Jump to content
  • articles
    10,022
  • comments
    87
  • views
    12,977,886

Contributors to this article

About this News

Articles in the news

 

Up to 100,000 on antipsychotics with no review

A national strategy is needed to tackle health risks linked to antipsychotic drugs because current policy is letting tens of thousands of people fall through the gaps, commissioners in London are warning.

Commissioners and clinicians in City and Hackney found more than 1,000 patients in their area who were on these drugs without having regular medication reviews or health checks. They warned that, if their findings applied across England, 100,000 patients could be in the same position. 

Although NHS England funds GP practices to carry out regular health checks on patients who are on the serious mental illness register, this excludes patients who are prescribed antipsychotics without having an SMI diagnosis — which typically covers psychoses, schizophrenia or bipolar active disorder. 

An audit by City and Hackney Clinical Commissioning Group, carried out in July 2019 and shared with HSJ, found 1,200 patients in the area were taking antipsychotics but did not have a formal SMI diagnosis.

The audit found most of these patients were not receiving regular health checks and a significant number may have benefited from having their medication reduced. 

Read full story (paywalled)

Source: HSJ, 27 January 2020

Read more
 

Hundreds recalled as consultant accused of ‘unnecessary’ surgery

A surgeon has been accused of carrying out “unnecessary” shoulder operations on several NHS patients at a private hospital linked to the Ian Paterson scandal, with 217 patients recalled.

HSJ has been told at least five patients, all commissioned by the NHS, have instructed solicitors to take legal action against Habib Rahman, a consultant orthopaedic surgeon at Spire Parkway Hospital in Solihull.

Mr Rahman is accused of undertaking “unnecessary or inappropriate surgical procedures at Spire Healthcare hospitals” . Spire has confirmed it has recalled 217 patients over the concerns.

The allegations come weeks before the findings are due from an independent inquiry into disgraced surgeon Ian Paterson – who was found guilty of wounding with intent after giving hundreds of patients unnecessary breast surgeries in Spire hospitals across the Midlands.

Read full story (paywalled)

Source: HSJ, 24 January 2020

Read more
 

Morecambe Bay inquiry chief voices criticisms over East Kent hospital scandal

The failure to pass a damning report about a scandal-hit hospital trust to the care watchdog has been criticised by the man who led the inquiry into baby deaths at Morecambe Bay.

On Friday, a coroner ruled that the death of baby Harry Richford in 2017 resulted from neglect in the maternity unit of East Kent Hospitals NHS Trust.

A report by the Royal College of Obstetrics and Gynaecologists (RCOG) completed a year earlier had warned of issues that contributed to Harry’s death, including senior doctors not showing up for their shifts. However, the report was never passed on to the Care Quality Commission (CQC), despite the recommendation of the Morecambe Bay inquiry in 2015 that relevant external reviews should be passed on to the watchdog.

Bill Kirkup, who chaired the inquiry into deaths of mothers and babies at Furness General Hospital in Barrow-in-Furness, told The Independent: “When there is sufficient concern about a service to prompt an external review, the report must be available immediately to those responsible for assuring the quality of the service. That was the reason for the recommendation of the Morecambe Bay investigation, and it is disappointing that the Care Quality Commission apparently had no sight of this report until now.”

Read full story

Source: 26 January 2020

Read more
 

Health secretary to investigate allegations of women denied epidurals

Women in labour are being denied epidurals by NHS hospitals, amid concern that a “cult of natural childbirth” is leaving rising numbers in agony.

Last night, Matt Hancock, the Health Secretary, promised an investigation, and action to ensure women’s choices were respected, pledging to make the NHS maternity services the world-leader.

An investigation by The Sunday Telegraph found hospitals refusing clear requests from mothers-to-be, in breach of official guidelines from the National Institute for Health and Care Excellence (NICE).

Mr Hancock said all expectant mothers should be able to make an informed choice, knowing their choice would be fully respected.

“Clinical guidance clearly state that you can ask for pain relief at any time – before and during labour – and as long as it is safe to do so this should never be refused. I’m concerned by evidence that such requests are being denied for anything other than a clinical reason,” he said.

“It's vital this guidance is being followed right across our NHS, as part of making it the best place in the world to give birth. Women being denied pain relief is wrong, and we will be investigating.”

One mother, describing her experience at one NHS Hospital said: "It made me feel unsafe psychologically - I couldn't speak up, I couldn’t say what I wanted to say, I couldn’t advocate for myself medically because people were ignoring or belittling me. It feels that in childbirth, it’s a given that the doctor is taking their personal beliefs with them to the table, whereas in any other area of healthcare that would be unacceptable."

Read full story

Source: The Telegraph, 26 January 2020

Read more
 

Justice is being denied to too many families

Harry Richford's death underlines the need for the health secretary to bring back the national maternity safety training fund – and there are other issues that require urgent attention – The Independent reports. 

Harry Richford had not even been born before the NHS failed him. An inquest has concluded he was neglected by East Kent University Hospitals Trust in yet another maternity scandal to rock the NHS. His parents and grandparents have fought a tireless campaign against a wall of obfuscation and indifference from the NHS. In their pursuit of the truth they have exposed a maternity service that did not just fail Harry, but may have failed dozens of other families.

As with the family of baby Kate Stanton-Davies at Shrewsbury and Telford Hospitals Trust, or Joshua Titcombe at the University Hospitals of Morecambe Bay Trust, it has taken a family rather than the system to expose what was going wrong. It is known that there are about 1,000 cases a year of safety incidents in the NHS across England, including baby deaths, stillbirths and children left brain damaged by mistakes.

Last week, the charity Baby Lifeline, joined The Independent to call on the Department of Health and Social Care (DHSC) to reinstate the axed maternity safety training fund. This small fund was used to train maternity staff across the country. Despite being shown to be effective, it was inexplicably scrapped after just one year. 

There are other issues that also need urgent attention. The inquest into Harry’s death, which concluded on Friday, lasted for almost three weeks. Without pro bono lawyers from Advocate, Brick Court Chambers and Arnold & Porter law firm, the family would have faced an uphill struggle. At present, families are not automatically entitled to legal aid at an inquest, yet the NHS employs its own army of lawyers who attend many inquests and can overwhelm bereaved families in a legal battle they are ill-equipped to fight. Even the chief coroner, Mark Lucraft QC, has called for this inequality of legal backing to end, but the government has yet to take action.

Read full story

Source: The Independent, 26 January 2020

 

Read more
 

England's poorest 'get worse NHS care' than wealthiest citizens

England’s poorest people get worse NHS care than its wealthiest citizens, including longer waiting for A&E treatment and worse experience of GP services, a new study has shown.

Those from the most deprived areas have fewer hip replacements and are admitted to hospital with bed sores more often than people from the least deprived areas. With regard to emergency care, 14.3% of the most deprived had to wait more than the supposed maximum of four hours to be dealt with in A&E in 2017-18, compared with 12.8% of the wealthiest. Similarly, just 64% of the former had a good experience making a GP appointment, compared with 72% of those from the richest areas.

Research by the Nuffield Trust and Health Foundation thinktanks found that the poorest people were less likely to recover from mental ill-health after receiving psychological therapy and be readmitted to hospital as a medical emergency soon after undergoing treatment.

The findings sparked concern because they show that poorer people’s health risks being compounded by poorer access to NHS care.

Read full story

Source: The Guardian, 23 January 2020

Read more
 

East Kent hospitals: Care watchdog inspects trust after baby death apology

England's care watchdog has carried out a no-notice inspection of an NHS trust at the centre of concerns over the possible preventable deaths of babies. The Care Quality Commission (CQC) is investigating East Kent Hospitals NHS Trust but has not yet decided whether to prosecute.

It comes as the trust is likely to be heavily criticised at an inquest into the death of baby Harry Richford.

On Thursday, the BBC revealed significant concerns have been raised about maternity services at the trust, and a series of preventable baby deaths may have occurred there. On Wednesday and Thursday this week, the trust's maternity services were subject to an unannounced inspection from the CQC.

On Thursday night, East Kent Hospitals University NHS Foundation Trust said in a statement: "We are truly sorry for the death of baby Harry and our thoughts and deepest sympathies go out to Harry's family. We accept that Harry's care fell short of the standard that we expect to offer every mother giving birth in our hospital and we are fully cooperating with the CQC's investigation into Harry Richford's death."

Read full story

Source: BBC News, 24 January 2020

Read more
 

Cancer care backlog may cost 30,000 lives, Boris Johnson told

Scores of MPs and former ministers have urged the prime minister to tackle a backlog in NHS cancer care that threatens to lead to thousands of early deaths over the next decade.

More than 100 MPs have written to Boris Johnson after the coronavirus lockdown caused severe disruption to cancer diagnoses and treatments. They have called on him to deliver an emergency boost to treatment capacity.

One senior oncologist has claimed that in a worst-case scenario the effects of the pandemic could result in 30,000 excess cancer deaths over the next decade.

Read full story (paywalled)

Source: The Times, 22 August 2020

Read more
 

LloydsPharmacy launches pilot programme to help and support mental health patients

LloydsPharmacy is piloting an innovative new service that offers extra help and support to mental health patients. Funded by The National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which is a partnership between The University of Manchester and Salford Royal, the pilot is being carried out in ten community pharmacies in Greater Manchester.

The new service, referred to as AMPLIPHY, enables pharmacists to provide personalised support to people who have been newly prescribed a medicine for depression or anxiety, or those who have experienced a recent change to their prescription.

The pilot programme has been funded and designed by researchers at the NIHR GM PSTRC in collaboration with LloydsPharmacy. Central to the programme is the ability for patients to lead the direction of support they receive. They set their own goals and objectives and the pharmacist supports them in these. 

Professor Darren Ashcroft, Deputy Director of the NIHR Greater Manchester PSTRC, said: "The NIHR Greater Manchester PSTRC focuses on improving patient safety across four themes, which include Medication Safety and Mental Health. AMPLIPHY covers two of these areas and we believe it has the potential to make a difference to patients, by providing enhanced support for their care in the community."

The pilot is set to run until April 2020 when its impact will be evaluated before a decision is made on the next steps.

Read full story

Source: News-Medical.net, 22 January 2020

Read more
 

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.”

Read full story

Source: The Independent, 22 January 2020

Read more
 

East Kent hospitals: Baby deaths 'could have been prevented'

At least seven preventable baby deaths may have occurred at one of the largest groups of hospitals in England since 2016, a BBC investigation has found.

Significant concerns have been raised about maternity services at the trust.

East Kent NHS Foundation Trust has apologised, saying it has "not always provided the right standard of care".

The trust has struggled to improve maternity care for years, despite repeatedly being made aware of the problems.

In 2015, the medical director asked experts from the Royal College of Obstetricians and Gynaecologists to review maternity care, amid "concerns over the working culture". Their review, seen by the BBC, found poor team working in the unit, a number of consultants operating as they saw fit, a lack of performance management of the consultant body and out of date clinical guidelines.

It highlights consultants who:

  • failed to carry out labour ward rounds, review women, make plans of care or attend out of hours when requested
  • rarely attended CTG training
  • were reported "as doing their own thing rather than follow guidelines".

Read full story

Source: BBC News, 23 January 2020

Read more
 

Earlier recognition of aortic dissection needed to prevent deaths

Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care, according to a new Healthcare Safety Investigation Branch (HSIB) report.

The report highlights the difficulty which can face hospital staff in recognising acute aortic dissection. The investigation was triggered by the case of Richard, a fit and healthy 54-year old man, who arrived at his local emergency department by ambulance after experiencing chest pain and nausea during exercise. It took four hours before the diagnosis of an acute aortic dissection was made, and he spent a further hour waiting for the results of a CT scan. Although Richard was then transferred urgently by ambulance to the nearest specialist care centre, he sadly died during the journey.

The report has identified a number of risks in the diagnostic process which might result in the condition being missed. These include aortic dissection not being suspected because patients can initially appear quite well or because symptoms might be attributed to a heart or lung condition.

It also highlighted that, once the diagnosis is suspected, an urgent CT scan is required to confirm that an acute aortic dissection is present. 

Gareth Owens, Chair of the national patient association Aortic Dissection Awareness UK & Ireland, welcomed the publication of HSIB’s report, saying: “HSIB’s investigation and report have highlighted that timely, accurate recognition of acute Aortic Dissection is a national patient safety issue. This is exactly what patients and bereaved relatives having been telling the NHS, Government and the Royal College of Emergency Medicine for several years."

Read full story

Source: HSIB, 23 January 2020

 

Read more
 

Hundreds of serious incidents recorded at struggling small trust

One of the country’s smallest trusts recorded 277 serious incidents over a two-year period, HSJ can reveal.

Delays in treatment, missed diagnoses, adverse media coverage and “suboptimal” care were among the hundreds of serious incidents reported at the struggling Isle of Wight Trust from the start of 2018 and up to November 2019.

There were also two never events in 2019 — a “wrong site” surgery and an incident in which a patient was mistakenly connected to an air flow meter, rather than an oxygen supply.

The trust said the level of incidents did not neccessarily reflect poor care, and did not mean patients had come to harm.

The trust was placed in special measures in April 2017 after it was rated “inadequate” by the Care Quality Commission due to “significant” concerns over patient safety. It was upgraded to “requires improvement” in September 2019, but remains in special measures. 

Read full story (paywalled)

Source: HSJ, 22 January 2020

Read more
 

Dementia patients being 'dumped in hospital'

Dementia patients are being dumped in hospitals in England because of a lack of community care, a charity says.

The Alzheimer's Society called for action, highlighting data showing one in 10 dementia patients spends over a month in hospital after being admitted.

The figures also suggested the overall number of emergency admissions among people with dementia is rising - with some patients yo-yoing back and forth.

Ministers said they were "determined" to tackle the problems. Central to this, the government said, would be plans for reforming the social care system, which encompasses care home places and support in people's homes.

Alzheimer's Society Chief Executive Jeremy Hughes said people were falling through the "cracks of our broken social care system".

"People with dementia are all too often being dumped in hospital and left there. Many are only admitted because there's no social care support to keep them safe at home. They are commonly spending more than twice as long in hospital as needed, confused and scared."

Read full story

Source: BBC News, 22 January 2020

Read more
 

Cosmetic nurse leaders issue warning over Scottish regulation plans

Proposals by the Scottish Government to give a licence to unregistered professionals to carry out cosmetic procedures are “fundamentally flawed” and put lives at risk, leading nurses in the field have warned.

A consultation has been launched seeking views on plans for a new regulatory regime of non-surgical aesthetic treatments that pierce or penetrate the skin like dermal fillers or lip enhancements. Ministers want to bring non-health professionals under existing legislation allowing them to obtain a licence to perform these procedures in unregulated premises such as beauty salons and hairdressers.

The move comes after a UK-wide review carried out in 2013, by then NHS medical director Sir Bruce Keogh, identified that little regulation existed within the cosmetic industry. Since then there has been growing concern that people are coming to physical and psychological harm from treatments gone wrong.

Leaders at the British Association of Cosmetic Nurses (BACN) told Nursing Times that they were “totally opposed” to non-medical practitioners carrying out injectable beauty procedures.

BACN Chair Sharon Bennett said holding a medical, nursing or dentistry qualification should be a “basic prerequisite” before being accepted to an aesthetics training course. SHe said BACN believed even clinically trained practitioners, including nurses, needed further training in aesthetics before working in this “specialist” area.

“[This is] because there is no educational framework, training or statutory provision to establish or task beauty therapists to detect disease, care for patients or carry out medical treatment, so to do so would breach public health safety and endanger lives.”

Read full story

Source: The Nursing Times, 20 January 2020

Read more
 

Patient had wrong eye injected after software error

Herefordshire clinicians injected a patient in the wrong eye after a technical blunder, board papers have revealed.

The Wye Valley Trust patient was injected with an antivascular endothelial growth factor to treat age-related macular degeneration. They did not come to harm as a result of the incident.

The mistake occurred after the ophthalmology department deleted a poor quality image of one of the patient’s eyes. This shifted up the other images, which were stored sequentially using software called IMAGEnet6, which led to the mistake. 

Although initially reported as a “never event,” the incident was downgraded to a “serious incident” after a review by the Herefordshire Clinical Commissioning Group (CCG). 

The trust, which is still using the software, is updating its standard operating procedure and has installed new technology that can take higher quality images. A spokesman said: “Patient safety is the trust’s priority. While no harm was caused to this patient, the trust has taken this incident seriously.”

Read full story (paywalled)

Source: HSJ, 21 January 2020

Read more
 

NHS England asked ‘inadequate’ hospital to admit patient despite ban

NHS England asked an “inadequate” hospital for people with learning disabilities and autism to admit a patient, despite the service having a “voluntary” ban on admissions in place — and shortly before inspectors decided to impose a legal restriction.

The provider said it was an “exceptional case”, where the individual “had several failed placements”, and had stayed at the hospital — Jeesal Cawston Park in Norfolk — “in the past”. 

However, it appears to highlight the shortage of good quality accommodation and placements available and pressure on commissioners to make use of “inadequate” facilities.

Read full story (paywalled)

Source: HSJ, 21 January 2020

Read more
 

NHS faces huge clinical negligence legal fees bill

The NHS in England faces paying out £4.3 billion in legal fees to settle outstanding claims of clinical negligence, the BBC has learned through a Freedom of Information request. Each year the NHS receives more than 10,000 new claims for compensation. 

The Department of Health has pledged to tackle "the unsustainable rise in the cost of clinical negligence".

Estimates published last year put the total cost of outstanding compensation claims at £83 billion. NHS England's total budget in 2018-19 was £129 billion.

The Association of Personal Injuries Lawyers (APIL) believes the cost is driven by failures in patient safety.

Doctors represented by the Medical Defence Union (MDU), which supports doctors at risk of litigation, are calling for "a fundamental" reform of the current system.

Suzanne White, from APIL, said people came to her on a daily basis with no intention of suing the NHS. But she said they often found it difficult to get answers from the medical authorities - and were left with no other option but to sue.

"What they want to do is find out what went wrong, why they have received these injuries ... and to make sure it doesn't happen to other patients."

Read full story

Source: BBC News, 21 January 2020

Read more
 

Hospice receives outstanding CQC rating

The Care Quality Commission (CQC) has awarded 'Outstanding' ratings to St Giles Hospice in Walsall and Whittington. 

The CQC, an independent regulator of health and social care services in England, has recently introduced a new regime holding hospices to the same level of scrutiny as hospitals, making this outstanding rating all the more impressive.

St Giles hospice, founded in 1983, started as a charity caring for local people dying from cancer and now supports people living with incurable illnesses and their families for free.

Care providers from the hospice work on-site and in patients’ own homes, and their level of care has made them one of only a handful of hospices to ever have been awarded this accolade.

In the CQC report inspectors complimented the hospice for its “compassionate” range of speciality services. 

Inspectors added: “People were truly respected and valued as individuals. They were empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service.”

Read full story

Source: National Health Executive, 16 January 2020

Read more
 

Coroner slams scandal-hit NHS hospital for serious failings after mother bled to death when medic refused vital blood clotting drugs after C-section following long labour

A coroner has today slammed a hospital for a series of serious failings after a mother bled to death when a medic refused to allow her vital clotting products.

Gabriela Pintilie, 36, from Grays, Essex, gave birth to her healthy baby girl, Stefania, in February last year following a C-section after a long labour. But she suffered a major haemorrhage and died from a cardiac arrest hours later.

Basildon University Hospital, in Essex, came under fire after it emerged a locum haematologist refused to give Mrs Pintilie the blood after he followed the wrong set of guidelines. The fresh frozen plasma, which could have saved her life, remained outside the theatre after senior staff were not told it was available.

Essex Coroner Caroline Beasley-Murray today slammed the hospital for a lack of clear leadership and teamwork during the crucial minutes and hours when Mrs Pintilie suffered a massive haemorrhage.

The court heard how the on-call haematologist Dr Asad Omran, who was at home,  was called but refused to give permission for vital blood-clotting drugs to be issued until further tests were run. 

An expert witness said she believed the use of clotting drugs in the 'extreme situation' would have 'significantly increased' the chances of a different outcome. Dr Omran did not initially issue blood-clotting drugs because he followed the wrong protocol. He was following protocol for a normal adult, instead of a woman in labour, which was 'completely at odds with clinical guidelines'.

Read full story

Source: Mail Online, 20 January 2020

Read more
 

Dementia patient’s family feel let down over death

The daughter of a man with dementia who died after being pushed by another patient in a care facility, has said her family has been let down by authorities.

John O'Reilly died a week after sustaining a head injury at a dementia care unit in County Armagh. The 83-year-old was pushed twice by the same patient in the days leading up to the fatal incident. His family were not made aware of this until after his death.

On 4 December 2018, Mr O'Reilly was pushed by another dementia patient causing him to hit his head off a wall. His family have said he was pushed with such force that it left a dent in the wall. He was admitted to Craigavon Area Hospital with severe head injuries and died a week later.

Last week, an inquest heard that the dementia patient who pushed Mr O'Reilly had a history of aggressive behaviour linked to dementia.

The Southern Trust is carrying out as Serious Adverse Incident (SAI) investigation into Mr O'Reilly's death.

Maureen McGleenon said: "Our experience of the SAI process has been dreadful. In our view it allows the trust to park the fact that something catastrophic has happened to a family. We were told it would be a 12-week process. It's over a year now and we've expended so much energy trying to figure out this process and find things out for ourselves."

She added: "The system just knocks you down and makes you want to give up."

"We'll never get over what happened to dad and we can't give up on trying to understand it."

Read full story

Source: BBC News, 20 January 2020

Read more
 

The FDA is still letting doctors implant untested devices into our bodies

When Kathleen Yaremchuk, Chair of the department of otorhinolaryngology (ear, nose and throat) at Henry Ford Hospital in Detroit, began getting calls about mysterious cases of respiratory distress, she launched a study to figure out what was going on.

All these patients, it turned out, had a small device implanted in the top of their spines to relieve pain. The object, used to hold a protein that stimulates bone growth, was cleared for sale by the Food and Drug Administration in 2003 without clinical testing in humans.

When Yaremchuk and her colleagues reviewed the records of all 260 patients implanted with the device at Henry Ford Hospital between 2004 and 2009, they found that a significant number developed airway obstruction, trouble swallowing and respiratory failure, in some cases leading to death.

The neck implant is just one of the products associated over the past decade with 1.7 million injuries and more than 80,000 deaths.

A searing global investigation last year by the International Consortium of Investigative Journalists places much of the blame on significant failings in the FDA’s oversight. The agency’s laissez faire attitude has resulted in artificial hips that cause cobalt poisoning (which can damage the heart and brain); surgical mesh that cuts through flesh and organs, causing infections and haemorrhage; and defibrillators that repeatedly shock patients beyond human endurance.

Safety problems have led to recalls of devices implanted in hundreds of thousands of people. And the devices can be difficult or impossible to remove if they go bad

No wonder many patient advocates cheered when the FDA announced in November that it planned to make “transformative” changes in the way more than 80% of medical devices are cleared for sale in the United States. But the promised transformation is mere window dressing. Two key loopholes still exist, allowing most products to be approved for sale without clinical trials in humans.

Read full story (paywalled)

Source: The Washington Post, 4 January 2019

Read more
 

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.”

Read full story

Source: EHR Intelligence, 13 January 2020

Read more
 

Hospital bosses launched ‘witch hunt’ to find whistleblower who revealed blunders in woman’s treatment, inquest told

Hospital bosses have been accused of launching a witch hunt to find a whistleblower who told a widower about blunders in the treatment his wife received.

The row emerged as an inquest began into the death of Susan Warby who died five weeks after bowel surgery. The 57-year-old died at West Suffolk Hospital in Bury St Edmunds after a series of complications in her treatment.

Her family received an anonymous letter after her death highlighting errors in her surgery, the inquest in Ipswich heard, and both Suffolk Police and the hospital launched investigations. These investigations confirmed that there had been issues around an arterial line fitted to Ms Warby during surgery, Suffolk’s senior coroner Nigel Parsley said.

Doctors were reportedly asked for fingerprints as part of the hospital’s investigation, with an official from trade union Unison describing the investigation as a “witch hunt” designed to identify the whistleblower who revealed the blunders.

Read full story

Source: The Independent, 17 January 2020

Read more
 

'Alarming' one in five deaths due to sepsis

One in five deaths around the world is caused by sepsis, also known as blood poisoning, shows the most comprehensive analysis of the condition.

The report estimates 11 million people a year are dying from sepsis - more than are killed by cancer. The researchers at the University of Washington said the "alarming" figures were double previous estimates. Most cases were in poor and middle income countries, but even wealthier nations are dealing with sepsis.

There has been a big push within the health service to identify the signs of sepsis more quickly and to begin treatment. The challenge is to get better at identifying patients with sepsis in order to treat them before it is too late. Early treatment with antibiotics or anti-virals to clear an infection can make a massive difference.

Prof Mohsen Naghavi said: "We are alarmed to find sepsis deaths are much higher than previously estimated, especially as the condition is both preventable and treatable. We need renewed focus on sepsis prevention among newborns and on tackling antimicrobial resistance, an important driver of the condition."

Read full story

Source: BBC News, 17 January 2020

Read more

© 2026 Patient Safety Learning. All rights reserved.

Patient Safety Learning is registered as a charity with the Charity Commission Registration number 1180689.

×
  • Create New...

Important Information

We have placed cookies on your device to help make this website better. You can adjust your cookie settings, otherwise we'll assume you're okay to continue.