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

Safety watchdog says NHS ‘never event’ mistakes are not yet truly preventable

At least seven so-called NHS “never events” should be reclassified because the health service has failed to put in place effective measures to stop them from repeatedly happening, safety experts have said.
The independent Healthcare Safety Investigation Branch (HSIB) said NHS England should remove the never event incidents from the list of 15 it requires hospitals to report, because they are not “wholly preventable” and the NHS has not adequately recognised the systemic risks that mean they keep happening.
The errors include examples such as a 62-year-old man having the wrong hip replaced during surgery and a nine-year-old girl who was given a drug by injection that should have been given by mouth.
Other incidents included a woman who had a vaginal swab left inside her following the birth of her first child and a 26-year-old man who had a feeding tube accidentally inserted into his lung rather than his stomach.
In a new report, investigators from HSIB carried out a detailed analysis of seven incidents it has investigated which account for the majority of never events recorded by NHS hospitals in 2018-19.
NHS England claims there are steps hospitals can take that mean the errors should never happen but HSIB says many of the steps are administrative, such as a checklist, and do not fully take into account the environment staff work in, the nature of the errors or how they happen.
Read full story
Source: The Independent, 21 January 2021
Sam

Discover the new technology managing cancer symptoms for patients

In a new trial, cancer patients across the UK have been using the eRAPID technology system to help them manage their cancer symptoms.
The system has been developed by the University of Leeds, and this is the first trial to offer automated advice to early-stage patients whose treatment aims to cure cancer. Hundreds of early-stage colorectal, breast, or gynaecological cancer patients took part in the trial which used computer algorithms to help manage their symptoms and improve their wellbeing. They were able to report online symptoms from home and receive instant advice on whether to self-manage or seek medical attention.
Cancer can cause a range of different symptoms for patients living with the disease, as well as from the side effects of treatments such as chemotherapy, which are sometimes life-threatening and all of which lower a patients’ quality of life. Better monitoring and management of these symptoms can help in improving treatment delivery and reducing patients’ physical distress.
All patients in the trial received their usual care, with 256 receiving the eRAPID system as additional care. The patients reported better symptom control and physical wellbeing in the early weeks of treatment, with the system preventing symptom deterioration in about 9% of patients after 12 weeks.
Dr Kate Absolom, University Academic Fellow in the Leeds Institute of Medical Research at St James’s and the Leeds Institute of Health Sciences at the University of Leeds, said: “The encouraging results from this study will help pave the way for future development and refinement of these interventions in broader cancer settings. The COVID-19 pandemic highlighted the need and speeded a shift towards technology-enabled care, so these study results are very timely.”
Programme lead Professor Galina Velikova, at the Leeds Institute of Medical Research at St James’s, University of Leeds, and the Leeds Cancer Centre, Leeds Teaching Hospitals NHS Trust, said: “Rising numbers of cancer patients are receiving a range of anti-cancer treatments which means patients are living longer and require longer periods of care and monitoring.
“Remote online monitoring options have the potential to be a patient-centred, safe, and effective approach to support patients during cancer treatment and manage the growing clinical workload for cancer care.”
Read full story
Source: Health Europa, 11 January 2021
Patient Safety Learning

More than 400 care homes investigated over deaths

A special Crown Office unit set up to probe Covid-linked deaths is investigating cases at 474 care homes in Scotland, the BBC can reveal.
The unit was set up in May to gather information on the circumstances of all deaths in care homes. Prosecutors will eventually decide if the deaths should be the subject of a fatal accident inquiry or prosecution.
Care homes say the investigation is "disproportionate" and placing a huge burden on overstretched staff.
The COVID-19 Deaths Investigation Team (CDIT) had received 3,385 death reports as of Thursday. The majority of them relate to people who lived in care homes.
Behind the Crown Office statistics are hundreds of families grieving for loved ones who died in Scotland's care homes.
Alan Wightman's 88-year-old mother Helen died in May last year during a Covid outbreak at Scoonie House in Fife
Helen's death is part of the Crown Office probe and Mr Wightman's hopes for the investigation are that it looks "at the bigger picture and appreciates that on the ground people were doing the best they could".
He added: "I thought that Scoonie House did the best they could in a very difficult situation, sourcing their own PPE and stopping people coming from hospital."
"My own view is that care homes were put in an impossible situation because we had successive governments which did not properly prepare for a pandemic, you only have to look at the lack of PPE at the beginning of the pandemic to see that."
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Source: BBC News, 22 January 2021
 
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Ambulance service facing 'terrifying' levels of risk, says trust chief

The chief executive of a small acute trust has described the “terrifying situation” faced by ambulance crews and hospital staff in trying to provide adequate emergency care as coronavirus threatens to overwhelm the local NHS services.
Susan Gilby, of Countess of Chester Hospital Foundation Trust, told HSJ staff are seeing “tragic and potentially avoidable” instances where patients with COVID-19 have reached the emergency department too late.
She suggested this is due to a combination of patients waiting too long to call 999, and then having to wait long periods for an ambulance to arrive.
Cheshire has been among the hardest hit areas in England during this third wave of coronavirus, with all four of its acute hospitals having very high covid occupancy rates.
Dr Gilby, a former critical care consultant, said her trust has been at around 60 per cent covid occupancy for the last fortnight, which has made her increasingly fearful of the difficulties in admitting patients through the emergency department due to a lack of beds. This can then cause knock-on delays for patients arriving in ambulances, and ties those ambulance crews up for long periods, preventing them from responding to further 999 calls.
She said ambulance turnaround times had been relatively good at the Countess of Chester, but she had spoken to paramedics handing over patients who were “really struggling” to get to people quickly enough.
Read full story (paywalled)
Source: HSJ, 22 January 2021
Patient Safety Learning

Huge local variation in covid vaccination rates

Just a third of people aged 80 and over have received the covid vaccine in one part of England, compared to four out of five in the area with the highest rate, new NHS England figures have revealed. 
Gloucestershire delivered at least one dose of the vaccine to 85% of its over 80s population between 8 December and 17 January. Three other STPs — Northamptonshire, Herefordshire and Worcestershire, and Lancashire and South Cumbria — have all delivered at least one dose to at least three-quarters of over 80s in the area.
By contrast, Suffolk and North East Essex has vaccinated just 36% of its over 80s population. A further seven of England’s 42 STP/Integrated Care Systems had vaccinated under half of their over 80s population.
The mixture of reasons for the differences are not known — it may be due to supply, delivery issues, the nature of the area, or the size of the over-80s population. NHS England has maintained that the vaccine is being used nearly as quickly as it is available each week, with supply the main constraint. NHSE decides when sites are able to open and when they have supply. 
Read full story (paywalled)
Source: HSJ, 21 January 2021
Sam

COVID-19: Working in medicine is “pretty awful” right now, says college president

The second wave of COVID-19 has put doctors under huge pressure, the Royal College of Physicians has warned, as two thirds of physicians report feeling tired or exhausted.
A survey of 25 500 members of the college from across the UK, conducted on 2 November, received 1890 responses. It found that two thirds (64%, 931) felt tired or exhausted, 48% (687) felt worried, and just under a third (29%, 424) felt demoralised. Almost a fifth (19%, 280) said they have sought informal mental health support, such as speaking to colleagues or friends, during the pandemic. Just 10% (155) said they had sought formal mental health support from either their employer, GP, or external services.
College president Andrew Goddard said he was concerned about the mental health of doctors, “There is no way to dress it up—it is pretty awful at the moment in the world of medicine. Hospital admissions are at the highest ever level, staff are exhausted, and although there is light at the end of the tunnel, it seems a long way away.”
He said that before the pandemic, few physicians would have expected to need formal mental health support during their career.
After the pandemic, staff will be in desperate need of a break, Goddard said, and will need specific time away if they’re to be at their best. “Doctors have demonstrated remarkable resilience throughout the pandemic, working under the most challenging conditions the NHS has ever faced, but they can’t continue working this way forever,” he said.
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Source: The BMJ, 21 January 2021
Sam

Covid: How a £20 gadget could save lives

One of the mysteries of COVID-19 is why oxygen levels in the blood can drop to dangerously low levels without the patient noticing.
It is known as "silent hypoxia" and as a result, patients have been arriving in hospital in far worse health than they realised and, in some cases, too late to treat effectively.
But a potentially life-saving solution, in the form of a pulse oximeter, allows patients to monitor their oxygen levels at home, and costs about £20.
They are being rolled out for high-risk Covid patients in the UK, and the doctor leading the scheme thinks everyone should consider buying one.
A normal oxygen level in the blood is between 95% and 100%.
"With Covid, we were admitting patients with oxygen levels in the 70s or low-or-middle 80s," said Dr Matt Inada-Kim, a consultant in acute medicine at Hampshire Hospitals.
He told BBC Radio 4's Inside Health: "It was a really curious and scary presentation and really made us rethink what we were doing."
Read full story
Source: BBC News, 21 January 2021
See hub resource on the 'Covid Oximetry @home' project
Sam

Severe and long Covid risk could be established ‘very early on’

New research has suggested there are specific molecular responses found in some COVID-19 patients which could be used to determine their likelihood of suffering from severe or long Covid symptoms, very early on following infection.
Researchers, supported by NIHR Cambridge Biomedical Research Centre, had set out to increase our understanding of the relationship between the immune response and COVID-19 symptoms by recruiting individuals who tested positive for the virus into a cohort of the NIHR BioResource.
Studying 207 people who had tested positive for COVID-19 over a three-month period, taking blood samples and measuring their symptoms, then comparing to samples taken from 45 healthy people, the researchers were able to uncover a number of interesting new findings.
Their research showed that people with either an asymptomatic or mild case of COVID-19 mounted a robust immune response to the virus soon after getting infected. These individuals produced a greater number of T cells, B cells and antibodies than patients with more severe COVID-19 infections and within the first week of infection - after which these numbers rapidly returned to normal.
The study also showed there was no evidence in these patients of widespread inflammation which can lead to damage in multiple organs.
In contrast, people with severe COVID-19 who required hospitalisation showed an impaired immune response, which led to a delayed and weakened attempt to fight the virus and widespread inflammation from the time of symptom onset. In patients requiring admission to hospital, the early immune response was delayed, and profound abnormalities were present in a number of immune cells.

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Source: NHE, 22 January 2021
Sam

My ‘Long Covid’ nightmare: Still sick after 6 months

A Times reporter caught the coronavirus during the New York City outbreak last April. But the acute phase of the illness was just the beginning.
Laura recounts her experience of Covid nearly 3 months after first being diagnosed. 
"I remember the second time I thought I would die."
Read full story
Source: The New York Times, 21 January 2021
Patient Safety Learning

We're about to see a wave of long Covid. When will ministers take it seriously?

Long Covid is no respecter of youth, health or fitness. It afflicts more women than men but it can strike anyone down, including people whose initial infection seemed mild, or even asymptomatic. In some cases, long Covid could mean lifelong Covid.
The effects can be horrible. Among them are lung damage, heart damage and brain damage that can cause memory loss and brain fog, kidney damage, severe headaches, muscle and joint pain, loss of taste and smell, anxiety, depression and, above all, fatigue. We should all fear the lasting consequences of this pandemic.
Long Covid is shorthand for a range of conditions. Some scientists divide them into three broad categories, others into four. Of these, one seems to ring a bell. It’s a cluster of symptoms that bear a strong similarity to myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS). This is a devastating condition that affects roughly a quarter of a million people in the UK, and is often caused, like long Covid, by viral infection.
Among the common symptoms of ME/CFS are extreme fatigue that is not relieved by rest, and “post-exertional malaise”: even mild physical or mental effort can make patients extremely unwell. Many sufferers are confined to their home or even their bed, with their working life, social life and family life truncated. There is, so far, no diagnostic test and no cure.
Yet ME/CFS has been disgracefully neglected by science and medicine. 
The NHS is now setting up specialist clinics to treat long Covid. But already, apparent mistakes are being made. Without the necessary caveats, the NHS recommends steadily increasing levels of exercise for people suffering from post-Covid fatigue. But as ME/CFS patients with post-exertional malaise know, this prescription, though it sounds intuitive, could be highly damaging.
We need massive research programmes into both long Covid and ME/CFS, coupled with better information for doctors. 
Read full story
Source: The Guardian, 21 January 2021
Patient Safety Learning

Care home worker cancer misdiagnosis

A care home worker who was wrongly diagnosed with cancer said she thought it was a "cruel joke" when she was told doctors had made a mistake and she did not have cancer at all.
Mum-of-four Janice Johnston said her "world crumbled" when she learned she had a rare form of blood cancer at Kent and Canterbury Hospital in 2017.
She had 18 months of oral chemotherapy treatment, during which she experienced weight loss, nausea and bone pain, and had to give up her job as an auxiliary nurse. When the treatment did not appear to be working, she says, medics upped the dosage.
In 2018, she sought alternative treatment at Guy's Hospital in London. It was there a specialist told her she did not have cancer at all but a different condition.
Mrs Johnston was awarded £75,950 in damages after East Kent Hospitals University NHS Foundation Trust admitted liability. Staff at the hospital had failed to do the necessary ultrasound scan and bone marrow biopsy before diagnosing her.
Read full story
Source:  BBC News, 25 January 2021
Patient Safety Learning

Cwm Taf maternity: Failings 'affected two-thirds of women'

Two-thirds of women at the heart of a review into maternity services at a Welsh health board could have had very different outcomes if they had received better care, a report has found.
The Independent Maternity Services Oversight Panel (Imsop) focused on the experiences of pregnant women at Cwm Taf Morgannwg health board.
Its maternity services have been in special measures since "serious failings" were found two years ago. 
Concerns emerged in late 2018 that women and babies may have come to harm because of staff shortages and failures to report serious incidents. This sparked a major independent review, which gave a damning verdict on maternity services in Cwm Taf Morgannwg health board.
Published on Monday, the Imsop report focuses on the care of mothers between January 2016 and September 2018. It found that 19 reviews of maternal care (68%) revealed at least one factor where "different management would reasonably have been expected to alter the outcome".
The panel's chairman, Mick Giannasi, said: "These findings will be concerning and potentially distressing for the women and families involved, and it will be difficult for staff."
"Of the 28 episodes of care, we concluded that in 27 of them, our independent teams who reviewed the care would have done something differently. Put simply, what went wrong, might not have gone wrong if things had been done differently."
Read full story
Source: BBC News, 25 January 2021
Patient Safety Learning

Record ethnicity of those getting covid vaccine to fight stigma, NHSE told

NHS England has been urged to introduce routine recording of race and ethnicity data when people are given their covid vaccination.
Documents seen by HSJ show Pinnacle, the IT system being used by GPs and mass vaccination centres to record jabs, does not directly require ethnicity to be recorded.
Jabeer Butt, chief executive of the Race Equality Foundation, which promotes race equality in public services, told HSJ that making it a requirement would help establish the facts on uptake among different groups, more quickly.
It is understood the NHS is able to ascertain data on vaccine uptake by ethnicity by connecting it with GP records, through the national immunisation management service, and potentially with other healthcare data. However, Mr Butt said this would provide only limited insight and take more time.
He believes the absence of data may allow ”misconceptions” to take hold about lower uptake among some minorities, which can lead to stigma, when in fact, he said, the trend may so far simply be due to there being fewer black and Asian people in the oldest age groups, who are the first eligible for vaccination. 
Read full story (paywalled)
Source: HSJ, 24 January 2021
Patient Safety Learning

Cancer operations down 800 in first two weeks of January

There were 800 fewer cancer surgeries in the first two weeks of January than usually take place during the period, according to provisional data seen by HSJ.
The bulk of this reduction came in London and the surrounding counties such as Essex, Bedfordshire, and Surrey.
London and the south east have been severely hit by coronavirus pressures, causing widely reported mass cancellations of non-urgent elective surgery. However, the impact on cancer cases has, so far, been less clear.
NHS England has insisted in the last week that urgent cancer cases should be given the same priority as coronavirus patients.
Read full story (paywalled)
Source: HSJ, 25 January 2021
Patient Safety Learning

Men working in care, leisure and service jobs three times more likely to die from Covid, ONS says

Men working in low-skilled jobs or care, leisure and service roles are more than three times as likely to die from Covid as professionals, according to new data.
Office for National Statistics (ONS) figures show there were 7,961 coronavirus-related deaths registered among the working-age population (those aged 20 to 64 years) in England and Wales between 9 March and 28 December last year.
Nearly two-thirds of those deaths were among men (5,128 fatalities).  
Analysis by the ONS shows men who worked in low-skilled occupations (699 deaths) or care, leisure and other service occupations (258 deaths) had the highest rates of death involving Covid-19, with 66.3 and 64.1 deaths per 100,000 males, respectively.
Men working in process plants, as security guards or as chefs, had some of the highest COVID-19 death rates.
Plant workers recorded a rate of 143.2 deaths per 100,000 males, while for security guards and related occupations, the figure stood at 100.7 deaths per 100,000 males.
Ben Humberstone, ONS head of health analysis and life events, said: “Jobs with regular exposure to Covid-19 and those working in close proximity to others continue to have higher COVID-19 death rates when compared with the rest of the working-age population.”
However, the figures do not prove that rates of death are caused directly by differences in employment.
“There are a complex combination of factors that influence the risk of death, from your age and your ethnicity, where you live and who you live with, to pre-existing health conditions,” Mr Humberstone said. 
Read full story
Source: The Independent, 25 January 2021
Sam

Trust accused of ‘emotional blackmail’ after asking junior doctors to work unpaid in covid-hit units

London’s largest acute trust has been accused of ‘emotional blackmail’ by suggesting junior doctors could do voluntary shifts in its ‘really short staffed’ critical care unit.
In an email cascaded to all junior doctors at Whipps Cross Hospital, run by Barts Health Trust, hospital medical director Heather Noble said day and night shifts at another trust site, the Royal London Hospital, “really need cover”.
She said doctors could work overtime through a “voluntary or paid shift”, and that if they made contact, should “state whether or not they want to be paid”.
Doctors working at the trust who received the email, who wished to remain anonymous, described the email as “tone deaf” and “not the right way to incentivise anyone to do what they want”.
One medic said: “There has been a lot of anger generated by this correspondence amongst junior doctors. People already working antisocial and demanding rotas are very unhappy about being asked to work more hours for free.”
Read full story (paywalled)
Source: HSJ, 26 January 2021 
Sam
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