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

NHS operations cancelled as consultants work to rule in pensions standoff

Hospitals are having to cancel operations and cancer scans are going unread for weeks because consultant doctors have suddenly begun working to rule in a standoff over NHS pensions. Doctors say the dispute is escalating so quickly that it will send NHS services “into meltdown” and is so serious that it poses “an existential threat” to the health service’s survival.
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Source: The Guardian, 8 July 2019
Sam

Caring GPs do more to prolong life than medication, study shows

Researchers at the University of Cambridge discovered that patients who had been diagnosed with Type 2 diabetes were up to 50 per cent less likely to die within a decade if their doctor showed empathy. In healthcare, empathy is defined as understanding the patient’s perspective, shared decision making between patient and doctor, and consideration how the illness may impact other areas of their life. But with financial and time pressures plaguing the NHS, doctors increasingly complain they do not have enough time to carry out the softer side of medicine. Now research, published in the Annals of Family Medicine, shows that showing care for a patient can be far more effective at prolonging life than giving drugs to lower cholesterol or blood pressure and so should be prioritised.
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Source: The Telegraph, 8 July 2019
Sam

NHS health information available through Amazon's Alexa

The NHS has teamed up with Amazon to allow elderly people, blind people and other patients who cannot easily search for health advice on the internet to access the information through the AI-powered voice assistant Alexa. The health service hopes patients asking Alexa for health advice will ease pressure on the NHS, with Amazon’s algorithm using information from the NHS website to provide answers to health questions. Matt Hancock, Health Secretary, said the move will help patients, especially the elderly, blind and those who are unable to access the internet in other ways, take more control of their healthcare and help reduce the burden on the NHS.
However, despite welcoming the move, the Royal College of GPs warned that independent research must be carried out to ensure the advice given is safe. Professor Helen Stokes-Lampard, Chairwoman of the Royal College of GPs, said: “This idea is certainly interesting and it has the potential to help some patients work out what kind of care they need before considering whether to seek face-to-face medical help... However, it is vital that independent research is done to ensure that the advice given is safe, otherwise it could prevent people seeking proper medical help and create even more pressure on our overstretched GP service.”
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Source: The Independent, 10 July 2019
Sam

Patient Safety Learning's response to the AHSN Network Strategy for Patient Safety

In June 2019, the Academic Health Science Network (AHSN), established by NHS England in 2013 and re-licensed from April 2018 to operate as the key innovation arm of the NHS, invited comment on its proposed patient safety strategy. The strategy aims to demonstrate the added value that AHSNs and Patient Safety Collaboratives can bring to patient safety by working much more collaboratively.
Chief Executive of Patient Safety Learning, Helen Hughes, has responded to the strategy. Helen comments: "We see the potential of the AHSNs: the capability and expertise, the desire to make a real difference and a belief in collaboration. We want to see this potential realised, and Patient Safety Learning wants to help."
See Helen's response in full
AHSN will launch its strategy at NHS Expo in September.
Sam

Record numbers struggle to see GP

Most patients who want to see their own GP can no longer get an appointment with them, according to new figures suggesting the days of the family doctor are over. The statistics show record numbers of patients struggling to even get through on the telephone, and increasingly long waits for an appointment. For the first time, the majority of patients who wanted to see a particular doctor were unable to do so, the survey of more than 770,000 patients shows. The research comes amid mounting evidence of a wider NHS crisis, with waiting lists reaching an all-time high.  
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Source: The Telegraph, 11 July 2019
Sam

Warning issued over adrenaline pen fault

Allergy patients are being warned of a potential fault with Emerade adrenaline pens. The Medicines and Healthcare products Regulatory Agency (MHRA) said some have blocked needles, so cannot deliver adrenaline. Around two in every 1,000 pens are thought to be affected and patients are advised to follow the existing advice to carry two pens at all times. If patients follow the advice to carry two pens at all times, the risk of not being able to deliver a dose of adrenaline falls to virtually nothing - 0.23% to 0.000529%.
The MHRA added: "Healthcare professionals should contact all patients, and their carers, who have been supplied with an Emerade device to inform them of the potential defect and reinforce the advice to always carry two in-date adrenaline auto-injectors with them at all times."
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Read MHRA alert
Source: BBC News, 12 July 2019
Sam

Patients who suffer from medical errors in Canada face 'rigged system,' critics say

Medical errors aren’t uncommon in Canada. In 2013, 28,000 people died from safety incidents in acute and home care settings, according to the Canadian Patient Safety Institute. Those preventable incidents may include errors with medication, preventable infections and injurious falls. Last year, more than 900 new medical lawsuits were filed in Canadian courts. About half of all medical mistakes are considered preventable, researchers say. In many cases, injured patients are unable to work and require financial assistance to pay the bills. 
The widespread problem has grown to epidemic levels in Canada, according to Kathleen Findlay, CEO and Founder of the Center for Patient Protection. “I think it is a national health care crisis and it’s not getting nearly the attention it deserves,” said Findlay, who founded the advocacy group after her mother suffered a series of medical errors during a six-month hospitalisation.
What’s worse, critics say, is that the system in place to hold doctors accountable is unfairly stacked against patients, who can only get compensation by taking legal action against their doctor. Critics say that doctors often have a financial leg up over patients thanks to the Canadian Medical Protective Association (CMPA), which has access to more than $3 billion to cover legal defense.
“I believe we have a rigged system that does more to help doctors than the patients they have harmed,” said Findlay, who described the CMPA as a Frankenstein-like creation designed specifically to help doctors. “We are paying as taxpayers for a healthcare system that harms us, and the perversity of it is that we have to pay again to defend the doctors who have done the harm. If that isn't perverse I don't know what is.”
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Source: CTV News, Canada, 14 July 2019
Sam

Patients die after multiple warnings about national 999 IT system dismissed

Patients have died after the government overruled multiple safety concerns raised about an IT system used to triage 16 million NHS patients a year. An HSJ investigation has uncovered at least three instances where patients triaged by the NHS Pathways software died months, sometimes years, after central agencies were alerted to safety concerns by ambulance trusts, but declined to make changes requested.
NHS Digital, the organisation that oversees NHS Pathways, told HSJ it had assessed the complaints but made changes only where “clinically necessary”. It has repeatedly asked coroners to “strike from the record” concerns raised about the safety of NHS Pathways’ advice.
Since 2015, coroners investigating 11 patient deaths have called for changes to the NHS Pathways software, used by NHS 111 and 999 services to triage patient calls, to prevent future deaths. Coroners have raised these concerns with health and social care secretary Matt Hancock, his predecessor Jeremy Hunt, NHS England, NHS Digital, the Care Quality Commission and service providers. Although NHS Pathways is run by NHS Digital, overall responsibility rests with NHS England.
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Source: HSJ, 15 July 2019
Sam

Patient Safety Learning Awards 2019 now open

The Patient Safety Learning Awards 2019 are here!
The Patient Safety Learning Awards publicly acknowledge and celebrate important work in patient safety, while sharing learning and successes to improve patient safety. This year, our Awards are inspired by our latest report, A Blueprint for Action. A Blueprint for Action sets out actions needed to progress towards a patient-safe future. These address six foundations of safer care for patients - one of these foundations is shared learning.
The Awards this year have six different categories, based on our foundations for safer care:
shared learning for patient safety leadership for patient safety professionalising patient safety patient engagement for patient safety data and insight for patient safety patient safety culture. A seventh award, the Patient Safety Learning Award, will be made to the individual, team or organisation who our judges believe has gone above and beyond. Each winning entry will receive a cash prize to enable them to visit another team or organisation to learn more about patient safety. As well as this prize, winners will receive two complimentary tickets to our annual conference, awards and drinks reception, held in London on 2 October 2019.
Enter now
The deadline for entries is midnight on Friday 30 August.
Sam

Cuts to investigations of killings by mental health patients ‘put people at risk’

People have been put at risk because the NHS has stopped funding the automatic investigation of all killings by mental health patients, according to psychiatrists and victims’ families. Experts who had looked into every such homicide for 20 years had to stop doing so last year after NHS England stopped paying the £100,000-a-year cost involved, the Guardian has reported.
Previously, for 26 years until last year, researchers from Manchester University had looked into the mental health history and NHS care received by the perpetrator of every such homicide to try to identify patterns and flaws which could be tackled to reduce the risk of similar attacks in the future. Their findings had led to improved care of potentially dangerous mental health patients.
“This is a risky and reckless decision.... It’s outrageous,” said Julian Hendy, the founder of Hundred Families, a charity that helps bereaved families. 
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Source: The Guardian, 17 July 2019
Sam

Majority of avoidable patient deaths in the US occur in hospitals with 'C' grade or below according to Leapfrog report

Patients treated at US hospitals that earned 'D' or 'F' grades when it comes to patient safety face a 92% higher risk of death from avoidable medical errors than at hospitals with an 'A' grade, according to a new report from The Leapfrog Group, a national nonprofit healthcare watchdog. In Leapfrog's Annual Hospital Safety Grades, about 32% of the 2,600 hospitals evaluated received an 'A' grade for safety, 26% earned a 'B' grade and 36% earned a 'C' grade. The hospital safety group awarded a 'D' or an 'F' grade to about 7% of the hospitals it examined. Patients at hospitals with a "C" grade when it came to safety were 88% more likely to die from an avoidable error compared with patients treated at hospitals that received an 'A'.
"It was pretty shocking to us and should be pretty sobering to hospitals that are not getting an 'A.' It's really time to take this seriously. You know you can do better," said Leah Binder, president and CEO of The Leapfrog Group.
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Source: FierceHealthcare, 15 May 2019
Sam

Majority of US hospitals not meeting surgical safety standards, survey shows

The Leapfrog Group, an independent national healthcare watchdog organisation, today released Safety In Numbers: The Leapfrog Group’s Report on High-Risk Surgeries Performed at American Hospitals. The report analyses eight high-risk procedures to determine which hospitals and surgeons perform enough of them to minimise patient harm or death, and whether hospitals actively monitor to assure that each surgery is necessary. Findings on these measures pointed to alarmingly poor performance across the board and red flags for patient safety. The voluntary survey found that the vast majority of participating hospitals do not meet The Leapfrog Group’s minimum hospital or surgeon volume standards for safety. Rural hospitals are particularly challenged in meeting the standards. 
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Source: The Leapfrog Group, 18 July 2019
Sam
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