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

Patients given wrong air in oxygen mix-up at hospital

A hospital has made changes after two patients were accidentally given medical air instead of oxygen.
The two incidents, which took place at the Norfolk and Norwich University Hospital (NNUH), were classed as "never events" meaning they were serious but preventable.
They happened to patients in November who were being handed over to the hospital by the East of England Ambulance Service.
The patients should have been given oxygen but were given medical air instead which only contains 20pc oxygen.
The ambulance service said in a message to staff: "Severe harm or death can occur, if medical air is accidentally administered to patients instead of oxygen. As per NNUH's request, with immediate effect, when handing over at the NNUH, all medical equipment and oxygen should be swapped only by an emergency department doctor or registered nurse."
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Source: Eastern Daily Press, 2 December 2019
Patient Safety Learning

RCOG launches 'Better for Women' report

UK women face widespread barriers to essential healthcare services. 
A survey of over 3,000 women in the UK shows many are struggling to access basic healthcare services including contraception, abortion care and menopause support . The Royal College of Obstetricians and Gynaecologists (RCOG) calls for one-stop women’s health clinics to provide healthcare needs for women in one location and at one time. The RCOG launched a landmark report “Better for Women” – to improve the health and wellbeing of girls and women across their life course –  in The House of Commons. The RCOG is calling for better joined up services, as part of its 'Better for Women' report. It emphasises the need for national strategies to meet the needs of girls and women across their life course – from adolescence, to the middle years and later life.
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Women needlessly having their appendix out in almost one in three cases

Women are having their appendixes removed wrongly in nearly a third of cases, British research suggests.
Researchers said too many female patients were being put under the knife when they should have undergone investigations for period pain, ovarian cysts or urinary tract infections. They said the study, which compared practices in 154 UK hospitals with those of 120 in Europe, suggests that Britain may have the highest rate of needless appendectomies in the world. 
Surgeons said they were particularly concerned by the high rates among women, with 28% of operations found to be unnecessary. 
They said the NHS was too quick to book patients in for surgery, when further scans and investigations should have been ordered. 
Researchers warned that such operations put patients at risk of complications, as well as fuelling NHS costs.
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Source: The Telegraph, 4 December 2019
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NHS facing “critical” shortage of lung specialists this winter, professional body warns

A “critical” shortage of lung specialists may leave the NHS struggling to cope with a spike in hospital admissions related to complications of pneumonia and flu this winter, the British Thoracic Society (BTS) has warned.
At its winter meeting this week (taking place 4-6 December), the society presented results from a survey it conducted of almost 250 UK NHS respiratory specialists. Some 83% of respondents (199) thought respiratory healthcare staff shortages would impair the ability of the NHS to cope with the increase in lung disease hospital admissions this winter.
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Source: BMJ, 4 December 2019
Patient Safety Learning

Shrewsbury maternity scandal: NHS used report to create ‘false narrative’ on maternity services

NHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years.
The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”.
The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service.
Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time.
A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes.
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Source: The Independent, 4 December 2019
Patient Safety Learning

Patients harmed after doctors ‘failed to respond’ to nurse concerns

Two patients at a hospital in West Lancashire came to “avoidable harm” after medical staff failed to act on concerns raised by nurses, according to a health watchdog.
The issue was highlighted by the Care Quality Commission (CQC) following an inspection of children and young people’s services at Ormskirk Hospital in July and August.
In there report CQC stated: “In children and young people’s services we found evidence that there had been occasions when medical staff had not responded to nursing concerns, which led to avoidable harm occurring to two patients.”
The document added that the two serious incidents, which had both been reported by staff, were "relating to babies".
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Source: The Nursing Times, 3 December 2019
Patient Safety Learning

Long waits 'leave mental health patients in limbo'

Patients with mental health problems are being left in limbo on "hidden" waiting lists by England's NHS talking therapy service, the BBC can reveal.
The service, Improving Access to Psychological Therapies, provides therapy, such as counselling, to adults with conditions like depression, post-traumatic stress disorder and anxiety.
It starts seeing nine in 10 patients within the target time of six weeks, but that masks the fact many then face long waits for regular treatment. Half of patients waited over 28 days, and one in six longer than 90 days, between their first and second sessions in the past year.
Charities said the headline target was giving a false impression of what was happening, warning that patients were facing "hidden waits" that were putting their health at risk.
NHS England acknowledged the pressure on the system was causing delays, but pointed out that despite the delays, half of patients given treatment still recovered.
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Source: BBC News, 5 December 2019
Patient Safety Learning

Father-to-be died in hospital 'screaming in pain'

The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life.
Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December.
The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate".
The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance."
At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset".
It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient".
The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety".
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Source: BBC News, 5 December 2019
Patient Safety Learning

Two patients die after hospitals ignore key safety warning

Two patients have died as a result of NHS hospitals failing to heed warnings about the use of super-absorbent gel granules, which patients mistakenly eat thinking they are sweets or salt packets.
A national patient safety alert has been issued by NHS bosses to all hospitals, ambulance trusts and care homes instructing them to stop using the granules unless in exceptional circumstances.
An earlier alert in 2017 warned the granules, which are used to prevent liquid being spilled, had caused the death of one patient who choked to death after eating a sachet left in an empty urine bottle in their room. The 2017 alert warned hospitals there had been a total of 15 similar incidents over a six-year period between 2011 and 2017.
The latest warning from NHS England says most hospitals concentrated on “raising awareness” rather than stopping the use of gel granules.
Read alert
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Source: The Independent, 4 December 2019
Patient Safety Learning

NHS forced to close 1,100 beds after virus outbreak

An outbreak of norovirus on hospital wards across the NHS has forced the closure of more than 1,100 beds in the last week.
The news comes amid record numbers of patients turning up to emergency departments at some hospitals and higher than expected cases of flu.
There are fears the dire situation could herald the start of a winter crisis for the NHS which is starting earlier than in previous years.
Miriam Deakin, Director of Policy and Strategy at NHS Providers, which represents hospitals said: “We are going into what is traditionally the NHS’s busiest time with a health and care system already under severe demand pressure."
“Patient safety is the top priority for trusts, but alongside high levels of staff vacancies, an outbreak of flu or norovirus could have a serious effect on the delivery of services.”
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Source: The Independent, 5 December 2019
Patient Safety Learning

Nearly 70,000 patients injured in Ontario’s hospitals each year, auditor says

Nearly 70,000 patients are injured while receiving care in Ontario's hospitals each year, the province's auditor general said Wednesday, calling for immediate government action to help reduce that number.
In her 2019 annual report, Bonnie Lysyk said her team's audits of acute-care centres found that six in every 100 patients treated and discharged from provincial hospitals were harmed during care.
"Each year, Ontario hospitals discharge one million people," Lysyk said. "Of those, about 67,000 people were harmed during their hospital stay."
The audit found that hospitals are currently not required to report to the Ministry of Health so-called "never-events" — a medical error that should never happen, such as leaving a foreign object inside a patient.
Lysyk said her team visited six of the 13 hospitals that track "never-events," and found that 214 such incidents had occurred since 2015.
Ontario's rates of patient harm are the second-highest in Canada, after Nova Scotia.
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Source: Niagara Falls Review, 5 December 2019
Patient Safety Learning

Shrewsbury maternity scandal: Inspectors warn of unsafe staffing amid signs of improvement

Maternity services at Shrewsbury and Telford Hospitals Trust were 50 midwives short of what was safe, hospital inspectors have said.
A new report by the Care Quality Commission, published today, revealed the trust, which is at the centre of the largest maternity scandal in the history of the NHS, had a 26% vacancy of midwives in April this year.
An independent investigation has been examining poor maternity care at the hospital since 2017 and the trust was put into special measures and rated inadequate by the CQC in 2018.
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Source: The Independent, 6 December 2019
Patient Safety Learning

Patient Solidarity Day 2019: "Patient engagement is essential for a patient-safe future" says Helen Hughes

Today marks the seventh annual Patient Solidarity Day, where people and organisations across the world rally around one of the key issues facing patients and help to raise awareness of this. The theme this year is ‘Acceleration for Safe Patient-Centred Universal Health Coverage’ with a call to hold leaders accountable for the commitments they have made to ensure safe and patient-centred universal health coverage for all.
In a bog released today, Patient Safety Learning's Helen Hughes discusses why patient engagement is essential for a patient-safe future and how we are currently working with Joanne Hughes, founder of Mother’s Instinct, to take action to help patients engage for patient safety. 
Read blog
Patient Safety Learning

Community pharmacists to expand role in patient care

Greater Manchester community pharmacies have signed up to a new national scheme, which will see patient consultations booked via NHS 111 for the very first time.
The scheme launched on the 29 October is part of major plans to boost the role of pharmacists in patient care, outlined in the national NHS Long Term Plan. People who call the free NHS 111 phone service can now be offered same day consultation with their local community pharmacist, if they need an urgent supply of a prescription medicine or advice on minor illnesses.
The aim of the scheme is to leverage pressure on GP practices and A&E departments, which come under increasing strain when the winter hits.
Early stages of the initiative in other parts of the country found that an estimated 6% of all GP consultations could be handled by a community pharmacist, freeing up around 20 million GP appointments each year nationally.
Sarah Price, Executive Lead for Population Health and Commissioning at Greater Manchester Health and Social Care Partnership said: “Our health services are facing unprecedented challenges and that means finding new ways to deliver the standard of care that patients expect, whilst ensuring that services are sustainable and fit for the future. Doing things the way we’ve always done, is no longer an option. Greater Manchester pharmacists are rising to the challenge and becoming more closely involved in patient care, often in close partnership with other health and care professionals." 
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Source: National Health Executive, 4 December 2019
Patient Safety Learning

Mental health: North Wales A&E support scheme extended

A "life-changing" mental health service at three hospitals in north Wales is to be expanded to GP surgeries.
More than 2,500 people have used 'I Can' centres at Glan Clwyd, Gwynedd and Wrexham Maelor hospitals since the trial was launched earlier this year. The centres offer support to patients at A&E departments who may not require medical treatment or a bed. They employ both volunteers and paid staff, many of whom have experienced mental health issues themselves.
Betsi Cadwaladr University Health Board said the service allowed people to talk about mental health issues away from wards.
It hopes extending the scheme to GP surgeries and community hubs will allow people to get support close to home if they do not need medical treatment.
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Source: 9 December 2019
Patient Safety Learning

NHS e-health systems 'risk patient safety'

Hospitals across England are using 21 separate electronic systems to record patient health care – risking patient safety, researchers suggest.
A team at Imperial College say the systems cannot "talk" to each other, making cross-referencing difficult and potentially leading to "errors". Of 121 million patient interactions, there were 11 million where information from a previous visit was inaccessible.
The team from London's Imperial College's Institute of Global Health Innovation (IGHI) looked at data from 152 acute hospital trusts in England, focusing on the use of electronic medical records on the ward.
Around a quarter were still using paper records. Half of trusts using electronic medical records were using one of three systems: researchers say at least these three should be able to share information. 10% were using multiple systems within the same hospital.
Writing in the journal BMJ Open, the researchers say: "We have shown that millions of patients transition between different acute NHS hospitals each year. These hospitals use several different health record systems and there is minimal coordination of health record systems between the hospitals that most commonly share the care of patients."
Lord Ara Darzi, lead author and co-director of the IGHI, said: "It is vital that policy-makers act with urgency to unify fragmented systems and promote better data-sharing in areas where it is needed most – or risk the safety of patients."
A spokesperson for NHSX, which looks after digital services in the NHS, said: "NHSX is setting standards, so hospital and general practioner IT systems talk to each other and quickly share information, like X-ray results, to improve patient care."
Read research article
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Souce: BBC News, 5 December 2019
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