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Keep up to date with the latest news, research and activity in patient safety.

Practices eradicate racial inequalities in blood pressure control

GPs in South London have eradicated a large gap in blood pressure control between white patients and those from a Black or minority ethnic background, after a year-long project.
AT Medics Streatham PCN in Lambeth found that among their patients under 80 diagnosed with hypertension, there was a 12% inequality gap in blood pressure control, with 67% of white patients and 55% of black patients treated to target.
The two practices in the PCN have 45,000 patients, with around 3,100 diagnosed with hypertension. They set up a centralised recall system and made use of practice pharmacists and healthcare assistants to provide guidance, education around self-care, lifestyle and medicines.
Dr Tarek Radwan, GP director said: ‘This project has delivered incredible results, and this is all down to the dedication of our amazing team, especially our administrators, healthcare assistants and pharmacists.
"The last 12 months have proved that we can not just reduce but actually eradicate health inequalities and raise the quality of care for everyone at the same time.
"I know the difference this will make to our local communities, and it really shows what is possible with a highly motivated multidisciplinary team."
Read full story
Source: Pulse, 3 May 2023
Patient Safety Learning

‘A fundamental lack of awareness that these people are actually human’

The Government’s “blanket erasure” of older people with learning disabilities is leaving a growing population unsupported and piling further pressure on family carers, new research will warn.
Byline Times has seen early findings from a forthcoming national study which outlines the urgent need to avoid a crisis by creating a government strategy for this unacknowledged community.
With around 1.5 million people with learning disabilities in the UK, Manchester Metropolitan University (MMU)’s ‘Growing Older Planning Ahead‘ research lays bare the Government’s short-sighted approach to learning disability support. 
The study estimates around 81,000 over-50s within this population in England alone, many of whom are not in contact with services. In addition, figures show that between 2012 and 2030 in England, the number of learning disabled people needing social care will have increased by almost 70% (from more than 140,000 to 235,000).
Sara Ryan, MMU Professor of Social Care who led the three-year project, said: “Ageing opens up all sorts of different things, you turn down the dial on some things and up on others. If you’re lucky enough, you have a lot to look forward to – but for people with learning disabilities, there’s a blanket erasure of age.”
Read full story
Source: Byline Times, 3 May 2023
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USA: What is the healthcare cost of racial health disparities, inequity?

There is a considerable human and healthcare cost that could have been avoided at the onset of COVID-19 had more been done to ameliorate eventual racial health disparities, amounting to thousands of lives lost and billions of dollars spent, according to analysis from Altarum on behalf of Episcopal Health Foundation.
Using figures up until the end of September 2020, the researchers found that had Black and Hispanic people in Texas been hospitalised at the same rate as their White counterparts, the state would have seen 24,000 fewer hospitalisations. That would have amounted to $550 million in healthcare cost savings, the analysis showed.
That is not to mention the human costs associated with racial health disparities during the pandemic. Had Black and Hispanic patients had the same COVID-19 mortality rates as White people, the state of Texas would have seen about 5,000 fewer deaths, cutting the total number of COVID-19 deaths in the state by 30%.
“These numbers are a glaring reminder of how non-medical factors like economic status and living conditions impact health and how COVID-19 is highlighting that in the worst way,” Elena Marks, president and CEO of the Episcopal Health Foundation, said in a statement. “The human and economic costs of health disparities continue to grow during the pandemic and we’re learning why we can’t address them through medicine alone. Something has to change in Texas.”
Read full story
Source: Patient Engagement HIT, 13 January 2021
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UK surgical workforce census 2023 opens

The Royal College of Surgeons of England is conducting a census to gain a better understanding of the surgical workforce.
Through the census, they will be able to gather comprehensive information on the composition of the surgical workforce, its demographics and working practices. Most importantly, it allows members of the surgical workforce to share the most pressing challenges they are facing. 
It aims to:
Better appreciate the needs, challenges, and working practices of the surgical workforce. More effectively represent and advocate for the workforce. Offer better support Create a better working environment. Enhance sustainability, including measures to improve retention, recruitment and work-life balance. Improve future planning. Take part in the survey
Patient Safety Learning

Majority of NHS trusts provide no dedicated training to prevent sexual harassment

Only one NHS trust in England provides dedicated training to prevent sexual harassment, according to research, raising concerns that the NHS is failing to adequately protect staff and patients.
According to health union figures, sexual harassment of staff is pervasive. A 2019 survey by Unison found that one in 12 NHS staff had experienced sexual harassment at work during the past year, with more than half saying the perpetrator was a co-worker. In a recent BMA survey, 91% of female doctors reported sexism, 31% had experienced unwanted physical contact and 56% unwanted verbal comments.
Yet research by the University of Cambridge, published in the Journal of the Royal Society of Medicine found that the vast majority of NHS trusts did not provide any dedicated training to prevent sexual harassment.
The report analysed data from freedom of information requests from 199 trusts in England and found that just 35 offered their workers any sort of active bystander training (ABT), while only one NHS trust had a specific module on sexual harassment.
ABT is designed to give individuals the skills to call out unacceptable behaviour, from workplace bullying to racism and sexual misconduct. It is widely used by the military, universities and Whitehall, including the Home Office.
Read full story
Source: The Guardian, 5 May 2023
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Whistleblower says career shattered by treatment

A former top medic on the Isle of Man who was unfairly dismissed has said her career has been "shattered" by her treatment.
Rosalind Ranson was the Department of Health and Social Care's (DHSC) medical director from January 2020.
She was awarded a record £3.19m in compensation after a lengthy tribunal which ruled she had been unfairly dismissed for whistleblowing.
Dr Ranson raised a number of serious concerns about the coronavirus advice on the island that was not being passed on to ministers.
She was later marginalised before being dismissed as the island's top medic when the operational services of DHSC transitioned into Manx Care.
Dr Ranson said: "For me it is a tragedy that my 35-year career in medicine has come to an end through these circumstances.
"I was proud of my professional integrity, my resilience, and my strength to stand up for those that I protected through my work as a doctor."
Read full story
Source: BBC News, 4 May 2023
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NHS treatment algorithms ‘not taking transgender patients into account’

A host of algorithms used by medics to assess disease risk and help make decisions on treatment are failing to take transgender patients into account, doctors have said.
Many metrics and thresholds in medicine, including ideal body weight, alcohol clearance rates, kidney function and risk of cardiovascular disease vary by gender.
A team of UK doctors and medical students have issued a warning over a lack of evidence as to whether trans patients should be considered for these gender-based scores according to their gender assigned at birth or the gender they have transitioned to – or whether alternative scores are required.
In an effort to tackle the issue, the team have launched a research initiative called Trans Gap Project.
Dr Michael Niman, a junior NHS doctor and chair of the project, said: “Currently, daily medical decisions involving gender-based scores have limited to no research for the trans community. This means that trans patients are often forgotten about or not considered in the medical world, leading to a significant gap in their access to appropriate medical care.”
“When scores that haven’t considered trans people are used, patient autonomy is impaired for trans and gender-diverse patients, as they can’t make true informed decisions on their care – which is one of the bioethic pillars,” Niman said.
In some cases, there could be safety concerns. “Clinicians are currently faced with uncertainty regarding the best clinical practice to address these scenarios, owing to a lack of evidence-based guidance,” Niman said. “It is vital clinicians take a vested interest in the research of gender-based scores for the trans community due to the importance of safe practice considerations within the NHS.”
Read full story
Source: The Guardian, 5 May 2023
Patient Safety Learning

Ministers missed chances to prepare social care for a pandemic, review finds

Distress and heartbreak for millions could have been avoided if the government had not missed opportunities to prepare social care for a pandemic, according to a big investigation into how the first wave of Covid hit care homes.
A review of events in spring 2020, when almost 20,000 care home residents died with Covid in England and Wales, found it was the result of “letting one of our most important public services languish in constant crisis for years”.
A two-year study by the Nuffield Trust health thinktank and the London School of Economics found successive governments failed to respond to risks already exposed by cross-government pandemic planning exercises, didn’t have enough civil servants working on social care, and failed to appreciate the sector’s fragility when sending patients into ill-prepared care homes.
The study is the latest independent assessment to undermine the claim by the former health secretary, Matt Hancock, to have thrown “a protective ring around social care”. It comes before the Covid-19 public inquiry’s investigation into the care sector, the timing of which has yet to be announced.
Read full story
Source: The Guardian, 5 May 2023
Patient Safety Learning

Patient scarred for life after botched operation left him with severe burns

A patient who was left scarred for life when a botched operation left him with horrific burns has received a payout after suing the NHS.
Paul Hickman, 44, underwent routine surgery to improve circulation in his legs when medics at Russell Hall Hospital in Dudley, West Midlands, wrongly used a heated mattress.
He ended up with significant burns on his buttocks after an alcohol-based solution came into contact with the back of both thighs and his backside.
Mr Hickman, of Walsall, West Midlands, said: “I hoped that the surgery would go well and would improve my health.
“However, all I remember afterwards was being in severe pain.
“To be told I had suffered burns was a complete shock and at first was difficult to try and take in. I couldn’t understand how that had happened".
An NHS investigation found the use of heated mattresses was stopped in the type of procedure Mr Hickman underwent after another patient was burnt in 2016.
The report found the use of alcohol-based solution during Mr Hickman’s preparation for surgery and the “inappropriate use” of a heated mattress in surgery led to his burns.
Read full story
Source: The Independent, 4 May 2023
Patient Safety Learning

Rise in UK measles cases causing concern

A "very concerning" rise in the number of people catching measles in the UK has been reported by health officials.
There were 54 cases of measles in the whole of last year. However, there have already been 49 in the first four months of 2023.
The UK Health Security Agency (UKHSA) is encouraging parents to ensure their children's vaccinations are up to date.
The main symptoms of measles are a fever and a rash. But it can cause more serious complications including meningitis, and an infection can be fatal.
Vaccination rates had been falling in the UK before the Covid pandemic. However, the disruption caused by Covid has dented vaccination programmes around the world, including in the UK, meaning even more children have missed out.
The World Health Organization has already warned of a "perfect storm" for measles, because the fewer people who receive protection from vaccines, the easier it is for outbreaks to happen.
Read full story
Source: BBC News, 4 May 2023
Patient Safety Learning

Sick and tired: Australia's Long Covid inquiry report released

A national Long Covid and Covid-19 database is among the key recommendations of a unanimous report released by an Australian parliamentary Committee for its inquiry into Long Covid and repeated Covid infections.
The House of Representative’s Standing Committee on Health, Aged Care and Sport’s report aims to improve Australia’s response to Long Covid, an often-debilitating condition possibly affecting hundreds of thousands of Australians.
The Chair of the Committee, Dr Mike Freelander MP said: ‘It is clear that the emergence of Long Covid has created challenges for patients and health care professionals alike. People with Long Covid suffer from a lack of information and treatment options. Health care professionals, who worked tirelessly over the acute phase of the pandemic, are now in a difficult situation trying to support patients with this new and poorly understood condition.’
The Committee made nine unanimous recommendations aimed at strengthening the Australian Government’s management of Long Covid, including regarding:
A definition of long COVID for use in Australia Evidence-based living guidelines for long COVID, co-designed with patients with lived experience A nationally coordinated research program for long COVID and COVID-19 The COVID-19 vaccination communication strategy Access to antiviral treatments for COVID-19 Support for primary healthcare providers Indoor air quality and ventilation. Read full story
Source: Parliament of Australia, 24 April 2023
Patient Safety Learning

Global hernia repair devices market is estimated to grow at a CAGR

The rising prevalence of hernia disorders, technological advancements in hernia repair devices, growing adoption of mesh in hernia repair surgeries, rising geriatric population and high adoption of hernia repair surgical procedures are some of the key factors driving the global hernia repair devices market, reports Yahoo News.
Leading players operating in the global hernia repair devices market are adopting both organic and inorganic growth strategies such as collaborations, acquisitions, and new product launches to garner a higher market share.
For instance:
In February 2023, TELA Bio, Inc announced the launch of two additional configurations of its OviTex LPR device. The new configurations are 15 x 20 cm and 15 x 25 cm ellipses designed for ventral and incisional hernias. In December 2022, Deep Blue Medical Advances announced that they have received an additional 510(k) clearance from the US FDA for its T-Line Hernia Mesh for the subway technique in open hernia surgery. However, in a recent Tweet, campaign group Sling the Mesh voice their concerns:

Patient Safety Learning

US drug regulator approves world's first RSV vaccine

The US Food and Drug Administration has approved a vaccine against respiratory syncytial virus (RSV) - an illness that kills thousands of Americans each year.
The vaccine still needs approval from the US Centers for Disease Control and Prevention before it can be rolled out to the public.
Officials say the vaccine, named Arexvy by the manufacturer GSK, is a major breakthrough that will save many lives.
It could be available to people over 60 within months, officials say.
"Today's approval of the first RSV vaccine is an important public health achievement to prevent a disease which can be life-threatening," said Dr Peter Marks, who leads the Center for Biologics Evaluation and Research at the Food and Drug Administration (FDA).
RSV is a respiratory illness that typically results in cold-like symptoms for adults, but can be dangerous for young children, the elderly, and those with underlying health conditions.
Read full story
Source: BBC News, 4 May 2023
Patient Safety Learning

The anorexia patients abandoned by the NHS because 'they are too sick to treat'

Charlotte Nolan, 23, has been fighting the deadly eating disorder anorexia for seven years. And in November she hit rock bottom.
The student nurse was having weekly therapy sessions, but they weren’t helping and promised additional weekly visits from a support worker failed to materialise.
Her food obsessions were spiralling out of control and her mental health was plummeting. Hopes were pinned on a meeting with her community mental health team, where it would be decided what to do next.
There were discussions about several different treatment options. But the ultimate decision they made was baffling. Instead of continuing therapy, trying another treatment or hospital admission, they simply discharged her from care. She says: ‘I was sobbing, trying to express to a room full of strangers that I wasn’t sure I could cope, I wasn’t sure I could stay safe.
Charlotte’s story is heartbreaking but, alarmingly, she is not alone.
In fact, there are a rising number of desperately ill anorexia patients being deemed too sick to treat.
Experts have voiced concerns about both NHS and private clinics withdrawing life-saving treatment.
"I’ve been contacted by people who say they are discharged because they’re too sick or not recovering fast enough, and being told there’s nothing more that can be done,’ says Hope Virgo, an eating disorder campaigner and former patient.
"It’s heartbreaking. Some have been referred to palliative care. We don’t give up on patients with physical illnesses, we find different treatment methods which work for them. And yet, with eating disorders, it’s still a case of one-size-fits-all. Why aren’t we setting people up to have a chance of recovery? Instead, if treatment doesn’t work, services are washing their hands of them."
Read full story
Source: Mail Online, 29 May 2023
Read a blog Hope Virgo wrote for the hub last year: People with eating disorders should not face stigma in the health system and barriers to accessing support in 2022
Patient Safety Learning

USA: Predictable, preventable medical errors kill thousands yearly. Is it getting any better?

Two years ago, administrators and caregivers at St. Bernard Hospital in Chicago were stunned when they flunked a basic standard for patient safety.
"It was a real jolt," said Charles Holland, the hospital's president and CEO. "We thought we were doing patient safety and we thought we were doing it well."
But the Leapfrog Group, a nonprofit health care watchdog organisation, found the hospital fell short on documenting and having comprehensive approaches to hand-washing, medication safety systems and fall and infection prevention.
The wake-up call led Holland to hire a Patient Safety and Quality Officer and to use Leapfrog's criteria as a roadmap for improving patient safety.
It worked. In its latest annual review of hospital safety, released Wednesday, Leapfrog awarded the century-old charity hospital an A.
The fact that St. Bernard could turn around so quickly and so effectively without spending a fortune in the process shows that patient safety is an attainable goal, said Leah Binder, Leapfrog's president and CEO.
Read full story
Source: USA Today, 3 May 2023
Patient Safety Learning

Regulator withdraws midwifery programme accreditation

The Nursing and Midwifery Council (NMC) has withdrawn its accreditation of the midwifery programme at a Kent university due to fears over quality and safety.
The regulator highlighted concerns that Canterbury Christ Church University students were not gaining the expertise needed to deliver safe, effective and kind care.
An NMC director said the decision was made in the “best interests of women, babies, and families”.
The university said the decision had “devastating consequences” for their student midwives.
“Our absolute priority is the wellbeing of our students and staff, and ensuring that our students can continue to complete their studies and begin their future careers, to be the high quality, much needed midwives that this region needs,” a university spokesperson said.
Sam Foster, NMC executive director of professional practice, said while the decision would impact students and the local workforce, the regulator's role was to uphold the high standards that “women and families have the right to expect”.
Read full story
Source: BBC News, 4 May 2023
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