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

Patients Know Best launches education programme for medical students

Patients Know Best has launched an education programme which can be used by medical schools. 
Among the first to use the programme are undergraduate Pharmacy students at Liverpool John Moores University (LJMU).
The Patients Know Best platform, which recently became the first personal health record to be fully integrated into the NHS App, has been incorporated into the curriculum to facilitate simulated interactions between patients and pharmacists.
This has involved training the students to use Patients Know Best to enable their use of the platform to interact and collaborate with each other.
Read the full article here.
Clive Flashman

Social care at breaking point in England after 'lost decade'

Policymakers’ failure to tackle chronically underfunded social care has resulted in a “lost decade” and a system now at breaking point, according to a new report.
A team led by Jon Glasby, a professor of health and social care at the University of Birmingham, says that without swift government intervention including urgent funding changes England’s adult social care system could quickly become unsustainable.
Adult social care includes residential care homes and help with eating, washing, dressing and shopping. The paper says the impact has been particularly felt in services for older people. Those for working-age people have been less affected.
It suggests that despite the legitimate needs of other groups “it is hard to interpret this other than as the product of ageist attitudes and assumptions about the role and needs of older people”.
Read full story
Source: The Guardian, 9 August 2020
Patient Safety Learning

NHS told to let patients initiate follow-up appointments

Trusts are being encouraged to adopt a system in which patients initiate follow up appointments by the lastest guidance from NHS England designed to help the NHS recover from the covid crisis. 
It is hoped the approach can reduce unnecessary demand and therefore help trusts cut waiting lists that have soared as a result of the restrictions placed on hospital activity during the pandemic.
Under 'patient initiated follow up' (PIFU) patients decide when they require follow up appointments. They are given guidance as to what symptoms and other factors they should take into account when deciding if a follow up appointment is necessary. PIFU is already used by some trusts, but it has not yet become widely adopted. 
The plan to increase PIFUs was set out in a guidance published today designed to underpin the “phase three letter” sent out to NHS leaders last week.
The guidance, Implementing phase 3 of the NHS response to COVID-19 pandemic , says “individual services should develop their own guidance, criteria and protocols on when to use PIFUs”. The document also sets out some overarching principles.
It says services will be rated against the following headline metrics: “total number and proportion of patients on the PIFU pathway; patient outcomes, e.g. recovery rates, relapse rates; waiting times; and DNA rates”.
Read full story (paywalled)
Source: HSJ, 7 August 2020
Patient Safety Learning

NHS hospitals ordered to remove drug after mistakes led to two baby deaths

All NHS hospitals in England have been told to destroy a powerful medicine mistakenly used by staff because its packaging looks the same as another drug.
A national safety alert was issued following several incidents, including two deaths of babies, in which patients were inadvertently given a dose of sodium nitrite – which is used as an antidote to cyanide poisoning – rather than sodium bicarbonate.
The errors are thought to have been caused by similarities between the labelling and drug packaging used by manufacturers. Now hospitals have been told to check all wards and medicine storage areas for sodium nitrite and to destroy any of the unlicensed product. The drug should only be available in emergency departments and may have been supplied to medical wards by mistake.
There are an estimated 237 million medication errors in the NHS every year – with a third linked to packaging and labelling.
Read full story
Source: The Independent, 9 August 2020
Patient Safety Learning

Coronavirus: Randox recalls up to 750,000 test kits over safety concerns

Up to 750,000 unused coronavirus testing kits are being recalled due to safety concerns.
The UK's medicines and healthcare products regulator (MHRA) asked Randox to recall the kits sent out to care homes and individuals.
The government said it was a "precautionary measure" and the risk to safety was low.
It comes weeks after the health secretary said Randox kits should not be used until further notice.
A spokeswoman said: "We have high safety standards for all coronavirus tests. Following the pausing of Randox kits on 15 July, Randox have now recalled all test kits as a precautionary measure."
Care home residents or staff with symptoms of coronavirus can continue to book a test, she said.
Read full story
Source: BBC News, 8 August 2020
Patient Safety Learning

Patient deaths prompt ambulance chiefs to look for alternative defibrillators

Ambulance chiefs are looking at alternative defibrillators after coroners highlighted confusion over how to correctly use their existing machines.
London Ambulance Service (LAS) Trust has received two warnings from coroners since 2016 after the delayed use of Lifepak 15 defibrillators “significantly reduced” the chances of survival for patients, including a 15-year-old boy.
Coroners found some paramedics were unaware the machines had to be switched from the default “manual” mode to an “automatic” setting.
The first warning came after the death of teenager Najeeb Katende in October 2016. A report by coroner Edwin Buckett said the paramedic who arrived had started the defibrillator in manual mode and did not detect a heart rhythm that was appropriate for administering the device, so it was not used until an advanced paramedic arrived on scene 24 minutes later.
The report stated the defibrillator had been started in manual mode but it needed to be switched to automatic to detect a shockable heart rhythm. The coroner warned LAS that further deaths could occur if action was not taken to prevent similar confusion.
But another warning was issued to the LAS in March this year, following the death of 35-year-old Mitica Marin. Again, a coroner found the paramedic, who was on her first solo shift, had started the machine in manual mode and had not detected a shockable rhythm. It was suggested this caused a four minute delay in the shock being administered.
Coroner Graeme Irvine said this was “not an isolated incident” for LAS and noted the trust had reviewed other cases of delayed defibrillation. They found that the defibrillator’s manual default setting was a “contributing factor” to the delays.
Read full story (paywalled)
Source: HSJ, 10 August 2020
Patient Safety Learning

Surgeons told not to discuss lack of PPE

Dozens of surgeons have reported being told by the NHS employer to stop discussing shortages of personal protective equipment (PPE) during the coronavirus crisis.
The Confederation of British Surgery (CBS) said almost 70 surgeons working in major hospitals around the country had been warned off discussing a lack of PPE by their trust.
A third of surgeons said the supply of PPE was inadequate at their hospital, with many complaining of inconsistent guidance, rationing of supplies and poor quality PPE when it was available. When asked if their concerns were dealt with satisfactorily, nearly a third said they were not addressed, or not effectively.
A survey of 650 surgeons by the union found many were now considering changes to the way they worked as a result of the crisis – with more than half, 380, saying they would be avoiding face-to-face meetings with patients in the future.
More than 40 surgeons, around 7%, said they were now considering leaving surgery altogether.
Read full story
Source: The Independent, 10 August 2020
Patient Safety Learning

Boris Johnson announces £300m for A&Es ahead of potential winter spike

Boris Johnson has said the government will allocate £300m to NHS trusts to upgrade A&E facilities ahead of a potential spike in coronavirus cases this winter.
The funding, which will be split between 117 trusts, comes alongside attempts to reassure members of the public that it is safe to visit A&E departments during the COVID-19 pandemic.
“Thanks to the hard work and tireless efforts of NHS staff throughout the pandemic, our A&Es have remained open for the public,” the prime minister said in a statement.
“It is vital that those who need emergency treatment this winter access it, and for those who remain concerned about visiting hospitals, let me assure you that the NHS has measures in place to keep people safe.”
Hospitals will be able to use the funding to expand waiting areas and increase the number of treatment cubicles to boost A&E capacity, while social distancing rules and hygiene measures are in place to protect patients from COVID-19.
Read full story
Source: The Independent, 10 August 2020
Patient Safety Learning

Long-term COVID-19 health impacts research study launched

Health Secretary Matt Hancock has announced one of the world’s largest comprehensive research studies into the long-term health impacts of coronavirus on hospitalised patients.
Backed by an award of £8.4m in funding by the Government, through UK Research and Innovation (UKRI) and the National Institute for Health Research (NIHR), the study is expected to include around 10,000 across the UK and will support the development of new measures to treat NHS patients with coronavirus.
The study will be led by the NIHR Leicester Biomedical Research Centre, a partnership between the University of Leicester and University Hospitals of Leicester NHS Trust and will draw on the expertise of a consortium of leading researchers and doctors from across the UK.
They will assess and publish findings on the impact of COVIDd-19 on patient health and their recovery, including looking at potential ways to help improve the mental health of patients hospitalised with the virus and how individual characteristics such as gender and ethnicity influence recovery.
Patients on the study from across the UK will be assessed using techniques such as advanced imaging, data collection and analysis of blood and lung samples, creating a comprehensive picture of the impact COVID-19 has on longer-term health outcomes.
The findings will support the development of new strategies for clinical and rehabilitation care, including personalised treatments based on the particular disease characteristics that a patient shows, to improve their long-term health.
Read full story
Source: National Health Executive, 10 August 2020
Patient Safety Learning

GPs want legally mandated face masks in practices

Over 8 out of 10 (84%) of members of the Medical Protection Society thinks a face covering should be mandatory when attending any healthcare setting.
This was the finding of a survey including 562 of the GP indemnity providers' members, out of which 473 said masks should be mandated by law as they are on public transport and in shops.
Effective from 13 July, PHE guidance says all clinical and non-clinical staff as well as patients should wear a face mask in areas of GP practices that cannot be made 'Covid-secure' through social distancing, optimal hand hygiene, frequent surface decontamination, ventilation and other measures.
But NHS England has said GPs cannot refuse to treat patients who present at the practice without a face covering because they are not legally required to wear them. In response to its member survey, MPS has urged political leaders to ‘reconsider’ this decision.
Medicolegal lead for risk prevention Dr Pallavi Bradshaw stressed that ‘it cannot be right’ for frontline healthcare workers to be put at ‘unnecessary risk by patients who refuse to wear a face mask’.
Read full story
Source: Pulse, 8 August 2020
Patient Safety Learning

Coronavirus: Severe mental health problems rise amid pandemic

Doctors are seeing a rise in people reporting severe mental health difficulties, a group of NHS leaders says.
It follows a more than 30% drop in referrals to mental health services during the peak of the pandemic.
But there are predictions that the recent rise will mean demand actually outstrips pre-coronavirus levels - perhaps by as much as 20%.
The NHS Confederation said those who needed help should come forward.
But the group, which represents health and care leaders, said in a report that mental services required "intensive support and investment" in order to continue to be able to help those who needed it.
Read full story
Source: BBC News, 12 August 2020
Patient Safety Learning

A third of NHS staff in two hospital units were infected with coronavirus without showing symptoms, study finds

A new study has highlighted the number of NHS staff who can be infected with coronavirus but be completely unaware they are a risk to their colleagues and patients.
The research by doctors at University College London Hospitals (UCLH) found a third of staff working in two maternity departments at UCLH and St George’s Hospital tested positive for the virus but had no symptoms.
Overall, one in six staff who had not previously been diagnosed with the virus were tested for COVID-19 antibodies and were found to be positive for infection.
Prof Keith Neal, emeritus professor of epidemiology of infectious diseases at the University of Nottingham, who was not involved in the research, said: “Asymptomatic healthcare workers with COVID-19 pose a risk of spreading the virus depending on the personal protective equipment in use. We know many cases were acquired in hospital.
“Regular testing of healthcare workers is clearly warranted.”
Read full story
Source: The Independent, 12 August 2020
Patient Safety Learning

Coronavirus: Deaths of hundreds of frontline NHS and care workers to be investigated

The deaths of hundreds of NHS and social care workers infected with coronavirus are under investigation by medical examiners, The Independent has learnt.
Ministers have asked medical examiners in England and Wales to review all deaths of frontline health and social care staff infected with the virus to determine whether the infection was caught as a result of their work.
The review, which started last month, is likely to cover more than 620 deaths including nurses, doctors and care home staff across England and Wales, since the beginning of March.
It could trigger a number of investigations by hospitals, the Health and Safety Executive, and coroners into the protection, or lack of, for staff during the pandemic when many hospitals ran out of protective masks and clothing for staff.
Hospitals have already been ordered to risk assess workers who may be more susceptible to the virus, such as those from a black and minority ethnic backgrounds or those with existing health conditions.
Read full story
Source: The Independent, 12 August 2020
Patient Safety Learning

New A&E models may increase 'discrimination’ against some patients

The development of separate emergency units to help acute trusts manage demand during the covid pandemic may risk increasing “discrimination” against mental health patients, a royal college has warned.
In a report shared with HSJ, the Royal College of Psychiatrists said separate emergency assessment units being set up by mental health trusts offered a calmer environment for mental health patients and reduced pressure on emergency departments.
But the report, based on 54 survey responses from liaison psychiatry teams, also warned there was a “potential to increase the stigmatisation of mental illness by emergency department staff”.
It added: “Within a general hospital there is a risk that prejudicial attitudes amongst staff translate into discriminatory behaviour towards patients. The provision of a separate mental health emergency assessment facility on another site may reinforce the erroneous view that the assessment and management of mental health problems is not a role for an emergency department.”
Read full story (paywalled)
Source: HSJ, 11 August 2020
Patient Safety Learning

Trust declares critical incident over ‘relentless demand’

Gloucestershire Hospitals FT declares critical incident after ‘relentless demand’ on emergency care Pressure comes two months after trust downgraded one of its A&Es ‘Tired’ staff warned a ’Herculean effort’ is needed to reset emergency system NHS 111 cited as pinch point A trust has declared a critical incident after experiencing “relentless demand” on urgent and emergency care, months after downgrading one of its emergency departments.
The internal critical incident was raised by Gloucestershire Hospitals Foundation Trust yesterday. An internal memo said the previous three days “have seen unprecedented demand fall on the Gloucestershire urgent and emergency care system”.
Clinicians have been told that early discharges need to be identified on both its Cheltenham General and Gloucestershire Royal hospital sites, to try to free up bed-space, and that all non-essential meetings, besides those at executive level, should be cancelled.
The incident comes after the trust decided in June to downgrade the A&E department at Cheltenham General to a minor injuries unit, operating from 8am to 8pm. Previously, the unit offered a full A&E service between 8am and 8pm, with a “nurse-led” minor injuries service outside these hours.
The problems appear to be unrelated to covid-19, although infection control measures are known to have reduced capacity in many A&Es and wards.
HSJ understands that local managers believe NHS 111, run by Care UK Health Care, has been a particular cause of the problems in recent days, because it has not been directing enough people to alternative services; as well as workforce pressures and the hot weather.
Read full (paywalled) article here in the HSJ.
Clive Flashman

Breast screening women in their 40s 'could save lives'

Screening women for breast cancer from their 40s rather than their 50s could save lives without adding to the diagnosis of harmless cancers, a UK study has found.
The research was based on 160,000 women from England, Scotland and Wales, followed up for around 23 years.
Lowering the screening age could save one life per 1,000 women checked, the scientists say.
But experts caution there are many other considerations, including cost.
Cancer Research UK says it is still "not clear if reducing the breast screening age would give any additional benefit compared to the UK's existing screening programme".
The charity says the priority should be getting cancer services "back on track" for women aged 50-70, after disruption caused by the pandemic.
Read full story
Source: BBC News, 13 August 2020
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