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

A third of maternity doctors 'burnt out' and at risk of losing empathy for women in their care

More than a third of maternity doctors are “burnt out,” and at risk of lacking empathy for the women in their care, researchers have warned.
The study of more than 3,000 obstetricians and gynaecologists found high levels of long-term stress and overwork, especially among trainee medics. 
Researchers said the findings – from the largest UK study on the topic – were “very worrying,” with serious implications for patients. 
Overall, 36% of those surveyed met the criteria for “burnout,” which is associated with emotional exhaustion, lack of empathy and connection with others, researchers said. 
Medics who met the criteria for burnout were three times as likely to report anxiety, irritability and anger. They were also four times more likely than colleagues to practice “defensively”- meaning they tried to avoid difficult cases, or else carried out more interventions than necessary, for fear of error. 
Read full story
Source: The Telegraph, 26 November 2019
 
Patient Safety Learning

Reflecting on To Err is Human: 20 Years of Patient Safety Work

It’s been 20 years since the Institute of Medicine — known now as the National Academy of Medicine — published the groundbreaking report, To Err is Human. And in that time, the healthcare industry has seen vast changes, bringing patient safety and healthcare quality to the forefront.
The notion that patient safety issues are not only common, but they are preventable, challenge previously held industry beliefs, Craig Clapper, a partner in strategic consulting at Press Ganey, said during a recent interview with PatientEngagementHIT.com. 
In this article he discusses the progress that has been made and what still needs to be done.
Looking into the future, Clapper sees an industry that integrates patient safety as a key element of everything it does. While clinicians focus on boosting patient satisfaction, delivering good clinical outcomes, and fulfilling other obligations, they should feel and see the connection with patient safety.
“We should talk less about safety culture in isolation and more about how to make it about the entire patient experience,” Clapper concluded. “That'll be our biggest single advantage in the next decade. Instead of having a subculture for every outcome, we must have one seamless performance culture that can emphasize the safety, quality, and experience of care.”
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Source: PatientEngagementHIT, 26 November 2019
Patient Safety Learning

CervicalCheck: Review finds hundreds of previously missed abnormal results

Large numbers of previously missed abnormalities have been uncovered in the biggest review of smear tests undertaken since cervical cancer screening began in Ireland.
The review led by the Royal College of Obstetricians and Gynaecologists in the UK has found hundreds of “discordant” results after re-examining the slides of over 1,000 women who had been tested for the disease under CervicalCheck, were given the all-clear and later developed cancer, according to an informed source.
Discordant means the re-examination of the smear test by Royal College reviewers has produced a result that is different from the original finding by CervicalCheck.
The extent of the individual divergences from the initial results is not yet known, but the review has found some cancers could have been prevented, it is understood.
The college is due to submit an aggregate report on its findings to Minister for Health Simon Harris shortly.
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Source: The Irish Times
Patient Safety Learning

New legislation to provide for mandatory open disclosure

Hospitals will face penalties if staff do not notify patients of serious adverse incidents under proposed new legislation.
Due to be brought to Cabinet by the Minister for Health Simon Harris in early December, it will provide for mandatory open disclosure of patient safety issues. It is understood that the new Bill would mean that where a hospital or health service provider was satisfied that a notifiable patient safety incident had occurred, information in its possession on the issue should be disclosed. A doctor or practitioner would be obliged to inform the patient and hospital of the incident.
Under the proposals, failure to comply with this requirement on disclosure would mean the health service provider would be penalised. The nature or extent of the proposed penalties is unknown.
The department is preparing a list of notifiable patient safety incidents for the mandatory open disclosure proposals.
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Source: The Irish Times, 25 November 2019
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Nursing shortages forcing NHS to rely on less qualified staff

The NHS is relying on less qualified staff to plug workforce gaps because of a huge shortage of nurses, according to a new report.
Support staff, such as healthcare assistants and nursing associates, have been used to shore up staffing numbers, said the Health Foundation charity.
The NHS has relied upon overseas recruitment, but a lack of EU nurses because of Brexit means it is now taking more nurses from countries such as India and the Philippines.
At present, there are almost 44,000 nursing vacancies across the NHS (12% of the nursing workforce), but this could hit 100,000 in a decade, the report said.
The report said most changes to the skill mix – meaning the ratio of fully qualified to less qualified staff – are implemented well and led by evidence, but added: “It is important that quality and safety are at the forefront of any skill mix change.”
Read full story
Source: The Guardian, 28 November 2019
Patient Safety Learning

NHS Trust introduces artificial intelligence for monitoring eye health

East Kent Hospitals University NHS Foundation Trust has adopted artificial intelligence (AI) to test the health of patient’s eyes. In collaboration with doctors at the trust, the University of Kent has developed AI computer software able to detect signs of eye disease.
Patients will benefit from a machine-based method that compares new images of the eye with previous patient images to monitor clinical signs and notify the doctor if their condition has worsened.
Nishal Patel, an Ophthalmology Consultant at the Trust and teacher at the University said: “We are seeing more and more people with retinal disease and machines can help with some of the capacity issues faced by our department and others across the country."
“We are not taking the job of a doctor away, but we are making it more efficient and at the same time helping determine how artificial intelligence will shape the future medicine. By automating some of the decisions, so that stable patients can be monitored and unstable patients treated earlier, we can offer better outcomes for our patients.” 
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Source: National Health Executive, 22 November 2019
Patient Safety Learning

Australia needs to “get real on medicine safety”

Australia needs to “get real on medicine safety”, Federal Parliament heard this week.
Speaking in the House of Representatives, Julian Hill (ALP, Vic) said “too many Australians are being seriously injured, sometimes with lifelong impacts or dying, because of the weakness in our pharmacovigilance system”.
Mr Hill, Deputy Chair of the Parliamentary Joint Committee of Public Accounts and Audit, referred to a recent study by the Pharmaceutical Society of Australia which “estimated the extent of the problem at 250,000 annual hospital admissions as a result of medication related problems and 400,000 additional presentations to emergency departments, likely because of medicine related problems.
There’s an annual cost of $1.4 billion, and yet 50 per cent of this harm is estimated to be preventable,” he said.
“I have spoken before about my concerns in this area, and so have many other advocates, but the  government is still not taking these issues seriously. Every day of inaction means Australians are at risk of death or serious harm from medicines when it could be avoided”.
Read full story
Source: AJP.com.au, 28 November 2019
Patient Safety Learning

'We try our best as nurses, but it's not enough'

Georgina Day works as an A&E nurse in a London hospital. Every shift, her team of just over 20 starts four nurses short because there are posts it cannot fill.
"It can be worse - if people are sick or agency staff don't turn up. It makes providing good patient care difficult."
She says the demands are huge - her department sees more than 400 patients a day. But the shortages mean patients face delays or have to be given care, such as intravenous antibiotics, in corridors instead of in cubicles.
She says that can make patients angry, recounting the experience of one father shouting at her and saying she didn't care about his sick son.
"I care massively," she says. "When patients are angry it makes me really sad. I want more for them."
Georgina's experience is not unique. A survey by the Royal College of Nursing found six in 10 nurses felt they could not provide the level of care they wanted to.
Read full story
Source: BBC News, 2 December 2019
Patient Safety Learning

Health strike: Action could delay cancer diagnoses

Patients are facing a week of disruption, with more than 10,000 outpatient appointments and surgeries cancelled in Belfast.
Some people referred by their GPs on suspicion of cancer could have their diagnosis delayed, the head of the Belfast Trust has said. The trust apologised, blaming industrial action on pay and staffing.
Martin Dillon said outpatient cancellations "could potentially lead to a delay in treatment" for cancer.
The Department of Health said the serious disruption to services was "extremely distressing".
Read full story
Source: BBC News, 2 Decmeber 2019
Patient Safety Learning

Six hospitals plummeted to ‘inadequate’ in wake of Whorlton Hall

The Care Quality Commission (CQC) has rated six mental health hospitals “inadequate”, just months after describing them as either “good” or “outstanding”, since the Whorlton Hall scandal was revealed.
HSJ analysis shows that of the 13 mental health hospitals admitting people with learning disabilities or autism which have been rated “inadequate” by the CQC since May this year, six of them dropped at least two ratings in a short space of time. The six hospitals which dropped at least two ratings include Whorlton Hall — the County Durham hospital closed following a BBC Panorama report in May showing residents being mistreated — which the CQC rated as “good” in December 2017 before revising this to “inadequate” in May.
The BBC investigation prompted the CQC to investigate all similar mental health hospitals run by Cygnet, which took over the running of Whorlton Hall in January 2019. 
Cygnet Newbus Grange in Darlington — which was rated “outstanding” in a report published in February 2019 – was judged “inadequate” by September, while Cygnet Acer Clinic in Chesterfield fell from “good” in November 2018 to “inadequate’ in a report published 12 months later.
The other three hospitals were the Breightmet Centre for Autism in Bolton, Kneesworth House in Hertfordshire and The Woodhouse Independent Hospital in Staffordshire.
It comes as the CQC prepares to publish independent reports on its role in relation to the Whorlton Hall scandal. NHS England — one of the commissioners, along with local authorities and clinical commissioning groups, of learning disability inpatient care — also last month initiated a “taskforce” on the issue.
The CQC has acknowledged it needed to “strengthen” its assessments of this type of care and said it had begun to do so, and was reviewing them further “from a human rights perspective”.
Read full story (paywalled)
Source: HSJ, 2 December 2019
Patient Safety Learning

Fewer than half of pharmacists issue warning cards for patients using valproate

It is a requirement that patient cards detailing information on the risks are issued every time valproate is dispensed, under Medicines and Healthcare products Regulatory Agency (MHRA) guidance.
Only 40% of pharmacists are meeting a patient safety requirement when dispensing valproate to women, an audit carried out by the Company Chemists’ Association (CCA) has found.
The drug can cause birth defects in women who take it when pregnant.
In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) stated that valproate must not be used by women and girls of childbearing age unless a pregnancy prevention programme (PPP) is in place.
Duncan Rudkin, Chief Executive of the General Pharmaceutical Council (GPhC), said pharmacies must do more to ensure the safe dispensing of valproate.
Read full story
Source: The Pharmaceutical Journal
Patient Safety Learning

Health strike: Nurses start industrial action on pay and staffing

Industrial action by healthcare workers is intensifying as Northern Ireland's nurses take part in 24 hours of action. Health workers are staging industrial action in protest at pay and staffing levels which they claim are "unsafe".
In an unprecedented joint statement, the five health trusts said the action was likely to result in "a significant risk to patient safety".
Last week, the Royal College of Surgeons warned NI's healthcare system was "at the point of collapse". On Tuesday, members of the Royal College of Nursing (RCN) are refusing to do any work that is not directly related to patient care.
Full details and advice on current health care services can be found on the Health and Social Care Board website.
Read full story
Source: BBC News, 3 December 2019
Patient Safety Learning

Sepsis: getting the balance right

Public and professional understanding of sepsis has increased greatly in recent years. This has led to campaigns to diagnose sepsis early in the clinical course of the illness and to start treatment with antibiotics and fluid replacement promptly. But could this pressure to improve sepsis management be counterproductive and lead to overdiagnosis of sepsis? This was the argument made by the authors of a recent letter to the Lancet.
One problem arising from overdiagnosis of sepsis is the overuse of broad spectrum antibiotics, says Paul Morgan in an Editorial to the BMJ. Another concern is that the emphasis on the early treatment of sepsis detracts from the recognition, diagnosis, and treatment of other acute illnesses. 
Read full story (paywalled)
Source: BMJ, 28 November 2019
Patient Safety Learning

How safe is our care?

All healthcare leaders, providers, patients and the public should wrestle with a fundamental question:  How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky?  
Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?”
“The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.”
Read full story
Source: Hospital News, 3 December 2019
Patient Safety Learning

Royal Cornwall Hospital deploys AI tool for secure surgical videos

Royal Cornwall Hospital has deployed an artificial intelligence (AI) tool that allows clinicians to view case videos safely and securely.
Touch Surgery Enterprise enables automatic processing and viewing of surgical videos for clinicians and their teams without compromising sensitive patient data. These videos can be accessed via mobile app or web shortly after the operation to encourage self-reflection, peer review and improve preoperative preparation.
James Clark, consultant upper gastrointestinal and bariatric surgeon at the trust, said: “Having seamless access to my surgical videos has had an immense impact on my practice both in terms of promoting patient safety and for educating the next generation of surgeons."
Read full story
Source: Digital Health, 28 November 2019
Patient Safety Learning

Nearly 100 preventable deaths over the last decade at California psychiatric facilities, Times investigation finds

How many people die in California psychiatric facilities has been a difficult question to answer. No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation.
In an effort to assess the scope of the problem, The Times submitted more than 100 public record requests to nearly 50 county and state agencies to obtain death certificates, coroner’s reports and hospital inspection records with information about these deaths.
The Times review identified nearly 100 preventable deaths over the last decade at California psychiatric facilities. It marks the first public count of deaths at California’s mental health facilities and highlights breakdowns in care at these hospitals as well as the struggles of regulators to reduce the number of deaths.
The total includes deaths for which state investigators determined that hospital negligence or malpractice was responsible, as well as all suicides and homicides, which experts say should not occur among patients on a psychiatric ward. It does not include people who died of natural causes or other health problems while admitted for a psychiatric illness.
Read full story
Source: Los Angeles Times, 1 December 2019
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