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

The NHS staffing crisis is about the expanding knowledge gap – not just numbers

A lot has been written about the workforce crisis in health and social care. 43,000 registered nurse vacancies, a 48% drop in district nurses in eight years and not enough GPs to meet demand.
When we talk about workforce, the focus is always on numbers. There are campaigns for safe staffing ratios and government ministers like to tell us how many more nurses we have. But safety is not just about numbers. Recent workforce policy decisions have promoted a more-hands-for-less-money approach to staffing in healthcare. More lower-paid workers mean something in the equation has to give. In this case, it’s skill and expertise.
In this article in The Independent, Patient Safety Learning's Trustee Alison Leary  discusses how healthcare has failed to keep frontline expertise in clinical areas due to archaic attitudes to the value of the experienced workforce.
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Source: The Independent, 15 December 2019
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Weston General A&E rated 'inadequate' after warnings

A hospital A&E department has been rated "inadequate" after warnings over urgent and emergency care.
The Care Quality Commission (CQC) reported a lack of support for staff and safety concerns in Weston General hospital's A&E department.
Dr Nigel Acheson, deputy chief inspector of hospitals for the South NHS , said it was "disappointing". Weston Area Health NHS Trust "fully recognises that while improvements have been made... further work is required."
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Source: BBC News, 17 December 2019
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Coroner criticises NHS after death of patient with broken neck who was shunted between hospitals three times

An 88-year-old woman with a broken neck died after being transferred three times between two hospitals in the space of just 48 hours, The Independent has reveal.
The death of Jean Waghorn, who died after contracting pneumonia in hospital, sparked criticism from a coroner who said the NHS trust had ignored earlier warnings over moving patients between hospitals. Senior coroner Veronica Deeley had issued two official alerts to Brighton and Sussex Hospitals Trust last year after the deaths of frail elderly patients who were wrongly shuttled between hospitals.
But despite this, in June this year Ms Waghorn, who broke her neck after falling at home, was repeatedly transferred between the Princess Royal Hospital in Sussex and Brighton’s Royal Sussex County Hospital. She caught pneumonia and died two days later.
The hospital, which is rated good by the CQC, has now apologised and said it has learned lessons from the case. A spokesperson said it did take action following the previous warnings and added that work was ongoing to ensure the changes were consistently applied.
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Source: The Independent, 17 December 2019
Patient Safety Learning

Royal Derby Hospital: Disposable sterile hijabs introduced

A hospital trust believes it is the first in the UK to introduce disposable sterile headscarves for staff to use in operating theatres.
Junior doctor Farah Roslan, who is Muslim, had the idea during her training at the Royal Derby Hospital. She said it came following infection concerns related to her hijab that she had been wearing throughout the day.
It is hoped the items can be introduced nationally but NHS England said it would be up to individual trusts.
Ms Roslan looked to Malaysia, the country of her birth, for ideas before creating a design and testing fabrics. "I'm really happy and looking forward to seeing if we can endorse this nationally," she said.
Consultant surgeon Gill Tierney, who mentored Ms Roslan, said the trust was the first to introduce the headscarves in the UK. "We know it's a quiet, silent, issue around theatres around the country and I don't think it has been formally addressed," she said.
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Source: BBC News, 19 December 2019
Patient Safety Learning

Report highlights common ‘never event’ that leaves women at risk of harm after childbirth

Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. That’s the safety risk the Healthcare Safety Investigation Branch highlight in their new report published yesterday.
Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete.
The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found.
Sandy Lewis, HSIB’s Maternity Investigation Programme Director, said: “Although measures have been put in place to reduce the chance of swabs and tampons being left in, it continues to happen, leaving women in pain and distress when they may have already gone through a traumatic labour.
“There are numerous physical effects; pain, bleeding and possible infection, but we can’t forget about the psychological impact as there was in Christine’s case – she had to seek private counselling and felt that what happened affected her ability to bond with her baby."
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Source: Healthcare Safety Investigation Branch, 18 December 2019
Patient Safety Learning

Safety fears for hundreds of ‘hidden’ children on ventilators

Experts have warned hundreds of “hidden” children who rely on machines to help them breathe at home are at significant risk of harm due to staff shortages, poor equipment and a lack of training.
The number of children who rely on long-term ventilation is rising but new research has shown the dangers they face with more than 220 safety incidents reported to the NHS between 2013 and 2017.
In more than 40% of incidents the child came to harm, with two needing CPR after their hearts stopped. Other children had to have emergency treatment or were rushed back to hospital.
Many parents reported concerns with the skills of staff looking after their children or reported paid carers falling asleep while caring for their child. Families reported having to cover multiple night shifts due to staff shortages, while also having to care for their child during the day. Other patient safety incidents including broken or faulty equipment or information on packaging that did not match the item or incorrect equipment being delivered.
Consultant Emily Harrop, who led the study, said it was “easy for the plight of individual complex children to slip down the agenda”.
She warned: “This is a very hidden group of very vulnerable children who are at risk without investment in staffing, access to training and good communication."
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Source: The Independent, 18 December 2019
Patient Safety Learning

Dublin mental health centre falls short on physical restraint code

A Dublin mental health centre has failed to comply with the code of practice on physical restraint for four consecutive years, an inspection report has found.
The 39-bed Elm Mount Unit at St Vincent’s University Hospital said the issue was now high risk. 
Two episodes were recorded by the Mental Health Commission (MHC) where the staff member responsible for leading the physical restraint did not monitor the person’s head or airway, and that this went undocumented. In another case, inspectors noted, the physical restraint was not reviewed by members of the multidisciplinary team and recorded correctly.
There was also concern regarding the administration of medicine, specifically deficits in the prescription and administration record “which could potentially lead to medication errors”.
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Source: The Irish Times, 17 December 2019
Patient Safety Learning

NHS bed occupancy beyond safe levels ahead of Christmas

Hospital wards across the country are having to look after an unsafe number of patients, with hundreds of beds closed due to an outbreak of norovirus.
NHS England has said that on average almost 900 beds were closed each day during the week to Sunday 15 December.
Hospitals have reported fewer empty beds with bed-occupancy rates reaching as high as 95 per cent, 10 per cent higher than the recommended safe level.
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Source: The Independent, 20 December 2019
Patient Safety Learning

Coroner and friends criticise NHS treatment of 24-year-old anorexia victim

A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed.
Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder.
Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital.
He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria.
Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS.
Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.”
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Source: The Telegraph, 21 December 2019
Patient Safety Learning

New national investigation looks at outpatient appointments after hospital stays

The Healthcare and Safety Investigation Branch (HSIB) started a new national investigation looking into a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient hospital stay.
If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.
The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.
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Source: HSIB, 20 December 2019
Patient Safety Learning

Doctors told to use 'least unsafe' option in Norwich hospital

An NHS hospital has been so overwhelmed that it told senior doctors to make “the least unsafe decision” when treating patients.
Medical groups have voiced concern that Norfolk and Norwich hospital trust’s instruction to its consultants this week showed it was struggling so much to cope with the number of people needing care that patient safety was being put at risk.
At the time the hospital had no spare beds, a full accident and emergency department, 35 patients waiting on trolleys to be admitted, and had declared a major internal incident.
In its message, seen by the Guardian, it said: “We would like you to know that the trust will support you in making difficult decisions that may be the least unsafe decision, and we would appreciate your cooperation over the coming days with this.”
The circular from the Norwich hospital added: “We are facing our most challenging situation with our trust today,” because it was so overcrowded and unable to find a bed for the 35 patients doctors had decided needed to be admitted as emergencies.
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Source: The Guardian, 20 December 2019
Patient Safety Learning

Pharmacy staff are less concerned about prosecution when reporting patient safety incidents

Only 14% of pharmacy professionals are worried about criminal prosecution when reporting a patient safety incident, compared with 40% in 2016, survey results have showed.
The results of the 2019 ‘Patient safety culture survey’ of 917 pharmacy professionals, carried out by the Community Pharmacy Patient Safety Group (PSG) in April and May 2019 came after the introduction of a legal defence for dispensing errors in 2018.
The survey also showed that 22% of pharmacy professionals would not report a patient safety incident inside their organisation owing to fears of criminal prosecution. This is compared with 40% of 623 respondents saying in 2016 that they would not report a patient safety incident because of the possibility of criminal prosecution.
Janice Perkins, chair of the PSG, said the results “demonstrate that there have been significant positive improvements since 2016”.
“Nurturing an open and honest safety culture in community pharmacies is vital. It requires everyone to feel confident in openly sharing when things go wrong to learn from errors and prevent them occurring again,” she added.
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Source: The Pharmaceutical Journal. 19 December 2019
Patient Safety Learning

Two dead and hundreds harmed after being given wrong drugs in North East hospitals

Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal.
Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage.
At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died.
City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed.
An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world."
“As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.”
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Source: Chronicle Live, 22 December 2019
Patient Safety Learning

Nurses' strike in Northern Ireland: RCN confirms January strike dates

Nurses in Northern Ireland have announced their plans for further strike action in the new year.
Earlier this month, more than 15,000 nurses took to the picket lines over pay and staffing levels. It was the first time in the 103-year history of the Royal College of Nursing (RCN) that its members had taken such action.
It has announced nurses will strike on 8 January and 10 January 2020, unless a resolution is reached.
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Source: BBC News, 24 December 2019
Patient Safety Learning

Harvard researchers find significant clinical impact and cost savings with MedAware's patient safety platform

MedAware, a developer of AI-based patient safety solutions, has announced the publication of a study by The Joint Commission Journal on Quality and Patient Safety, validating both the significant clinical impact and anticipated ROI of MedAware's machine learning-enabled clinical decision support platform designed to prevent medication-related errors and risks.
The study analysed MedAware's clinical relevance and accuracy and estimated the platform's direct cost savings for adverse events potentially prevented in Massachusetts General and Brigham and Women's Hospitals' outpatient clinics. If the system had been operational, the estimated direct cost savings of the avoidable adverse events would have been more than $1.3 million when extrapolating the study's findings to the full patient population.  
Dr David Bates, study co-author, Professor at Harvard Medical School, and Director of the Center for Patient Safety Research & Practice at Brigham and Women's Hospital, said: "Because it is not rule-based, MedAware represents a paradigm shift in medication-related risk mitigation and an innovative approach to improving patient safety."
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Source: CISION PR Newswire, 16 December 2019
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