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

Deaths of 4,600 NHS patients linked to safety incidents

Safety incidents at hospital, mental health and ambulance trusts were linked to more than 4,600 patient deaths in the last year, data shows.
The types of patient safety issues recorded by the National Reporting & Learning System (NRLS), which compiles NHS data, include problems with medication, the type of care given, staffing and infection control.
In total 4,668 deaths were linked to patient safety incidents, of which 530 deaths specifically linked to mental health trusts and 73 to ambulance trusts.
Guidance accompanying the data from the NRLS, which was set up in 2003, states deaths are not always “clear-cut” and cannot always be attributed to patient safety incidents. However, under the “degree of harm” section recorded on the system, there were 4,688 cases listed as death. In total, 4,356,277 reports of patient safety incidents were reported between November 2018 and October 2019. They are described as issues where unintended or unexpected incidents which could have – or did – lead to harm of a patient under the care of the NHS.
Other safety incidents had links to consent, paperwork, facilities, and in some cases patient abuse by staff or a third party.
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Source: The Guardian, 9 December 2019
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Latest data shows true scale of the number of patients waiting longer than 12 hours in A&E

The first publication of data from the Royal College of Emergency Medicine’s 2019-20 Winter Flow Project shows that existing data does not reflect the true scale of the problem of 12 hour stays in A&E.

RCEM data shows that in the first week of December over 5,000 patients waited for longer than 12 hours in the Emergency Departments of 50 Trusts and Boards across the UK. The sample of trusts and boards from across the UK is the equivalent to a third of the acute bed base in England. 

From the beginning of October 2019 over 38,000 patients have waited longer than 12 hours for a bed at the sampled sites across the UK – yet data from NHS England reports that in England alone a total of only 13,025 patients experienced waits over 12 hours since 2011-12. 

President of the Royal College of Emergency Medicine, Dr Katherine Henderson said: “In a nine-week period, at only a third of trusts across the UK, we’ve seen nearly three times the number of 12 hour waits than has been officially reported in eight years in England. This must be fixed."
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Source: Royal College of Emergency Medicine, 9 December 2019
 
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Allergy pens recalled after death of girl, 18

One of the main brands of adrenaline auto-injector pen, which can save lives during serious allergy attacks, is being recalled in the UK after the death of a teenager whose family say the product failed.
Shante Turay-Thomas, 18, died in September last year after it is claimed that her adrenaline pen did not work although she tried it twice. She told her mother, “I’m going to die,” as she succumbed to an allergic reaction to hazelnuts. Her death was the subject of an inquest hearing last month, which resumes this week.
The Medicines and Healthcare products Regulatory Agency (MHRA) confirmed this weekend that all batches of Emerade auto-injector had been recalled from pharmacies after an error was identified that can cause some pens to fail to activate. Between July and November, the agency said it had been made aware of 16 suspected activation failures. The agency said it was aware of two fatalities of patients reported to have used the pens but the fault had not been confirmed as a contributor to the deaths.
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Source: The Times, 8 December 2019
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Half of unexpected deaths in Belgian hospitals are due to shortage of staff

Half of the unexpected deaths in Belgian hospitals are due to a shortage of nurses, according to a study by the University of Antwerp.
Researchers from the University of Antwerp show the link between the number of nurses in hospitals and the death of the patients they care for, based on data from 34,567 patients’ medical records in four Flemish, one Walloon and two Brussels hospitals. The records showed that, on average, three out of every thousand patients in the hospital died ‘unexpectedly’. A death is considered as unexpected when a patient suddenly dies during active treatment, with no care plan for the end of their life having been started.
“We know from previous research that part of these unexpected deaths can be avoided, which is always heartbreaking for the family as well as the staff,” said Filip Haegdorens, a researcher at the university. “As a sector, we must do everything we can to prevent this,” he added.
The average nurse in Belgium is responsible for 9.7 patients at a time. For 89% of all departments, the number of nurses per hospital department was too low to be able to ensure good quality care. “Compared to, for example, Australian hospitals, where legal minimums exist, our Belgian figures could be improved,” said Haegdorens.
The study also shows a link between the training level of nurses and the number of unexpected deaths in the hospital. “In some hospital services, we found that more nurses with a high level of education would reduce the risk of unexpected deaths,” Haegdorens added.
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Source: The Brussels Times, 4 December 2019
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Surgeons withdraw support for heart disease advice

European clinical guidelines on how to treat a major form of heart disease are under review following a BBC Newsnight investigation.
Europe's professional body for heart surgeons has withdrawn support for the guidelines, saying it was "a matter of serious concern" that some patients may have had the wrong advice. Guidelines recommended both stents and heart surgery for low-risk patients, but trial data leaked to Newsnight raises doubts about this conclusion.
Thousands of people in the UK and hundreds of thousands worldwide will be treated for left main coronary artery disease each year. This is a narrowing of one of the main arteries in the heart.
The guidelines on how to treat it were largely based on a three-year trial to compare whether heart surgery or stents – a tiny tube inserted into a blocked blood vessel to keep it open – was more effective. The trial called Excel started in 2010 and was sponsored by big US stent maker, Abbott. Led by US doctor Gregg Stone, the study and aimed to recruit 2,000 patients. Half were given stents and the other half open heart surgery. Success of the treatments was measured by adding together the number of patients that had heart attacks, strokes, or had died.
The research team used an unusual definition of a heart attack, but had said that they would also publish data for the more common "Universal" definition of a heart attack alongside it. There is debate around which is a better measure and the investigators stand by their choice.
In 2016, the results of the trial for patients three years after their treatments were published in the New England Journal of Medicine. The article concluded stents and heart surgery were equally effective for people with left main coronary artery disease. But researchers had failed to publish data for the common, "Universal" definition of a heart attack.
Newsnight has seen that unpublished data and it shows that under the universal definition, patients in the trial that had received stents had 80% more heart attacks than those who had open heart surgery.
The lead researchers on the trial have told Newsnight that this is "fake information". But Newsnight has spoken to experts who say they believe the data is credible.
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Source: BBC News, 9 December 2019
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Royal Bolton Hospital on 'black alert' due to winter pressures

A hospital in Greater Manchester has declared a "black alert" due to "heightened pressure," the Bolton NHS Foundation Trust has said.
The Royal Bolton Hospital triggered the alert on Monday, which is the highest level of escalation in the NHS for measuring demand against capacity.
NHS chief Rae Wheatcroft said patient safety remained a "top priority".
"We have been busier than we would have expected across the hospital," the deputy chief operating officer added. "We are working hard to ensure that everyone who needs a bed is admitted and treated as quickly as possible."
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Source: BBC News, 9 December 2019
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Online prescribing 'must get safer'

More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner.
Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online.
Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet.
The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken.
The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online.
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Source: BBC News, 9 December 2019
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GP Manish Shah guilty of sex assaults on 23 female patients

Manish Shah preyed on cancer concerns to carry out invasive intimate examinations for his own sexual gratification, the Old Bailey heard.
He convinced his victims to have unnecessary checks between May 2009 and June 2013. He was convicted of 25 counts of sexual assault and assault by penetration. Jurors acquitted 50-year-old Shah, of Romford, of five other charges.
They were told afterwards he had already been found guilty of similar allegations relating to 17 other women, bringing the total number of victims to 23.
Prosecutor Kate Bex QC told the trial: "He took advantage of his position to persuade women to have invasive vaginal examinations, breast examinations and rectal examinations when there was absolutely no medical need for them to be conducted."
The NHS in London said it "extended sympathies" to the victims and added: "As soon as the allegations came to light, swift action was taken and we have supported the police throughout their investigation."
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Source: BBC News, 11 December 2019
Patient Safety Learning

Patient has recurring nightmares of having skin cut after not properly anaesthetised

An NHS hospital has admitted it failed to properly anaesthetise a patient who was operated on while conscious – leaving her with post-traumatic stress disorder (PTSD) and recurring nightmares.
The woman, who has chosen to remain anonymous, said she screamed out as the gynaecological surgery at Yeovil District Hospital began to operate, but could not be heard through her oxygen mask as the surgeon cut into her belly button.
Medical negligence lawyers said she was given a spinal rather than general anaesthetic during the procedure at the hospital in Somerset last year. She remained conscious while a laparoscope – a long camera tube – was placed inside her, and her abdomen was filled with gas. Her law firm Irwin Mitchell said that an increase in blood pressure had alerted staff to her discomfort, but that the procedure was continued.
The woman, who is in her 30s, said: “While nothing will change what has happened to me, I just hope that lessons can be learned so no one else faces similar problems in the future."
A spokeswoman for Yeovil Hospital said the incident was the result of “a breakdown of communication” which “led to the use of a different anaesthetic to that normally required for such an operation”.
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Source: The Independent, 10 December 2019
Patient Safety Learning

Health systems must tackle workplace, patient safety in tandem, IHI says

A nationwide effort in the US to improve and coordinate patient safety measures will strive to make a connection between workplace and patient safety.
The Institute for Healthcare Improvement (IHI) gave an update during its National Forum this week on the creation of a national patient safety plan intended to encourage better coordination of safety efforts. A key goal of the plan, expected to be released next year, was to emphasise the role of improving workforce safety.
“In our view, too many systems have a separation between workforce safety and patient safety and yet we know the two are connected,” said Derek Feeley, President and CEO of IHI, in a briefing with reporters Monday before the start of the forum in Orlando, Florida. “Patient safety incidents are much less likely to occur when workers feel safe.”
The steering committee developing the plan includes 27 organizations that range from patient advocates and professional societies to provider organizations and government representatives. The committee's plan hopes to target healthcare leaders and policymakers.
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Source: Fierce Healthcare, 10 December 2019
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Australia: ‘Medicine safety is a priority for us all.’

Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday.
Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia.
This included brainstorming on what success in improving medicine safety would look like in 10 years.
“Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.”
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Source: AJP.com.au
Patient Safety Learning

The NHS robots performing major surgery

How would you feel about a robot performing major surgery on you?
2019 has seen a boom in the use of cutting edge robotic technology and there is more to come. Evidence suggests robotic surgery can be less invasive and improve recovery time for patients.
That could be good news with ever growing demand on health services. But how do patients feel? BBC News speaks to a patient as he prepares to put his trust in robotic assisted surgery, hoping it would mean he could get back to work more quickly.
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Source: BBC News, 12 December 2019
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Doctors at West Suffolk hospital 'too scared' to report safety issues

Doctors at a hospital accused of bullying its staff have told the NHS care regulator that they are too scared to report lapses in patient safety in case they end up facing disciplinary action. 
The Guardian revealed earlier this week that West Suffolk hospital stands accused by its own medics of secrecy, bullying and intimidation after it demanded they take fingerprint tests in its effort to identify a whistleblower.
Senior staff have privately passed on serious concerns to the Care Quality Commission (CQC) about the behaviour of the trust’s leadership. They used confidential meetings with CQC inspectors, who visited twice in the autumn, to explain why they lack confidence in Steve Dunn, the trust’s chief executive, Dr Nick Jenkins, its medical director, and Sheila Childerhouse, who chairs the hospital’s board.
The CQC is due to publish its report into the trust, including the performance of its leadership, in January.
 “Staff are scared that they’ll face disciplinary action [if they raise concerns about patient safety],” said one doctor, who declined to be named.
“As a result of recent events I can’t imagine that anyone at the trust will feel comfortable to speak out or whistleblow in the future. I fear that any future patient safety concerns will not be expressed and will simply be brushed under the carpet.”
The trust demanded fingerprints and handwriting samples after a staff member wrote anonymously to the family of Susan Warby, who died in August 2018 after undergoing treatment at the hospital, which was investigated as a “serious incident”.
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Source: The Guardian, 11 December 2019
Patient Safety Learning

Using temporary nurses can increase risk of patients dying, warns new study

Patients are more likely to die on wards staffed by a high number of temporary nurses, a study has found.
Researchers say the findings, published in the Journal of Nursing Scholarship, are a warning sign that the common practice by many hospitals of relying on agency nurses is not a risk-free option for patients.
The University of Southampton study found that risk of death increased by 12 per cent for every day a patient experienced a high level of temporary staffing – defined as 1.5 hours of agency nursing a day per patient. For an average ward, this increased risk could apply when between a third and a half of the staff on each shift are temporary staff, according to Professor Peter Griffiths, one of the study’s authors.
He told The Independent: “We know that patients are put at risk of harm when nurse staffing is lower than it should be.
“One of the responses to that is to fill the gaps with temporary nursing staff, and that is an absolutely understandable thing to do, but when using a higher number of temporary staff there is an increased risk of harm.
“It is not a solution to the problem.”
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Source: The Independent, 10 December 2019
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Hospital fined over death of patient who was given five times amount of drugs needed

A hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed.
Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions.
The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded.
Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days.
An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”.
Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made.
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Source: The Independent, 12 December 2019
Patient Safety Learning

Pager systems used in healthcare could be exposing patient data across Canada

Paging systems used across B.C could be exposing sensitive health data of patients, and the privacy researcher who first discovered the data breach believes it’s likely happening across the country.
“I wouldn’t be surprised to find this everywhere in Canada,” said privacy researcher Sarah Jamie Lewis, in an interview with CTVNews.ca in Vancouver. Lewis first discovered and reported the breach to Vancouver Coastal Health in November 2018. Now, internal emails released this month through a Freedom of Information request show that the vulnerability is not limited to Vancouver.
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Source: CTV News, 13 December 2019
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