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

Infected Blood Enquiry: Timetable and factsheet for expert hearings

This is the independent public statutory inquiry into the use of infected blood. 
The timetable and factsheet to provide information for those attending the hearings in London on 24-28 February have just been published.
Go to this link for more information >> https://www.infectedbloodinquiry.org.uk/news 
Clive Flashman

NHS staffing crisis: A critical exception to the immigration rules

Staffing shortages remain a pervasive challenge for the NHS, risking patient safety, care standards and the pursuit of innovation. 
There are now 106,000 vacancies across the NHS in England, with over 44,000 vacancies in nursing. Overseas staff are a crucial way of filling those vacancies, but the message to potential workers is confused to say the least.
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Source: Health Europa, 14 February 2020
Clive Flashman

The NHS should act now to avoid a worse crisis next winter

Action must be taken now if the NHS is to avoid an even worse winter crisis next year, the chief inspector of hospitals has warned.
The Care Quality Commission (CQC) said the use of corridors to treat sick patients in A&E was “becoming normalised”, with departments struggling with a lack of staff, poor leadership and long delays leading to crowding and safety risks. Professor Ted Baker said: “Our inspections are showing that this winter is proving as difficult for emergency departments as was predicted. Managing this remains a challenge but if we do not act now, we can predict that next winter will be a greater challenge still. “We cannot continue this trajectory. A scenario where each winter is worse than the one before has real consequences for both patients and staff.”
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Source: The Independent, 18 February 2020
 
 
Clive Flashman

Whistleblowing district nurse 'different person' after unfair dismissal

A senior district nurse who was unfairly dismissed after blowing the whistle over valid safety concerns has told how the ordeal has left her life in "chaos" and she feels forced to quit the profession for good. 
Linda Fairhall, who had worked at North Tees and Hartlepool NHS Foundation Trust for 38 years, has spoken to Nursing Times about her experiences after she successfully challenged her employer's decision to sack her. Between December 2015 to October 2016, Ms Fairhall raised 13 concerns to the trust regarding staff and patient safety. At the time, she was managing a team of around 50 district nurses in her role of clinical care co-ordinator.
Read full story (paywalled)
Source: Nursing Times, 17 February 2020
Clive Flashman

Not enough pharmacists are aware of the yellow card scheme

Every pharmacist must report adverse drug reactions using the yellow card scheme, says chair of the Community Pharmacy Patient Safety Group, Janice Perkins
Polypharmacy, when different medications are used by an individual at the same time, is becoming increasingly common because people are living for longer and with multiple different illnesses. One study, published in 2018 by the Oxford University Press, found that over half (54%) of those aged 65 years and above who took part in the study had two or more long-term conditions, for which they could have been taking a range of medicines.
Read full story
Source: Community Pharmacy News, 17 February 2020
Clive Flashman

The NHS In England: Patient safety news roundup from Harvard Law

There is always a lot happening with patient safety in the NHS (National Health Service) in England. Sadly, all too often patient safety crises events occur. The NHS is also no sloth when it comes to the production of patient safety policies, reports, and publications. These generally provide excellent information and are very well researched and produced. Unfortunately, some of these can be seen to falter at the NHS local hospital implementation stage and some reports get parked or forgotten. This is evident from the failure of the NHS to develop an ingrained patient safety culture over the years. Some patient safety progress has been made, but not enough when the history of NHS policy making in the area is analysed.
Lessons going unlearnt from previous patient safety event crises is also an acute problem. Patient safety events seem to repeat themselves with the same attendant issues.
Read full story
Source: Harvard Law, 17 February 2020
Clive Flashman

Baby boy died from sepsis after doctors’ delay giving antibiotics

A three-month-old boy died from sepsis after ‘gross failures’ by medics to give him antibiotics until it was too late, an inquest ruled. Lewys Crawford died a day after he was admitted to the University Hospital of Wales in Cardiff with a high temperature last March. Jurors at Pontypridd Coroner’s Court said the failure of doctors to treat his illness with antibiotics until seven hours after his arrival had ‘significantly contributed’ to his death. They found the little boy died from natural causes contributed to by neglect in his care.
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Source: The Metro, 15 February 2020
Patient Safety Learning

NHS Staff Survey 2019

Today the results of the National NHS Staff Survey 2019 are out. This is of the largest workforce surveys in the world with 300 NHS organisations taking part, including 229 trusts. It asks NHS staff in England about their experiences of working for their respective NHS organisations.
The results found that 59.7% of staff think their organisation treats staff who are involved in an error, near miss or incident fairly. While an improvement on recent years (52.2% in 2015) work is needed to move from a blame culture to one that encourages and supports incident reporting.
It also found that 73.8% of staff think their organisation acts on concerns raised by patients/service users. It is vital that patients are engaged for patient safety during their care and there is clear research evidence that active patient engagement helps to reduce unsafe care.
Patient Safety Learning has recently launched a new blog series on the hub to develop our understanding of the needs of patients, families and staff when things go wrong and looking at how these needs may be best met.
 
Patient Safety Learning

EFORT takes on the demanding implant and patient safety initiative

When orthopaedic surgeons plan a surgical procedure, they demand that safe implants be used. When a patient accepts to undergo surgery, he or she expects the implants used to be safe. When the manufacturer produces and delivers implantsto be used in patients, they take the implants through a meticulous investigation followed by an evaluation of the products by regulators and notified bodies, before the implant is released for free use on the European market by physicians. In this way, all “stakeholders” expect and desire to do their best to bring about safe implants that are used in surgery for patients, which fulfills patients’ expectations of receiving safe treatment.
However, history has shown that, although all participants in this process do their job to treat the patient safely, some implants may still unexpectedly fail. We need to know why this occurs and the trends associated with such failures, such as whether the implant or patient’s characteristics led to the problem or if there is some unforeseen reason that caused the implant to fail.
Incoming EFORT president Prof. Klaus-Peter Günther, of Dresden, Germany, has set up regular meetings to bring all 'stakeholders' in the safety of orthopaedic implants together to regularly discuss relevant issues related to safe implants used to safely treat patients. 
EFORT held the first such meeting, “EFORT Implant & Patient Safety Initiative. Inauguration Workshop,” on 21 January 21 in Brussels. Fifty participants from the EU Commission, notified bodies, regulators, patient organizations, European orthopaedic specialty societies, manufacturers and EFORT board participated in this first initiative. 
The next meeting on this initiative will be held on 10 June during the EFORT Congress in Vienna, Austria.
Read full story
Source: Orthopedics Today, 13 February 2020
Patient Safety Learning

‘Shameful’ data reveals NHS treatment of minority ethnic staff

Five years after launching a plan to improve treatment of black and minority ethnic staff, NHS England data shows their experiences have got worse.
Almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, according to “shameful” new data.
Minority ethnic staff in the NHS have reported a worsening experience as employees across four key areas, in a blow to bosses at NHS England, five years after they launched a drive to improve race equality.
Critics warned the experiences reported by BME staff raised questions over whether the health service was “institutionally racist” as experts criticised the NHS “tick box” approach and “showy but pointless interventions”.
Read full story
Source: The Independent, 18 February 2020
Patient Safety Learning

NHS Doctors bullied to the brink

The Doctors’ Association UK has compiled stories from 602 frontline doctors which expose a startling culture of bullying and overwork in the NHS.
The stories include:
a pregnant doctor who fainted after being forced to stand up for 15 hours straight and being denied water. The junior doctor was subsequently shouted at in front of colleagues and patients on regaining consciousness and told it was her choice to be pregnant and that ‘no allowances would be made’. a doctor who told us that a junior doctor hung themselves in a cupboard whilst on shift and was not found for 3 days as no-one had looked for them. His junior doctor colleagues were not allowed to talk about his suicide and it was all ‘hushed up’. a doctor who was denied a change of clothes into scrubs after having a miscarriage at work despite her trousers being soaked in blood. Full press release  
Clive Flashman

Skin cancer apps ‘cannot be relied upon for accurate results’, study finds

Smartphone apps designed to detect the risk of skin cancer are poorly regulated and “frequently cannot be relied upon to produce accurate results”, according to a new analysis. They found the apps may cause harm from failure to identify potentially deadly skin cancers, or from over-investigation of false positive results such as removing a harmless mole unnecessarily.
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Source: Digital Health, 14 February 2020
Clive Flashman

Doctors using AI to predict heart attack risk more accurately

London doctors are using artificial intelligence to predict which patients with chest pains are at greatest risk of death. 
A trial at Barts Heart Centre, in Smithfield, and the Royal Free Hospital, in Hampstead, found that poor blood flow was a “strong predictor” of heart attack, stroke and heart failure. Doctors used computer programmes to analyse images of the heart from more than 1,000 patients and cross-referenced the scans with their health over the next two years. The computers were “taught” to search for indicators of future “adverse cardiovascular outcomes” and are now used in a real-time basis to help doctors identify who is most at risk.
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Source: Evening Standard, 15 February 2020
Clive Flashman

New tech allowing district nurses to digitally monitor wounds

A new app has been piloted in North East London to help district nurses document chronic wound management more efficiently. The tech has been used in community services and stores a catalogue of photographs to accurately document chronic wounds. 
District nurses can use the app on a smartphone – making it lightweight, portable and easy to clean. Using two calibration stickers placed either side of the wound, the app can scan it and capture its size and depth to build a 3D image. Nurses can then fill out further characteristics on the software such as colour, pain level, location and smell to give a full picture of the wound’s development.
Read full story
Source: Nursing Times,  12 February 2020
Clive Flashman

Thousands of patients potentially harmed by undelivered NHS mail

The NHS has launched a patient safety inquiry after a private contractor failed to send more than 28,000 pieces of confidential medical correspondence to GPs. 
NHS bosses are trying to find out if any patients have been harmed after 28,563 letters detailing discussions at outpatient appointments were not sent because of a mistake by Cerner, an IT company. The letters should have been sent by doctors at Barnet and Chase Farm hospitals in north London to GPs after consultations with 22,144 patients between June last year and last month. However, a “clinical harm review” is under way after it was found they had not been dispatched.
The incident has prompted concern among GPs and patient representatives. “Patients who have attended these two hospitals will now be very worried about whether their care might have been compromised by this IT bungle”, said Rachel Power, the chief executive of the Patients Association.
Read full story
Source: The Guardian, 18 February 2020
Patient Safety Learning

Health Foundation to explore impact of data analytics and technology

The Health Foundation will begin exploring the impact of data analytics and technology on health and care in the UK.
The independent charity has launched its Data Analytics for Better Health strategy, which aims to tackle real-world problems that affect people’s health and develop a greater understanding of the role that technology and data plays in daily life. The strategy sets out how the Health Foundation aims to help policymakers, practitioners and the wider public get to grip with “seismic changes” taking place in the health sector.
Dr Adam Steventon, Director of Data Analytics at the Health Foundation, said: “Data is being used to drive innovation in ways that can revolutionise health care, including early disease detection, easier access to care services and encouraging health promoting behaviours. But such technological advances also carry the risk of harm to patients. As a nation we need to advance our understanding of these fast-moving changes. This new programme of work will help us to do that, enabling us to explore how analytics and data-driven technology can create better heath and care for people across the UK.”
Read full story
Source: Digital Health, 6 February 2020
Patient Safety Learning
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