Skip to content

News

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

Infection control experts issue open letter on care home visiting

A group of experts in nursing and infection prevention and control (IPC) is today warning against the use of IPC measures as a “rationale” for stopping safe and compassionate visits in care homes during the Covid-19 pandemic.
In a new open letter published in Nursing Times, the specialists say that preventing people from visiting loved ones in social care settings in the name of IPC is a “misinterpretation and at times even abuse” of IPC principles.
The letter is the brainchild of independent global health consultant and former Infection Prevention Society (IPS) president, Jules Storr. Among the signatories are five former IPC presidents, current president Pat Cattini as well as incoming president Jennie Wilson. Dr Ron Daniels, chief executive of the UK Sepsis Trust, is also on the list, Helen Hughes, chief executive of Patient Safety Learning, as well as leading IPC nurse specialists, nurse academics, a GP and carers.
Ms Storr, a nurse by background, and the hub topic lead, said she was motivated to take action after hearing “the most heart-breaking” stories from health professionals and relatives of residents about restricted visits in the UK in the wake of COVID-19.
Some had not seen relatives for weeks or months, whilst others were only allowed to see their loved one once a week for 20 minutes at a distance, she said.
One individual had told her how when their father had died only one family member was permitted in the home and they were not allowed to sit close enough to hold his hand.
Ms Storr said these practices were “absolutely outrageous and wrong from an infection prevention point of view”.
Read full story
Source: Nursing Times, 16 October 2020
Patient Safety Learning

Leaking vials supplied for NHS test and trace, say whistleblowers

Leaking vials and suspected contamination were identified in a batch of more than 500,000 test tubes produced for the NHS Covid test and trace operation over the summer, whistleblowers have said.
The test tubes were provided by a small UK-based company, Life Science Group (LSG), which produces materials for the diagnostics industry.
According to the whistleblowers, there have been repeated problems with test tubes filled by LSG leaking. Stocks of some 600,000 test tubes were inspected in August as a result, and records seen by the Guardian describe the discovery of what looked like hair and blood contamination.
It is understood firms in the supply chain concluded that the contamination was not hair or blood, following inspections. However, records seen by the Guardian suggested at least one bag of LSG test tubes thought to be contaminated “cannot now be found”.
The whistleblowers said that rather than rejecting the entire potentially compromised batch, as would be normal safety protocol with NHS supplies, only part of the batch with visible problems was removed from use. They said they had blown the whistle because they were concerned for public safety.
Read full story
Source: The Guardian, 16 October 2020
Patient Safety Learning

England's 'fragile' care sector needs immediate reform, says regulator

The government must immediately deliver a new deal for social care with major investment and better terms for workers, the Care Quality Commission (CQC) has said, as it warned that the sector is “fragile” heading into a second wave of coronavirus infections.
In a challenge to ministers, the regulator’s chief executive, Ian Trenholm, said overdue reform of the care sector “needs to happen now – not at some point in the future”.
Boris Johnson said in his first speech as prime minister, in July 2019: “We will fix the crisis in social care once and for all.” But no reform has yet been proposed, and more than 15,000 people have died from COVID-19 in England’s care homes.
Trenholm said Covid risked turning inequalities in England’s health services from “faultlines into chasms” as the CQC published its annual State of Care report on hospitals, GPs and care services.
The report reveals serious problems with mental health, maternity services and emergency care before the pandemic, and says these areas must not be allowed to fall further behind.
The regulator argued that the health system’s response to the pandemic needs to change. After focusing on protecting NHS services from being overwhelmed, health leaders must now adapt to prevent people who need help for non-Covid reasons from being left behind, it said.
These include people whose operations were cancelled and people from black and minority ethnic backgrounds, people with disabilities, and people living in deprived areas who have suffered more severely from the impact of Covid.
“Covid is magnifying inequalities across the health and care system – a seismic upheaval which has disproportionately affected some more than others,” said Trenholm.
Read full story
Source: The Guardian, 16 October 2020
Patient Safety Learning

Parents win six-year battle for truth after NHS ‘cover-up’ of son’s death

The parents of a three-year-old boy whose death was part of an alleged NHS cover-up have won a six year battle for the truth about how he died.
Shropshire coroner John Ellery backed the parents of three-year-old Jonnie Meek in a second inquest into his death on Thursday and rejected evidence from nurses about what happened at Stafford Hospital in August 2014.
Jonnie, who was born with rare congenital disability De Grouchy syndrome, died two hours after being admitted to hospital to trial a new feed which was being fed directly into his stomach. His parents, John Meek and April Keeling, from Cannock in Staffordshire, have always maintained their son died after a reaction to the milk feed caused him to vomit and suffocate.
But they have been forced to battle what they believe was an attempt to hide what happened after they discovered attempts to alter their son’s medical history with claims he had experienced several cardiac arrests requiring resuscitation which never happened.
In 2015, healthcare assistant Lauren Tew, who was with Jonnie and his mother when he died, told the HSJ that a statement in her name submitted to a child death overview panel stating Jonnie had died from a sudden cardiac arrest was false and she had never made such a statement.
Another statement said Jonnie had been admitted to hospital for three weeks months before his death which also never happened.
After his parents exposed the false statements an independent inquiry was launched, with three independent experts agreeing with Jonnie’s parents, and in April last year the High Court quashed the original inquest verdict that Jonnie died of natural causes and pneumonia.
Speaking to The Independent Jonnie’s father said: “This does bring us some peace after six years. For the coroner to say he believes April over the nurses after all this time is a big weight lifted off her.
“The hospital definitely decided to try and cover up what happened to Jonnie. We have always said we knew what happened and this has been a massive waste of resources. I am still very concerned about how these things can happen in the first place.”
Read full story
Source: The Independent, 15 October 2020
Sam

Ontario woman finds needle in her spine 16 years after giving birth

When the pain in her shoulders and weakness in her right leg started two years ago, Giovanna Ippolito thought it was just part of getting older — that's until the 46-year-old's doctor ordered an X-ray that showed a five-centimetre long, broken needle embedded in her spine.
It was a medical error that took more than a decade to discover — after medical staff at the time failed to report it. 
Exactly when the needle was left in Ippolito's spine is unclear, but she says she's only had something injected into her back twice — during the birth of her son in 2002 and her daughter in 2004. 
Ippolito says she believes the needle broke off when medical staff at Mackenzie Richmond Hill Hospital in nearby Richmond Hill (called York Central Hospital at the time) administered a spinal block or an epidural during one of the births.
She's now locked in a battle with the hospital for answers and accountability. But experts say, with a system that's stacked against Canadians harmed by medical errors, it's likely no one will have to take responsibility.
More than 132,000 patients experienced some kind of medical harm — something both preventable and serious enough to require treatment or a longer hospital stay — in 2018-19, according to the Canadian Institute for Health Information, an independent, not-for-profit organization that collects information on the country's health systems.
Read full story
Source: CBC, 5 October 2020
Patient Safety Learning

Hospitals Liverpool Covid admissions will 'devastate' other hospital care

The large number of COVID-19 patients being admitted to hospitals at the centre of the second wave will “devastate” care for people with other illnesses, a top doctor has said.
Dr Tristan Cope said Liverpool’s acute hospitals would not be able to continue providing normal care because of the high number of people being treated for serious Covid symptoms. Unless the surge in coronavirus admissions slowed down it would “have a devastating effect on planned care, such as operations”, he said.
Cope is the medical director of Liverpool university hospitals NHS trust, where almost all critical care beds are already full because the city’s high infection rate has placed intense pressure on the trust’s three hospitals: the Royal Liverpool, Broadgreen and Aintree.
“Liverpool hospitals are under enormous pressure with admissions of sick Covid patients. We are used to pressure, but this is over and above that,” Cope tweeted last week.
“We have the highest number of Covid patients in the UK, nearly as many now as at the peak of the first wave. We also have more Covid patients in ICU [intensive care units] than any other trust in the UK.”
Cope said: “If we don’t reduce the rate of infection in the community and Covid admission rates continue to rise, it will inevitably have a massive effect on non-urgent care."
“If we don’t get control of [the] spread of the virus in the community and admissions continue at the current rate, our hospitals will not be able to cope. This will have a devastating effect on planned care, such as operations.”
Read full story
Source: The Guardian, 15 October 2020
Patient Safety Learning

Deaths at home: More than 26,000 extra this year, ONS finds

More men than normal are dying at home from heart disease in England and Wales and more women are dying from dementia and Alzheimer's disease, figures show.
More than 26,000 extra deaths occurred in private homes this year, an analysis by the Office for National Statistics found.
In contrast, deaths in hospitals from these causes have been lower than usual.
The Covid epidemic may have led to fewer people being treated in hospital or it may be that people in older age groups, who make up the majority of these deaths, may be choosing to stay at home – but the underlying reasons for the figures are still not clear.
Read full story
Source: BBC News, 19 October 2020
Patient Safety Learning

Midwives and paramedics can deliver flu and covid vaccines after new laws come into force

A wider range of healthcare workers—including midwives, paramedics, physiotherapists, and pharmacists—are now allowed to give flu and potentially COVID-19 vaccines after the introduction of new laws by the UK government.
The changes to the Human Medicines Regulations 2012, first proposed in August1 and consulted upon last month, came into effect on 16 October.
The Department of Health and Social Care said that the expanded workforce will have to undergo additional training to ensure patient safety. It added that government planning will “ensure this does not affect other services in hospitals and in GP and community services, by drawing on a pool of experienced NHS professionals through the NHS Bring Back Scheme.”
Commenting on the changes, England’s deputy chief medical officer Jonathan Van-Tam said, “The measures outlined today aim to improve access and strengthen existing safeguards protecting patients.”
Read full story
Source: BMJ, 16 October 2020
Patient Safety Learning

Covid survivors say ‘brain fog’ has impaired their ability to function normally

After contracting COVID-19 in March, Michael Reagan lost all memory of his 12-day vacation in Paris even though the trip was just a few weeks earlier.
Several weeks after Erica Taylor recovered from her coronavirus symptoms of nausea and cough, she became confused and forgetful, failing to even recognise her own car, the only Toyota Prius in her apartment complex’s parking lot.
Lisa Mizelle, a veteran nurse practitioner at an urgent care clinic who fell ill with the virus in July, finds herself forgetting routine treatments and lab tests, and has to ask colleagues about terminology she used to know automatically.
It is becoming known as Covid “brain fog”: troubling cognitive symptoms that can include memory loss, confusion, difficulty focusing, dizziness and grasping for everyday words. Increasingly Covid survivors say brain fog is impairing their ability to work and function normally.
“There are thousands of people who have that,” said Dr Igor Koralnik, chief of neuro-infectious disease at Northwestern Medicine in Chicago, who has already seen hundreds of survivors at a post-Covid clinic he leads. The effect on the workforce that is affected is going to be significant, he added.
Read full story
Source: The Irish Times, 18 October 2020
Patient Safety Learning

Endometriosis care needs urgent improvement, MPs say

Endometriosis care across the UK needs urgent improvement and diagnosis times need to be cut in half, a report by MPs says. It found an average wait for a diagnosis was eight years and that has not improved in more than a decade.
Endometriosis affects one in 10 women in the UK and causes debilitating pain, very heavy periods and infertility.
Nadine Dorries, minister for women's health, said awareness was increasing but there was still a long way to go.
More than 10,000 people took part in the All-Party Political Group inquiry which found that 58% of people visited the GP more than 10 times before diagnosis and 53% went to A&E with symptoms before diagnosis.
The majority of people also told MPs their mental health, education and careers had been damaged by the condition.
About 90% said they would have liked access to psychological support but were never offered it, with 35% having a reduced income due to endometriosis.
Helen-Marie Brewster, 28, from Hull, has been told by doctors that her only remaining treatment option is a full hysterectomy. She had symptoms throughout secondary school but was only diagnosed when she left education.
"GPs ask me to explain to them what endometriosis is, because they don't know. They're the ones who are meant to help."
"Last year I visited the A&E department 17 times trying to find help and pain relief for this condition, even for just a few days so I can keep going. The wait time for diagnosis is so long that in that time it's spreading and doing more damage the longer it is left untreated... We can't carry on like this."
Read full story
Source: BBC News, 19 October 2020
Read press release
Patient Safety Learning

Covid: Greater Manchester running out of hospital beds, leak reveals

Greater Manchester is set to run out of beds to treat people left seriously ill by COVID-19, and some of the region’s 12 hospitals are already full, a leaked NHS document has revealed.
It showed that by last Friday the resurgence of the disease had left hospitals in Salford, Stockport and Bolton at maximum capacity, with no spare beds to help with the growing influx. The picture it paints ratchets up the pressure on ministers to reach a deal with local leaders over the region’s planned move to the top level of coronavirus restrictions.
It suggested that Greater Manchester’s hospitals are quickly heading towards being overwhelmed by the sheer number of people with Covid needing emergency care to save their lives, in the same way that those in Liverpool have become in recent weeks. By Friday 211 of the 257 critical care beds in Greater Manchester – 82% of the total supply – were already being used for either those with Covid or people who were critically ill because of another illness.
Read full story
Source: The Guardian, 18 October 2020
Patient Safety Learning

Coronavirus: Survival rate of intensive care patients improving, data suggests

As hospitalisations and intensive care admissions surge around the country, new figures indicate coronavirus patients in critical care have a better survival rate now than when the pandemic first began.
The latest report from The Intensive Care National Audit and Research Centre (ICNARC) into critical care for England, Wales and Northern Ireland looks at patients admitted to intensive care up until 31 August and those admitted from 1 September.
The data shows that on average, 39% of critical care coronavirus patients died up until the end of August while less than 12% have died since September.
The proportion of patients who died after being admitted to critical care fell by almost a quarter from the peak and as much as half in hospitals overall.
However, the Dean of the Faculty of Intensive Care Medicine, Dr Alison Pittard, told the BBC that the difference may be attributed to an insufficient amount of time having passed which impedes an accurate and longterm patient assessment, as some remain in hospital.
Meanwhile, scientific advisors continue to warn that the next few weeks are critical for regulating hospital admissions.
Read full story
Source: The Independent, 18 October 2020
Patient Safety Learning

WHO Quality of Health Care and Patient Safety Offices to be Located in Athens

The offices of the World Health Organisation (WHO) for the Quality of Health Care and Patient Safety will be located in Athens, Health Minister Vassilis Kikilias and the WHO Regional Director for Europe, Hans Kluge, announced on Friday after their meeting in Copenhagen.
"The choice of Greece is a recognition of the work by Prime Minister Kyriakos Mitsotakis, the Greek Ministry of Health and the Greek government in managing the pandemic and implementing public health policies, such as the successful implementation of the anti-smoking law, and promoting important reforms, such as passing the law for the establishment of the National Organisation for Quality Assurance in Health," the health ministry said in a statement.
"Greece has recently led important developments in the field of health, such as legislation banning smoking in public places, the launch of the National Anti-Smoking Action Plan and reforms in the field of primary health care."
"All the above, in combination with the excellence of the Greek health institutions and the leading researchers in the field of health and wellness, indicate a strong leadership within the European Region and beyond. In addition, they create an ideal framework for the creation of a much-needed centre of excellence in the field of quality healthcare and patient safety."
Read full story
Source: The National Herald, 16 October 2020
Patient Safety Learning

Down's syndrome language: 'No-one meant anything hurtful"

A mother of a young boy with Down's syndrome is helping to teach people about appropriate language, after being hurt by words people often used.
Becca, from Cornwall, uses flashcards to make sure people are aware to say things like saying someone "has Down's syndrome", rather than "suffers with Down's syndrome".
The campaign is being rolled out in hospitals for midwives and other healthcare workers to use, with many in the profession talking about it on social media.
A children's clothing company has offered to run it, with her son Arthur as the model, and she has been asked to translate it into other languages.
Source: BBC News, 15 October 2020
Patient Safety Learning

Pharmacist-led digital intervention reduces hazardous prescribing in general practice

A pharmacist-led, new digital intervention that improves patient safety when prescribing medication in general practice reduced rates of hazardous prescribing by more than 40%, 12 months after it had been introduced to 43 GP practices in Salford, finds a new study. Due to its success, plans are underway to roll it out across Greater Manchester.
Prescribing and medication are one of the biggest causes of patient safety incidents and the third WHO Global Patient Safety Challenge is focussed on Medication without Harm. The SMASH intervention addresses this. It was developed by researchers at the National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC), which is a partnership between The University of Manchester and Salford Royal hospital in collaboration with The University of Nottingham.
Pharmacists working in general practice use the SMASH dashboard to identify patients who are exposed to potentially hazardous prescribing. For example, patients with a history of internal bleeding may be prescribed medications such as aspirin which could increase the risk of further internal bleeds without prescribing other treatments to protect them. SMASH identifies this and warns healthcare professionals about it, who can then decide on a possible course of action.
The intervention is unique due to its ability to provide near real time feedback to prescribers as it updates every evening.
Professor Darren Ashcroft, Research Lead for the Medication Safety theme at the GM PSTRC, said: "We worked with the Safety Informatics theme at the GM PSTRC to develop then test SMASH. It is designed to improve patient safety in general practice by reducing potential problems made when prescribing medication and inadequate blood-test monitoring. It brings together people and data to reduce these common medication safety problems that all too often can cause serious harm."
Read full story
Source: EurekAlert, 14 October 2020
Patient Safety Learning

Covid: Burn-out fears of 'exhausted' unpaid carers

Many unpaid carers looking after vulnerable friends or relatives during the coronavirus crisis say they are worried about how they will cope this winter.
Almost 6,000 unpaid carers completed a Carers UK online questionnaire. Eight in 10 said they had been doing more, with fewer breaks, since the pandemic began - and three-quarters said they were exhausted.
The government said it recognised the "vital role" of unpaid carers.
In the Carers UK survey, 58% of carers said they had seen their physical health affected by caring through the pandemic, while 64% said their mental health had worsened.
People also said day centres and reductions in other services meant the help they once got had reduced or disappeared, leaving many feeling worn out and isolated. Carers UK wants such services up and running again as a matter of urgency.
Helen Walker, chief executive of Carers UK, said: "The majority of carers have only known worry and exhaustion throughout this pandemic.
"They continue to provide extraordinary hours of care, without the usual help from family and friends, and with limited or no support from local services."
"It's no surprise that carers' physical and mental health is suffering, badly. I am deeply concerned that so many carers are on the brink and desperately worried about how they will manage during the next wave of the pandemic."
Read full story
Source: BBC News, 20 October 2020
Sam
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.