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

PHE forced to issue urgent guidance to combat covid spread in ambulances

Rotating clinicians and keeping ventilation running are among Public Health England’s (PHE) recommendations for how to avoid spreading covid while looking after patients in the back of ambulances outside emergency departments.
The suggestions are made in unprecedented new guidance issued by PHE amid sky-high rates of very long ambulance handovers outside hospitals.
This is because emergency departments (EDs) are struggling with attempts to maintain distancing for infection control, along with high occupancy and severe operational pressures elsewhere in hospitals. It has led over the past two months to large numbers of patients being looked after in ambulances for extended times while they wait for space in ED.
The PHE guidance, added last week to existing covid guidance for ambulance services, says it should only happen in “exceptional circumstances”.
But it says staff in this situation should adopt infection prevention and control procedures including:
if more than one clinician is available, rotating them regularly, so allowing them time to change PPE and have a drink;  keeping ventilation systems running which may require the engine to be kept running; ensuring patients and any essential escorts wear surgical masks, as long as patient care is not compromised; minimising the number of people within the patient compartment and avoiding sitting face-to-face with patients; and decontaminating contact surfaces more frequently and during the delay if possible. Read full story (paywalled)
Source: HSJ, 25 January 2021
Sam

Mental Health Act: Doctors should not use video assessments to detain patients during pandemic, say judges

Guidance from NHS England that doctors may lawfully use video assessments during the pandemic to decide whether patients should be detained in hospital under the Mental Health Act was wrong, two High Court judges have ruled.
The act makes it a legal requirement that doctors must “personally examine” a patient before recommending detention. A code of practice requires “direct personal examination of the patient and their mental state.” But guidance from NHS England just after the start of the first lockdown last March said that “temporary departures from the code of practice may be justified in the interests of minimising risk to patients, staff, and the public.” Revised guidance in May 2020 included a section drafted jointly by NHS England and the Department of Health and Social Care for England (DHSC) “for use in the pandemic only.” This stated, “It is the opinion of NHS England and NHS Improvement and the DHSC that developments in digital technology are now such that staff may be satisfied, on the basis of video assessments, that they have personally seen or examined a person ‘in a suitable manner.’ ”
The guidance added, “While NHS England and NHS Improvement and the DHSC are satisfied that the provisions of the Mental Health Act do allow for video assessments to occur, providers should be aware that only courts can provide a definitive interpretation of the law.” It went on, “Even during the COVID-19 pandemic it is always preferable to carry out a Mental Health Act assessment in person. Decisions should be made on a case-by-case basis and processes must ensure that a high quality assessment occurs.”
Read full story
Source: BMJ, 25 January 2021
Sam

The Independent Medicines and Medical Device Safety Review: Patient reference group members wanted

The Department of Health & Social Care are working with Traverse, a research organisation, to appoint 15 people to a patient reference group. This group will work with DHSC as it develops and implements the Government’s response to the Report of the Independent Medicines and Medical Devices Safety Review (IMMDS Review).
What will the group be doing?
Meeting online to share experiences, ideas and recommendations. Helping to shape the Government’s response to the IMMDS Review, ensuring that patient voices are heard in the process. Providing advice, challenge, and scrutiny as the Government implements its response. They are looking for people who:
Have a personal experience of or understand the context of the IMMDS Review. Are committed to improving the experience of patients. Want to engage with others on the group and DHSC representatives to support the development and implementation of the Government’s response to the IMMDS Review. Can consider complex and emotive issues in a balanced and sensitive way. Have good communication skills, and want to build strong working relationships with the rest of the group. They are also looking for a co-chair to support group members contribute to the group and make sure group members are heard. If you know the English healthcare system well and are comfortable working on sensitive issues, take a look at the recruitment pack to find out more about the co-chair role and how to apply.
If you are interested in getting involved, contact [email protected] for the recruitment pack and more information on how to apply.
Patient Safety Learning

Patient Safety Movement: Lewis Blackman Leadership Award

In honor and recognition of the 20th anniversary of Lewis Blackman’s death on 6 November 2000, an award has been established with the goal of recognising outstanding leadership in patient safety by students pursuing a health profession and residents in training. Lewis Blackman was an outstanding student himself and because his mother, Helen Haskell, has dedicated her life to improving patient safety, especially through education, the Lewis Blackman Leadership Award has been created.
The Lewis Blackman Leadership Award will be awarded to an active health professional student or resident who has demonstrated exemplary leadership skills in patient safety in ways that will contribute to the vision of ZERO preventable patient deaths.
The purpose of the Lewis Blackman Leadership Award is to acknowledge the work being done by our future leaders, encouraging them to pursue a career in healthcare grounded in patient safety.
Eligibility criteria for nominations
Any student or resident, domestic or international, currently working toward an advanced degree or board certification in healthcare or a healthcare-related field, including but not limited to: MD/DO, DPT, PharmD, MHA/DHA, MPH/DPH, MSN/DNP, and PhD. Self-nominations are welcome.
Application Dates:
Take nominations: December 15 – January 31st
Judging period: January 31st – February 15th 
Announcement of Winner: March 1st 
Further information
Sam

Hospital warns it may become ‘impossible’ to stop patients catching covid

A trust has warned it may reach a ‘tipping point’ where it is ‘impossible’ to separate covid positive and negative patients.
Surrey and Sussex Healthcare Trust also revealed in papers published ahead of its Thursday board meeting that it planned to distribute a “duty of candour” leaflet for patients, warning them of the risk of contracting covid in hospital.
The papers noted covid patients at the trust increased from 80 pre-Christmas to 230 by January, filling half its beds. HSJ’s figures suggest covid patients at the trust continued to rise until around 14 January before dropping back slightly. 
The report from the trust’s safety and quality committee — which met on 7 January — said: “It is becoming more difficult to separate the covid+ and covid- patients. In an increasing number of instances, patients are admitted to cold areas for non-covid treatment and without symptoms but then test positive. These patients then need to be admitted to hot areas and any contacts (including patients from the same bay) isolated.
“At some point a tipping point could be reached where it may be impossible to retain hot and cold areas.”
Read full story (paywalled)
Source: HSJ, 27 January 2021
Sam

COVID-19: WHO's new coronavirus treatment guidelines - what's changed and why

New advice on how to treat coronavirus has been issued by the World Health Organisation (WHO) as it also begins a wide-reaching study into the effects of so-called "long COVID".
For COVID-19 patients at home, WHO is now suggesting the use of a pulse oximetry machine to measure oxygen levels in the blood - but warns that this should only be done after full patient education and with medical follow-up support if necessary.
For hospitalised patients, WHO is recommending the use of low-dose anticoagulants to prevent clots forming in blood vessels, known as thrombosis.
And for sufferers who are already using supplemental oxygen, the organisation is officially endorsing the positioning of patients on their stomachs to increase oxygen flow. This is known as "awake prone positioning".
The new guidelines also include a recommendation that healthcare professionals favour "clinical judgement over models" in making decisions for individual patients.
Read full story
Source: Sky News, 26 January 2021
Sam

NHS nurse is struck off after nearly 500 women had to have their smear test redone

Nearly 500 women had to have their cervical smear tests redone after it emerged the nurse who carried them out was not qualified.
'Dishonest' Alison Watts failed to tell her bosses at an NHS surgery that she failed her course and continued screening women for almost two and a half years.
When it was discovered Watts had not passed the qualification, 461 women had to be recalled to have the cervix test again so they could have 'quality assured' tests.
Now Watts has been struck off for the shocking breach of trust, with a tribunal ruling that she put patients at 'significant risk of harm'.
A Nursing and Midwifery Council [NMC] report said: 'This was not a single instance of misconduct but involved 461 patients over a two year period. There is evidence of sustained dishonesty and deep-seated attitudinal issues.'
Read full story
Source: Daily Mail, 26 January 2021
Sam

COVID-19: People are not being warned about pitfalls of mass testing

Only a third of local authorities that are rolling out lateral flow testing have made the test’s limitations clear to the public—including that it does not pick up all cases and that people testing negative could still be infected, an investigation by The BMJ has found.
A search of the websites of the 114 local authorities rolling out lateral flow testing found that 81 provided information for the public on rapid COVID-19 testing. Of these, nearly half (47%; 38) did not explain the limitations of the tests or make it clear that people needed to continue following the restrictions or safety measures even if they tested negative, as they could still be infected.
Although 53% (43) did advise people to continue to follow the current measures after a negative result, only 32% (26) were clear about the test’s limitations or its potential for false negatives. The advice the websites gave to the public about a negative test result ranged from “A single negative test is not a passport to carrying on your daily life ‘virus-free’... don’t let a negative COVID-19 test give you a false sense of security” to “It is good news that you don’t have the coronavirus.”
On 10 January England’s health secretary, Matt Hancock, launched the drive for local authorities to test asymptomatic people who cannot work from home, to try to halt the spread of the virus. But many public health experts are concerned about false reassurance from mass testing.
Read full story
Source: BMJ, 26 January 2021
Sam

NHS investigation body launches inquiry into medication errors in children

The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into the risks involved in prescribing, dispensing and administering medicines to children.
The investigation was triggered after HSIB was notified of an incident including a child aged four years, who, after being diagnosed with a blood clot in her leg following a surgical procedure, received ten times the intended dose of anticoagulant on five separate occasions, over three days.
This, HSIB said, was owing to errors that occurred during the prescription, dispensing and administration processes.
The errors resulted in the child being admitted to the paediatric intensive care unit, with evidence of a bleed in her brain, where she stayed for three months until she was discharged with an ongoing care plan.
HSIB said that studies showed that prescribing errors were the most frequent type of medication error in children’s inpatient settings.
The investigation will look at this and other incidents to examine the role of multidisciplinary teamworking and checking in medication errors, as well as considering the risks associated with the implementation of electronic prescribing and medication administration (ePMA) systems in clinical areas using weight-based paediatric prescribing.
“‘Wrong dose’ errors are a particular risk in children’s wards,” said Alice Oborne, consultant pharmacist in safe medication practice and medicines safety officer at Guy’s and St Thomas’ NHS Foundation Trust.
Read full story
Source: The Pharmaceutical Journal, 26 January 2021
Patient Safety Learning

Black over-80s 'half as likely' to have been vaccinated

Black people over the age of 80 were half as likely as their white peers to have been vaccinated against Covid by 13 January, a large study suggests. This is despite the fact black people are four times more likely to die with COVID-19 than their white counterparts.
People living in deprived areas or who have severe mental-health conditions or learning disabilities were also less likely to have received a vaccination. The study was based on more than 20 million patient records in England.
The OpenSafely study, by the University of Oxford and the London School of Hygiene and Tropical Medicine, found of the million of those over 80 but not living in a care home:
43% of the white people had been given their first dose of the vaccine 30% of the Bangladeshi and Pakistani people had 21% of the black people had. Bangladeshi and Pakistani people are twice as likely to die with COVID-19 as white peple.
Birmingham-based business owner Tru Powell told BBC Radio 5 Live of a "lack of trust between the government and people of colour".
"People of colour have been subject to institutionalised racism within the healthcare system," she said.
"We are five times more likely to be detained under the Mental Health Act and four times more likely to die in childbirth."
Read full story
Source: BBC News, 28 January 2021
Patient Safety Learning

Largest ever daily fall in covid hospital patients

The number of covid positive patients in English hospitals fell by 1,491 yesterday, by far the biggest decline recorded since the start of the pandemic.
The previous record was set during the decline of the first wave, when numbers fell 1,055 on 17 April. The largest drop in the third wave before yesterday’s record was the 798 seen last Saturday.
The national total of covid positive hospital patients now stands at 30,846, a drop of 9 per cent on the peak set on 18 January, but still 163 per cent of the mid-April peak.
All seven English regions are now seeing a week-on-week decline in the number of their covid hospital patients for the first time.
All have well established trends in falling admissions, with London and the south east seeing the running seven-day total fall by almost a third since a peak on 9 January. The east and south west have seen their admissions total decline by a fifth, while the midlands total has dropped 16 per cent in just five days and north east and Yorkshire nine in only four.
Read full story (paywalled)
Source: HSJ, 28 January 2021
Patient Safety Learning

UK variant less associated with loss of taste and smell

People infected with the new variant of coronavirus that first emerged in the UK are less likely to report a loss of taste or smell, but more likely to report “classic” symptoms, such as coughing, sore throat or fatigue, a survey has found.
According to the Office for National Statistics (ONS), the symptom of impaired taste and smell in those with COVID-19 was “significantly less common” in people who tested positive for the new variant compared with those who had other variants.
However, there was no evidence of any difference in symptoms related to shortness of breath or headaches, according to the provisional data published in the organisation’s infection survey.
The data also indicated that people infected with the new variant were more likely to report having symptoms. These were self-reported and not professionally diagnosed, and cover the period between 15 November and 16 January.
Read full story
Source: The Independent, 27 January 2021 
Patient Safety Learning

Medical breakthrough could help thousands in UK living with an aggressive type of breast cancer

Thousands of women living in the UK suffering from an aggressive type of breast cancer could be helped by a newly identified drug, according to a study.
The research, carried out by The Institute of Cancer Research, found medicine presently used to help other breast cancers that have spread to another area of the body, could actually be utilised to help around a fifth of women who have triple negative breast cancer.
Around 55,000 women are diagnosed with breast cancer in Britain each year, with approximately one in five of these being triple negative. Younger women and black women are more likely to develop this form of breast cancer which is generally more aggressive.
Researchers’ realisation the drug palbociclib could be used far more widely than previously thought could “provide a much-needed targeted treatment” for those who are at higher risk of witnessing their cancer spread more quickly, becoming incurable and often unresponsive to conventional chemotherapy.
Dr Simon Vincent, of Breast Cancer Now, a leading charity which funded the study, said: “It’s hugely exciting that this research has uncovered a new possible use for palbociclib as a targeted treatment for some women living with triple negative breast cancer."
Read full story
Source: The Independent, 28 January 2021
Patient Safety Learning

'People have to navigate through their grief'

Bereavement support charities are calling for more funding in light of what they call the "terrible toll of 100,000 deaths from Covid-19".
They say many families have been unable to be with loved ones as they died or gather to support one another. They argue there has been "huge demand" for counselling and guidance but some providers lack sufficient resources.
The government says it is committed to ensuring those who are grieving have access to the support they need. In a letter to the Health Secretary Matt Hancock, and mental health minister, Nadine Dorries, charities call for some of the £500 million funding allocated to mental health in England in the November spending review to be used to support the bereaved.
The request has come from the National Bereavement Alliance, which represents a range of charities. Members include CRUSE Bereavement Care, Support after Suicide Partnership and AtALoss.
The letter quotes academic research suggesting more than 80% of bereaved people since the start of the pandemic have had limited contact with family and friends and two-thirds have experienced social isolation or loneliness.
They say there are long waiting lists for support but some services providing advice and guidance are not adequately funded.
The alliance argues deaths have been heavily felt in disadvantaged and deprived communities where there is a greater need for assistance.
Read full story
Source: BBC News, 27 January 2021
Patient Safety Learning

Children's mental health services in England 'unable to meet demand'

Mental health services in England do not have the capacity to cope with the impact of the coronavirus pandemic on children, Anne Longfield, the children’s commissioner for England, has warned.
Despite an expansion in the four years before the pandemic, the supply of treatment for child mental health problems was already falling well short of demand, with referrals rising 35%, but treatments only increasing by 4%, the watchdog said as she called for a “rocket boost” in funding.
Longfield cited an NHS study before the latest national lockdown, which found one in six children had a probable mental health condition and said it is highly likely that the level of underlying mental health problems will remain significantly higher as a result of the pandemic, with an increase in referrals to NHS services already observed last autumn.
“Even before the Covid pandemic, we faced an epidemic of children’s mental health problems in England and a children’s mental health service that, though improving significantly, was still unable to provide the help hundreds of thousands of children required,” Longfield said. “It is widely accepted that lockdown and school closures have had a detrimental effect on the mental health of many children.”
Read full story
Source: The Guardian, 28 January 2021
Patient Safety Learning

Coronavirus outbreak: 22 deaths at Pemberley House Care Home

At least twenty-two people have died at a Basingstoke care home in one of the worst known outbreaks of the coronavirus pandemic to date. 
The deaths occurred at Pemberley House Care Home in Grove Road, Viables, operated by private firm, Avery Healthcare.
The outbreak was first declared on Tuesday, January 5, with 60 per cent of its residents testing positive for the disease, according to sources. Within three weeks, 22 people had died - over one-third of the home's residents. The Gazette's former picture editor Ron Boshier was among the residents to have died after contracting the disease. 
A spokesman for Avery Healthcare told The Gazette they were "deeply saddened" by the loss of a number of their residents.
Read full story 
Source: Gazette, 27 January 2021
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