest in the nursing staff, and we want to have more input into the recruitment and retainment of experienced [registered nurses]."

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Source: Business Insider, 

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More women and newborns survive than ever before

Developments in healthcare mean more women and babies are surviving than ever before, a new study has found.

The report, published by the World Health Organisation and the United Nations Children’s Fund (Unicef), found maternal deaths have decreased by more than a third since 2000. Deaths of children were found to have fallen by almost half in the same time period.

There was a 56% decrease in deaths of children younger than 15 since 1990 – from 14.2 million deaths to 6.2 million in 2018. 

But the research still found a pregnant woman or a newborn baby dies every 11 seconds from causes that are predominantly preventable and avoidable – with 2.8 million estimated to die every year.

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Source: The Independent, 19 September 2019

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'Systemic' failings with 999 call-handling service criticised

A woman who died after waiting almost two hours for an ambulance was let down by "systemic" failings with a computer call-handling system, a coroner said.

Daisy Filby, 90, was one of three people who died after delays in receiving care from the South East Coast Ambulance Service (Secamb). Coroner Alan Craze said a human would have "realised what was going on" and prioritised the calls differently. 

Mrs Filby, from Seaford, died in June 2017 as a result of an "accident contributed to by neglect," Mr Craze concluded at the Hasting's Coroner's Court inquest. "If an ambulance or anybody with or without medical knowledge had been able to reach this poor lady before her death, the situation would have been different," he added.

Mr Craze said: "The problem is not the actions of any one individual in Secamb Trust. The problem is ultimately systemic and at the heart of the call-taking and decision-making system."

A spokesman for the ambulance service said: "We are very sorry for the service they received. We have listened very closely to the coroner throughout and we are committed to making further improvements where necessary."

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Source: BBC News, 18 September 2019

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'The NHS has been destroyed': Boris Johnson confronted by father of sick child

Prime Minister Boris Johnson has been confronted by an angry father at a hospital who told him his baby daughter had nearly died because the ward on which she was treated was “not safe for children” after years of austerity.

In an encounter caught on camera, Omar Salem said the care given to his seven-day-old daughter at Whipps Cross university hospital, in north-east London, was “not acceptable”. He told the prime minister: “There are not enough people on this ward, there are not enough doctors, there’s not enough nurses, it’s not well organised enough.”

Salem told Boris Johnson: “My daughter nearly died yesterday. And I came here, the A&E guys were great but we then came down to this ward here and it took two hours and that is just not acceptable. This ward is not safe for children."

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Source: The Guardian, 18 Setpember 2019

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The harsh reality of underfunding at Whipps Cross University Hospital

Following Boris Johnson's confrontation by an angry father at Whips Cross University Hospital yesterday, a doctor gives anonymous account of chronic understaffing and lack of resources at Whipps Cross. 

"The hospital is held together only by the hard work and dedication of its healthcare workers but it cannot be sustained for much longer under these pressures."

"I’m so glad that Omar Salem  said the things he did. He was just telling the truth about what it is like to be on the receiving end of poor staffing levels and under-resourcing."

"I’ve been thinking about it all day and felt I had to say something because NHS hospitals today can be unsafe places. Whipps Cross is particularly understaffed and under-resourced so people don’t get the care that they need as promptly as they need."

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Source: The Guardian, 19 September 2019

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BMA sets out vision for reforming ‘unsafe, underfunded’ NHS

The British Medical A has outlined its vision for an ‘unsafe’ NHS with a culture of bullying.  

According to the BMA, doctors are working in hospitals and GP Practices that are hugely understaffed, where bullying and a culture of blame is the norm and where patient care is often unsafe. These are the findings of a year-long study – ‘Caring Supportive Collaborative: Doctors Vision for Change‘ – into the state of the NHS.

The chair of the BMA Council, Dr Chaand Nagpaul said: “Nine in 10 doctors tell us that staffing levels are inadequate and that they work in environments where they fear the toxic combination of ever-increasing demand for services and lack of staff capacity will lead to mistakes."

“They tell us there is a persistent culture of fear across the NHS, where blame stifles learning, contributing to the vicious cycle of low morale so staff leave and then there’s a problem of recruitment."

“This unsafe, underfunded environment is as damaging for patients as it is for doctors. Radical change is clearly needed.”

From the report comes a manifesto, which has today been sent to MPs, as well as the secretary of state for health and social care.

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Source: Practice Business, 17 September 2019

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The US Senate can save lives by removing ban on unique patient identifier

The US Senate has an unprecedented opportunity to remove a ban that has stifled efforts to establish a nationwide unique patient identifier. 

In June, the U.S. House of Representatives passed an amendment that would remove a ban that has stifled efforts to establish a nationwide unique patient identifier. Now, it is up to the US Senate to move this issue forward by rejecting inclusion of outdated rider language in their appropriations bill that prohibits the U.S. Department of Health and Human Services from spending any federal dollars to promulgate or adopt a national patient identifier.

According to a 2016 study of health care executives, misidentification costs the average health care facility $17.4 million per year in denied claims and potential lost revenue. More importantly, there are patient safety implications when data is matched to the wrong patient and when essential data is lacking from a patient’s record due to identity issues. 

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Source: The Hill, 11 September 2019

 

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NHS trust calls for police probe into deaths

NHS governors have called for a police investigation into the urology department of a health service trust following accusations that patients died and were harmed after a string of clinical errors and malpractice. 

Morecambe Bay NHS Foundation Trust (UHMBT) has now agreed to an external review after dozens of patients, relatives and staff have came forward following the publication of a book by whistleblower surgeon Peter Duffy, which exposed poor care in the unit. 

The call for a police investigation came at a meeting of the council of governors of the trust earlier this month. Governor Dave Welton told the meeting that the council had “very serious concerns about the shocking revelations.”

A former theatre nurse has also come forward claiming to have witnessed countless errors made by surgeons, while another healthcare worker said she was now speaking out to prevent further harm to patients.

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Source: BBC News, 16 September 2019

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BD supports World Patient Safety Day

The World Health Organization’s creation of an annual World Patient Safety Day is key to helping raise awareness and focus minds on improving the safe delivery of healthcare. BD fully supports this initiative and is partnering with care providers to ensure patient safety is prioritised, and efforts to reduce avoidable harm are enabled. 

"Patient Safety is integral to everything we do at BD and we believe it should be at the forefront of everyone’s minds when thinking about healthcare..."

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Source: BD, 17 September 2019

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Patient Safety Learning welcomes first ever WHO World Patient Safety Day

Monuments and fountains will be lit up across the globe today to herald the first ever World Patient Safety Day, organised by the World Health Organisation (WHO). 'Speak up for
patient safety' is the universal call as the spotlight is put on this global health priority. With the supporting strapline that “No one should be harmed in health care” the day brings
together patients, families, carers, communities, health workers, health care leaders and policy makers to show commitment to patient safety.

Patient Safety Learning's commitment to patient safety can be found in 'A Blueprint for Action', which we launched earlier this summer, which advocates six evidence-based foundations for action to address the causes of unsafe care. One of the six foundations is shared learning.  At the heart of our commitment to shared learning is the creation the hub, a community where people can share learning about patient safety problems, experiences and solutions.

Read more about Patient Safety Learning's commitment to patient safety in Chief Executive Helen Hughes' blog, Speaking up for patient safety on World Patient Safety Day

To mark World Patient Safety Day, Patient Safety Learning has released a series of short videos:

Patient safety is a purpose of health and social care

Shared learning for patient safety

Leadership for patient safety

On 2 October this year, we will be hosting in London our second annual conference attended by senior health and social care leaders, clinicians, patient safety experts, patients’ groups
and individuals who have experienced at first hand the traumas of losing a loved one where the quality of care has fallen down. We will also be officially launching the hub.

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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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Cancer survival in the UK improving, but lagging behind

Cancer survival in the UK is on the up, but is still lagging behind other high-income countries, analysis suggests.

Five-year survival rates for rectal and colon cancer improved the most since 1995, and pancreatic cancer the least. Advances in treatment and surgery are thought to be behind the UK's progress.

But the UK still performed worse than Australia, Canada, Denmark, Ireland, New Zealand and Norway, the study in Lancet Oncology found. Cancer Research UK said the UK could do better and called for more "investment in the NHS and the systems and innovations that support it".

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Source: BBC News, 12 September 2019

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Hundreds of patients suffer due to NHS errors

Hundreds of patients have suffered due to NHS blunders so serious they should never happen, new data shows.

Some 621 'never events' occurred in NHS hospitals between April 2018 and July this year – the equivalent of nine patients every week, according to data obtained by PA news agency. The figures show doctors have operated on the wrong body parts and left surgical tools (including surgical gloves, chest drains and drill bits) inside patients many times over.

Rachel Power, Chief Executive of the Patients Association, said: “Wrong site surgery incidents are preventable safety instances that can have devastating consequences for the patient and their family." “People who suffer harm because of mistakes can suffer serious physical and psychological effects for the rest of their lives, and that should never happen to anyone who seeks treatment from the NHS."

Professor Derek Alderson, president of the Royal College of Surgeons, said: “While these cases are very rare, never should mean never."

“NHS staff are there to care for patients, so knowing you have caused harm is incredibly distressing. It is vital that all theatre staff use, and are involved in, the World Health Organisation pre- and post-operative checklist process, as these have been designed to help prevent serious incidents."

“It is also important that the NHS continues to promote a culture of openness and transparency, both in terms of publishing surgeons’ outcomes and the number of ‘never events’ that, sadly, occur."

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Source: ITV News, 16 September 2019

 

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