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

Study reveals the most common serious safety errors on hospital wards

New research examining severe harm incidents and deaths in NHS hospitals has been published today in the Journal of the Royal Society of Medicine. The research, looking at more than 370 incidents has highlighted the risks to patients from fragmented care on busy wards and shortages of staff.
According to the findings, “errors occurred due to a lack of clarity regarding responsibilities for patient care coordination, especially during emergency situations or out of hours. Poor documentation of long-term management plans and no reliable review system to ensure follow-up by the most appropriate teams contributed,” with researchers also saying many of the errors in medication happened more often overnight due to a lack of out-of-hours pharmacy support. 
Read full story.
Source: The Independent, 5 August 2021
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Minority ethnic staff ‘told to adopt Western names’ by managers

Concerns have been raised amid allegations that hospital managers have told minority ethnic staff to adopt 'Western work names' as their original names were 'too difficult to pronounce'.
In a letter from the Care Quality Commission, published in the trust's July board papers, workers at University Hospitals Bristol and Weston Foundation Trust told inspectors about their experiences during an unannounced visit in June. 
“This is not acceptable, individuals can only truly thrive in a work environment where they feel safe as themselves and belong rather than having to ‘fit in’.” Wrote the CQC’s head of hospital inspections Amanda Williams. 
Read full story (paywalled).
Source: HSJ, 4 August 2021
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Kent Hospital improves safety rating in latest inspection

The Care Quality Commission have increased the safety rating for the William Harvey Hospital, in Kent, from 'inadequate' to 'requires improvement'. This comes after the hospital was hit with a safety scandal after staff and members of the public raised concerns about a lack of infection control amid outbreaks of Covid-19.
“I am pleased to report that since our last inspection, leaders have worked hard to improve infection control practices in the medical care services departments at both hospitals, although some improvements still need to be fully embedded, particularly at William Harvey Hospital. We also found that there was a positive culture in the service across both hospitals, and staff felt empowered to report incidents. These were fully investigated by managers and, importantly, learnings were shared with the wider team.” Amanda Williams, CQC’s head of hospital inspection has said. 
Read full story.
Source: The Independent, 5 August 2021
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PPE: Gateshead NHS Trust first to make its own masks

Gateshead Health NHS Trust in the north-east of England are the first NHS body in the UK to manufacture its own protective face masks. This move comes after Filtering Face Piece 3 masks (FFP3), which are used widely in hospitals, were in short supply early in the pandemic. 
"It's taken us a lot of hard work and investment to get to this stage. Every part and stage has had to be precision-engineered to make sure that these masks meet the standard and are effective at filtration." Said Managing director Anthony Robson. 
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Source: BBC News, 6 August 2021
Patient-Safety-Learning

Tens of thousands of children suffering long Covid as experts demand vaccine rollout for all over-12s

A new report has found tens of thousands of children are suffering from Long Covid, with experts worried children will be left vulnerable if the vaccine roll-out does not expand to include the 12-15 year old age group. Experts have also warned herd immunity cannot be achieved without the young people taking the jab. 
"There is no time to waste in getting on with this. We could have had all of this age group [16- and 17-year-olds] vaccinated before September." Said Dr Deepti Gurdasani, an epidemiologist at Queen Mary University London. 
Read full story.
Source: The Independent, 6 August 2021
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Intensive care units face ‘grim’ situation despite fall in Covid cases

The president of the Intensive Care Society has warned despite the fall in Covid cases, intensive care units in hospitals remain under substantial pressure, with Stephen Webb, a consultant in intensive care and deputy medical director at the Royal Papworth Hospital Trust, describing the situation as "grim".
“Cases of Covid infections are coming down but that’s not having much of an impact on hospitals and on intensive care units yet. The situation in ICUs is pretty grim at the moment and it’s grim for a completely different reasons from wave one and two of the pandemic.” Dr Webb told The Independent.
Read full story.
Source: The Independent, 5 August 2021
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Leap in mental health absences among NHS staff

According to data shared with HSJ, the amount of NHS staff taking time off for their mental health has leapt in the past few months. The data, collected by FirstCare and covering 46,000 NHS staff from nine trusts, showed mental health absences from May to June of this year was at least 20 per cent up on April and 35 per cent up on February with more than 40 per cent up on the same months last year. 
“Trust leaders remain acutely aware of the impact that the pandemic, coupled with existing NHS pressures, is having on the workforce. They are deeply concerned about their staff’s mental health and wellbeing and are doing what they can to look after their staff, but they cannot do this sustainably without a fully costed and funded multi-year workforce plan.” Said NHS Providers chief executive Chris Hopson. 
Read full story (paywalled).
Source: HSJ, 6 August 2021
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Wrong bodies released by NHS mortuaries dozens of times

New figures has revealed serious incidents have occurred in NHS trusts where the wrong bodies of patients were released to families or lost, damaged or kept the organs or bodies of babies without family permission. According to data from the Human Tissue Authority, these incidents have reduced over the years, however, the errors still affected more than 100 families in the latest year to March 2021.
Incidents such as these are extremely distressing for the friends and family of the deceased patient, but also for the staff working in the mortuaries involved, who try their best to uphold the highest standards of patient care in often difficult circumstances. The fact that the mortuary profession is not a profession regulated by statute – as other professions such as laboratory staff and paramedics are – makes the maintenance of these quality standards more difficult than it needs to be." Said John Pitchers, chair of the Association of Anatomical Pathology Technology
Read full story.
Source: The Independent, 8 August 2021
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Heart surgery waits in England may rise by 40%, warns charity

According to the British Heart Foundation, it may take up to five years for cardiac services to return to pre-Covid levels. This warning comes after it was revealed nearly 14 million people could be on NHS waiting lists in England by next autumn.
"Tragically, we have already seen thousands of extra deaths from heart and circulatory diseases during the pandemic, and delays to care have likely contributed to this terrible toll. At this critical moment, the government must act now to avoid more lives lost to treatable heart conditions. Addressing the growing heart care backlog is only the start," says Prof Samani, medical director at the British Heart Foundation. 
Read full story.
Source: BBC News, 9 August 2021
Patient-Safety-Learning

Fears over patient safety amid plans to ‘water down’ training for nurses

Health leaders have warned the public may be at more risk amid plans to simplify nursing training across the UK. Nursing leaders have also come out in opposition of the proposals by the Nursing and Midwifery Council (NMC) saying bosses could not be sure that the nurses they hired would have the skills required to care patients' safely.
Matthew Winn, chief executive of Cambridgeshire Community Services Trust, said "The changes being proposed by the Nursing and Midwifery Council will lead to a watering down of the educational and training standards of these specialist professionals. If courses are developed unilaterally by universities, as an employer I will have no idea if the district nurse is competent to undertake the role I am recruiting them to do.”
Read full story.
Source: The Independent, 08 August 2021
Patient-Safety-Learning

CQC found emergency caesarean taking place without basic safety measures

After an unannounced inspection at the Princess Alexandra Hospital Trust in June, the Care Quality Commission (CQC) found an “emergency c-section was being performed without the correct equipment available to monitor the mother”. According to reports, the inspectors stepped in immediately to raise concerns, which was then corrected straight away.
In a letter to the trust, the CQC wrote, “Overall, we were concerned that the safety culture in the service was underdeveloped. There were no dedicated maternity safety huddles in line with national guidance. Handovers doubled up as safety huddles. During our observations of handovers, we saw that staff did not discuss safety issues and the format was not safety focused.” 
Read full story (paywalled).
Source: HSJ, 6 August 2021
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Blood tests rationed amid equipment shortage

A national shortage in blood collection tubes has meant trusts are having to limit blood tests, with some trusts advising doctors to only order blood tests if they deem it absolutely necessary or using the same tubes for different tests rather than using a different tube of blood for each test.
It has also been reported that the global disruption to the supply chain may mean shortages could continue before the supply lines recover. The NHS Supply Chain, has said there was “some improvement in the supply position in September” but that controls on the products "are likely to continue to be applied beyond this until supply stabilises”.
Read full story (paywalled).
Source: HSJ, 9 August 2021
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Doctors have faced “worrying levels of abuse” in past month, BMA reports

New data has revealed doctors are experiencing “worrying levels of abuse” during the Codi-19 crisis. 
In a survey, doctors (51% of respondents) have reported that they have witnessed violence and abuse against other staff, with 67% showing this was particularly high for those working in general practice. 
We cannot let people take out their frustration at a system on individual doctors or their colleagues, who truly are doing their best in the most difficult of situations. Even before the pandemic we were vastly understaffed, and abusive behaviour will drive more and more talented and experienced doctors away from the NHS at a time when we need them most . . . We urge our patients to afford the same compassion to staff that they are shown in hospital, after what has been the most horrific year of our careers.” Said The chair of the BMA’s Consultants Committee, Vishal Sharma. 
Overall results for the abuse questions are here, and broken down by healthcare setting here.
Read full story.
Source: BMJ, 10 August 2021
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Artificial Intelligence may diagnose dementia in a day

New research has emerged that may be able to diagnose dementia after a single brain scan. 
Scientists have begun testing a new artificial intelligence system that could identify the condition and predict predict whether it will remain stable for many years, slowly deteriorate or need immediate treatment.  
Prof Zoe Kourtzi, of Cambridge University and a fellow of national centre for AI and data science The Alan Turing Institute, said "If we intervene early, the treatments can kick in early and slow down the progression of the disease and at the same time avoid more damage". 
Read full story.
Source: BBC News, 10 August 2021
Patient-Safety-Learning

NHS waiting list estimates ‘confirm immense task ahead’ for nurses

New data has revealed as many as 14 million people could be on NHS waiting lists in England by the autumn of 2022 unless action is taken now to avoid this outcome. 
The Royal College of Nursing has confirmed these latest figures confirmed the “immense task that lies ahead” for the profession saying that more investment is needed to help tackle the waiting list crisis. 
In response to the analysis, Patricia Marquis, RCN England director, said: “These figures confirm the immense task that lies ahead for health and care services in recovering from the pandemic.”
Read full story.
Source: Nursing Times, 9 August 2021
Patient-Safety-Learning

Independent providers ‘prioritising private patients over NHS’

Sources have indicated that with staff shortages, including doctors who work in the NHS, in some areas the private sector is prioritising patients who are insured or self-paying, according to the HSJ. 
A report from the Dorset Clinical Commissioning Group has said that the health system was aiming to use the independent sector to reduce waiting lists, however, there are staff limitations there as well, meaning they have to reduce the amount of capacity they could provide to the NHS.
“Amongst a range of initiatives, the Dorset healthcare system is increasing the use of independent providers to help reduce waiting lists, however in common with other providers they are facing their own limitations in terms of capacity and staffing.” A spokesman for the CCG has said. 
Read full story (paywalled).
Source: HSJ, 10 August 2021
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