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

Patients could receive notifications following abnormal scan results

NHS patients could be sent text messages or emails urging them to call their doctor if X-rays or scans show abnormal results. Under plans put forward to prevent delays in treatment, patients with worrying results would receive an automated message saying they need to speak to their GP. The idea is that this would act as a safety net in case results go missing in NHS systems, or if a doctor fails to act on results.The move comes after the Healthcare Safety Investigation Branch (HSIB) investigated a case where a 76-year old woman had a chest X-ray showing possible lung cancer which was not followed up. Her findings were sent to two hospital departments as well as her GP, but nobody acted on them. She died just over two months later but could have received treatment earlier.
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Read HSIB report
Source: Yahoo UK, 18 July 2019
Sam

New standard to make joined-up care a reality

The Professional Records Standard Body (PRSB) has published a new standard for shared care records that determines the vital information about a person that should be shared between health and care systems so care is safer, timely and more effective. Working with NHS England, the PRSB has asked citizens and health and care professionals to help produce a ‘core information standard’ that defines exactly what information should be shared in a person’s care record throughout their life. 
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Source: PRSB, 17 July 2019
Patient Safety Learning

GP Patient Survey 2019

NHS England together with Ipsos MORI, have published the latest Official Statistics from the GP Patient Survey. The survey provides information on patients’ overall experience of primary care services and their overall experience of accessing these services.
Read results of the survey
Patient Safety Learning

Hospital admissions for deadly sepsis have doubled in three years

Hospital admissions for sepsis in England have more than doubled in three years, according to new figures that shows a rise in recorded admissions among all age groups, including the very young.
The NHS Digital data shows there were 350,344 recorded hospital admissions with a first or second diagnosis of sepsis in 2017/18, up from 169,125 three years earlier. This includes 38,401 admissions among those aged four years and under, up from 30,981 in 2015/16. For all children and young people aged 24 years and under, there were 48,647 admissions in 2017/18.
Dr Ron Daniels, Chief Executive of the UK Sepsis Trust, and Patient Safety Learning topic leader, said the scale of the problem in children looks “alarming”, adding: “What this means is that parents need to continue to be aware of meningitis, but to arguably be even more aware of sepsis as it affects far more children and can be equally deadly.” He said: “These potentially alarming data show that the number of recorded episodes of sepsis has more than doubled in just three years, a period coinciding with the recent focus on sepsis by the NHS in England."
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Source: Mirror, 22 July 2019
Patient Safety Learning

AfPP launches new clinical audit tool to enhance patient safety

The Association for Perioperative Practice (AfPP), has launched the AfPP Perioperative Audit Tool; 2019 Edition, a robust audit tool that will assist both private sector and NHS theatre practitioners in creating a safer perioperative environment.
The tool comprises peer-reviewed standards and recommendations for safe perioperative practice and forms a ‘gold standard’ framework for operating theatre departments to examine service performance and identify potential improvements in patient care.
As the UK’s leading membership organization for operating theatre practitioners who put patient safety at the heart of all they do, AfPP created the tool for the theatre practitioners to review their current policies and processes to invest in the safety of their patients.
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Source: News Medical Life Sciences, 19 July 2019
Sam

‘Drug policy isn’t working... we need to try a completely different approach’

In a recent interview in The Times, former Chief Medical Officer, Professor Sir Harry Burns considers the symptoms of the country’s drug deaths epidemic. The total of 1,187 fatalities in 2018 represents 218 drug deaths per million of the population and a 27% year-on-year rise. The death rate is three times higher than in the UK as a whole and worse than that of the United States. Politicians should listen to people working on the front line to tackle rising deaths, according to Sir Harry. The trouble is, he says, “public policy tends to be made because someone has a clever idea which then gets picked up by a politician. Very few outcomes in society are determined by one thing.” He believes that health and social benefit on a national scale comes with incremental change over an extended period of time. 
When asked what one thing would you do to improve the health of the nation, Sir Harry said "Scotland has made enormous strides in improving patient safety using the concepts of improvement science in which front line staff have tested many different ideas and applied at scale the changes which they have seen work. It’s the principle of marginal gains that has been successful in sport. I would use this approach to improve wellbeing across society."
Read full interview
Source: The Times, 20 July 2019
Sam

UK newborn baby screening 'not good enough'

UK babies are missing out on checks for rare but serious health conditions, putting lives at risk, according to a report from the charity Genetic Alliance UK. The NHS offers newborns a blood test to screen for up to nine conditions, whereas many other European countries look for 20 or more illnesses and the US screens for more than 50, the charity says. 
The UK National Screening Committee says its recommendations are based on evidence and are regularly reviewed. It is up to the governments in England, Scotland, Wales and Northern Ireland to decide which tests to provide. Genetic Alliance UK says affordable ways to expand the screening exist, but are not being used.
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Source: BBC News, 23 July 2019
Patient Safety Learning

GP receptionists will offer patients appointments at chemists, in bid to take pressure off family doctors

GPs’ receptionists will divert patients to see pharmacists in a bid to relieve pressure on family doctors. The NHS plan aims to prevent 20 million GP appointments, with many of those telephoning for help instead offered a "same day” slot at a local chemist. Health officials said the moves would mean more accessible and convenient access to services. But patients’ groups said the measures were “worrying”, with fears that critical decisions could end up being taken by those with little training in how to assess patients. 
From October, those calling 111 will be offered appointments at their local pharmacists if call handlers believe they are suffering from a minor ailment. Meanwhile, the NHS will pilot the same system for patients trying to make a GP appointment - with hopes to introduce the system nationally within nine months. 
Health Secretary Matt Hancock said the moves were similar to “the French model” where pharmacists have a stronger role providing healthcare. Officials said the plans may be extended still further, to divert patients attempting to seek help from Accident & Emergency departments. 
The changes are part of a five-year contract with pharmacists. 
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Source: The Telegraph, 22 July 2019
Patient Safety Learning

Hundreds of patients at risk amid major delays to IV feed supplies

Hundreds of patients, including children, dependent on intravenous nutrition to keep them alive are experiencing delays in vital deliveries, because of restrictions placed on the manufacturer by the MHRA. Clinicians warn patients may need to be admitted to hospital, rather than stay at home, if delays continue.
Read full story (paywalled)
Source: HSJ, 23 July 2019
Patient Safety Learning

Anaesthetic devices 'vulnerable to hackers'

A type of anaesthetic machine that has been used in NHS hospitals can be hacked and controlled from afar if left accessible on a hospital computer network, says CyberMDX, a cyber-security company. For example, a successful attacker would be able to change the amount of anaesthetic delivered to a patient or alarms designed to alert anaesthetists to any danger could be silenced.
GE Healthcare, which makes the machines, said there was no "direct patient risk". But CyberMDX's research suggested the Aespire and Aestiva 7100 and 7900 devices could be targeted by hackers if left accessible on hospital computer networks.
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Source: BBC News, 10 July 2019
Patient Safety Learning

"I’m a doctor, and tried the new GP app. My experience was terrifying"

Dr Max Pemberton, columnist for the Daily Mail, gives his opinion of the app that offers patients a GP consultation via their mobile phone. In theory, it sounds great: the patient can dial up, speak to and (via phone camera) see a doctor, who could be anywhere. However, how effective can such consultations be?  "I have been able to test this service for myself — and what I have experienced left me worried", says Dr Pemberton.
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Source: The Spectator, 20 July 2019
Sam

CQC guilty of maladministration in £200k fit and proper person case

The Care Quality Commission (CQC) has been found guilty of maladministration over its handling of a fit and proper person test complaint which led to a £200,000 investigation by an NHS trust. A Parliamentary and Health Service Ombudsman (PHSO) investigation identified “several instances of maladministration” in the CQC’s handling of a complaint by former consultant paediatrician David Drew. 
Ombudsman Rob Behrens has now written to the Health Secretary, NHS England, Chair of the Commons Health Committee Sarah Wollaston, and Chair of the Parliamentary and Constitutional Affairs Committee Bernard Jenkin with a copy of the PHSO investigation. In his letter. Mr Behrens said: “I believe this case exemplifies the damaging impact that poor handling of allegations can have on people’s faith in the ability of the CQC to identify and act on misconduct when whistleblowers come forward. This underlines the need for reform to the [fit and proper person] system and the recommendations from the Kark review to be swiftly implemented.”
Read full story (paywalled)
Source: HSJ, 24 July 2019
Sam

Nurses from Northwest Pennsylvania fight for patient safety

Nurses from Northwest Pennsylvania convened at a billboard calling for greater limitations on the number of patients a nurse can attend to during a shift. The advertisement, located on state Route 8 outside of Centerville, is one of two billboards that Nurses of Pennsylvania, a non-profit advocacy group in the US for nurses and patients, crowd funded in order to raise awareness about the issue of safe staffing and possible legislation.
Registered nurse Kimberly Aldrich, said: “What gets me is that this is not an unprecedented idea in Pennsylvania... When we drop our kids off at daycare, we can rest assured that the facility is legally required to adhere to limits on the number of kids a childcare worker can be assigned. Why should we accept less if our kids are in the hospital?”
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Source: The Titusville Herald, USA, 24 July 2019
 
Sam
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