• There is an opportunity to clarify the consent requirements for diagnostic imaging facilitated by a general anaesthetic.

• There is variation in the information given to patients regarding anaesthesia at the point of referral for an MRI scan under general anaesthetic.

• The observations and examinations to be routinely performed in pre-anaesthetic assessment are not defined nationally. The investigation found variation in the hospitals it visited.

• Children coming into hospital for an MRI scan who had been assessed as fit for anaesthetic were perceived as “well” by ward staff.

• Children with autism, learning disabilities and/or learning difficulties often find clinical environments distressing, which may be reflected in their physiological observations. This may result in diagnostic overshadowing, where problems such as autism (or a medical condition) are attributed as the cause of other new problems, rather than considering other underlying causes, thereby leaving other co-existing conditions potentially undiagnosed.

• Children with autism, learning disabilities or learning difficulties may benefit from reasonable adjustments being made when attending hospital.

• Electronic flagging systems can help staff identify patients who may benefit from reasonable adjustments. Hospital passports provide valuable information to assist with implementation of these adjustments.

• The model of care for learning disability nursing teams is not standardised nationally.

• There is an opportunity to enhance the existing published guidance available to assist clinicians involved in general anaesthetics to prepare for adverse events in the MRI scanning environment.

• Professional networks for anaesthetists provide the opportunity for shared learning and consensus regarding best practice.

• It is challenging to comply fully with the existing published standards for anaesthetic equipment used in MRI environments. 

The report sets out four safety recommendations in response to the findings. They are focused on:

• Updating clinical information to include ectopic pregnancy as a possible alternative/serious diagnosis to lower urinary tract infection.
• Standardising the information that women receive on discharge from the emergency department.
• Providing expert guidance on the type and level of information that EPUs should collect to identify those at risk.
• Including assessment on early pregnancy services especially relating to potential complications in CQC inspections.

The investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again. 

The investigation focuses on hip replacement surgery but the findings are applicable to all orthopaedic joint replacements.

The safety recommendations are focused on:

• Updating clinical guidance (NICE) and the UK’s pharmaceutical reference source (the British National Formulary) on use of propranolol and highlighting the toxicity in overdose.
• National organisations supporting their staff membership to understand the risks when prescribing propranolol to certain patients.
• Improving the clinical oversight in ambulance control rooms and the treatment/transfer guidance for ambulance staff for propranolol/beta blocker overdose.

As well as the safety recommendations, the report makes several safety observations and highlights some safety actions that have already been undertaken by NHS England and NHS Improvement, and the Medicines and Healthcare products Regulatory Agency.

The report also emphasises that there is a link between anxiety, depression and migraine, and that more research is needed to understand the interactions between antidepressants and propranolol in overdose.

HSIB have made two safety recommendations to help improve the recognition of acute aortic dissection:

• The first is to add ‘aortic pain’ to the list of possible presenting features included in the triage systems used to prioritise patients attending emergency departments.
• The second recommends the development of an effective national process to help staff in emergency departments detect and manage this condition.

• It is recommended that the Royal College of Ophthalmologists, working with relevant stakeholders, develop models and review workforce required for the optimal delivery of glaucoma care. The models should be tested and evaluated.
• It is recommended that NHS England/Improvement require commissioners to agree, under their service contracts, the action that providers will take to ensure compliance with the Portfolio of Indicators for Eye Health and Care follow-up performance standard. Where the standard has not been met, there should be a requirement for providers to demonstrate that they have reviewed individual pathways and taken action to mitigate risk, as well as to understand the causes of any unnecessary delays to inform improvement.
• It is recommended that NHS England/Improvement commission NHS Digital to publish reports of hospital eye services’ compliance with the follow-up appointments performance standard included in the Portfolio of Indicators for Eye Health and Care.
• It is recommended that NHS England/Improvement review the payment for the ongoing management of patients with glaucoma, regardless of setting. Pricing should reflect the complexity and costs of follow-up appointments and encourage new ways of working.
• It is recommended that NHS Digital include provision for identifying, prioritising and monitoring patients at risk of developing sight loss within the next version of the national Commissioning Data Set.  Provision should include the ability to record a risk rating and the recommended follow-up date for each patient, meaning these are mandated data items for collection by hospital eye services.
• It is recommended that the Royal College of Ophthalmologists agree criteria for the risk stratification of patients with glaucoma so that practice can be standardised across NHS hospital eye services. 
• It is recommended that the International Glaucoma Association facilitate the funding of research into the development and evaluation of an automated, predictive risk stratification tool.

Further reading

Surveillance of sight loss due to delay in ophthalmic treatment or review: frequency, cause and outcome (Jan 2017)

National Patient Safety Agency: Preventing delay to follow up for patients with glaucoma (11 June 2009)

• 12 national investigations launched.
• 440 maternity referrals received.
• 100 safety awareness notifications submitted for national investigations.
• 127 investigators trained.
• 174 members of staff recruited.

Retained vaginal swabs are classed as a ‘never event’. A never event is a serious incident that is entirely preventable. Data compiled by NHS England/Improvement shows that accidental retention of vaginal swabs is the most common in the ‘retained foreign objects’ category.

The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found.

Safety recommendations

HSIB made the following safety recommendation to NHS England and NHS Improvement as a result of this investigation.

• It is recommended that NHS England/Improvement carries out its intention to commission and publish an independent evaluation of its alternative design for swabs and tampons. The evaluation should also consider other solutions or technologies and include usability, cost/benefit analysis and the impact on reducing harm.

NHS England and NHS  Improvement response

The Patient Safety team at NHS England and NHS Improvement is pleased to confirm that in line with its stated intention it had already commissioned a first stage independent evaluation of a proposed new design for swabs and tampons used in healthcare maternity services.

Whilst it would not be feasible to commission an evaluation of other solutions or technologies that have not yet been well developed, further independent evaluation to compare this proposed design with other available solutions, and to evaluate potential cost benefit and impact analyses will be considered, conducted and published, should final prototypes prove possible to manufacture to the required specification and standards, and before any staged roll-out is considered.

This response was received on 15 July 2020.

• It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System.
• It is recommended that NHSX supports the development of interoperability standards for medication messaging.
• It is recommended that NHSX continues its assessment of the ePRaSE pilot and considers making ePRaSE a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines administration safety.
• It is recommended that the Department of Health and Social Care should consider how to prioritise the commissioning of research on human factors and clinical decision support systems; particularly in relation to the configuration of software system alerting and alert fatigue, to establish how best to maximise clinician response to high risk medication alerts.
• It is recommended that NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines use.
• It is recommended that NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.

A summary and the final full report are available.

The HSIB report showed why these incidents happen and most importantly what can be done to reduce the risk of it happening again. The investigation looked at all the factors involved and found evidence to show that electronic systems could help staff in busy environments, by making the processes easier and more efficient, to manage and reduce the risk to patients.

Findings

• There is a risk of incorrect interpretation of the symptoms, diagnosis and treatment of testicular torsion due to issues relating to the accuracy and accessibility of national guidance on the condition.
• There are multiple sources of guidance for GPs on testicular torsion, which do not all state the same information.
• The arrangement of urological surgical services in relation to acute testicular pain had not been considered in the NHS England/Improvement ‘Getting It Right First Time’ programme for urology area networks, which are voluntary agreements between trusts in the same geographical area establishing comprehensive urology services.
• The NHS 111 service genital problems clinical pathway had been amended to upgrade the default urgency for treatment advice given to patients with acute testicular pain within the 16-25 age group.
• The lack of principles or guidance for GP services setting up and running primary care advice/triage by telephone consultation is likely to be contributing to variation in the quality and safety of these services across the country.

Safety recommendations 

• It is recommended that the National Institute for Health and Care Excellence revises the content and accessibility of its Clinical Knowledge Summary on testicular torsion.
• It is recommended that the NHS England/ Improvement ‘Getting It Right First Time’ programme ensures that testicular torsion/acute testicular pain is included on the checklist of emergency pathways to be considered by the newly established Urology Area Networks across England.
• It is recommended that NHS England/Improvement works with relevant stakeholders to develop guidance for handling telephone advice/triage in primary medical care settings.

Safety observation

There are multiple sources of guidance for general practitioners on testicular torsion. It would be beneficial to review whether this guidance is accurate and whether it reflects the information contained in the revised clinical knowledge summary to be issued by the National Institute for Health and Care Excellence.

Safety action

NHS Digital has amended all clinical pathways where testicular pain is assessed in Version 16 of NHS Pathways, to increase the detection of testicular torsion in people over the age of 16 and up to 25.

The investigation identified that there:

• are multiple opportunities for error in the processes used to communicate unexpected findings
• are many steps that have to be completed successfully before the patient is informed
• is variance in how clinicians receive findings and how they acknowledge receipt of them.