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

Healthcare worker catches Covid twice in less than three weeks

A healthcare worker caught Covid on two separate occasions over the course of just 20 days, a new study has shown.
It is believed to be the shortest recorded time between two infections since the start of the pandemic. Since the arrival of the highly infectious Omicron variant, reinfections have become far more prominent.
The 31-year-old woman from Spain first became infected with Delta in December 2021 – 12 days after she had received her Covid booster vaccine.
Lab analysis showed that she had initially been infected by the Delta variant, followed by Omicron.
Her case, which is being presented to the European Congress of Clinical Microbiology and Infectious Diseases in Portugal, is believed to represent the shortest recorded time between two separate infections.
Dr Gemma Recio of the Institut Catala de la Salut in Spain, who is one of the study’s authors, said: “This case highlights the potential of the Omicron variant to evade the previous immunity acquired either from a natural infection with other variants or from vaccines".
“In other words, people who have had Covid-19 cannot assume they are protected against reinfection, even if they have been fully vaccinated."
Read full story
Source: The Independent, 21 April 2022

Patient Safety Learning

FDA considers new approach to improve safe disposal of prescription opioid analgesics and decrease unnecessary exposure to unused medication

the U.S. Food and Drug Administration (FDA) announced it is seeking public comment on a potential change that would require opioid analgesics used in outpatient settings to be dispensed with prepaid mail-back envelopes and that pharmacists provide patient education on safe disposal of opioids. This potential modification to the existing Opioid Analgesic Risk Evaluation and Mitigation Strategy would provide a convenient, additional disposal option for patients beyond those already available such as flushing, commercially available in-home disposal products, collection kiosks and takeback events.
Patients commonly report having unused opioid analgesics following surgical procedures, thereby creating unfortunate opportunities for nonmedical use, accidental exposure, overdose and potentially increasing new cases of opioid addiction. Since many Americans gain access to opioids for the first time through friends or relatives who have unused opioids, requiring a mail-back envelope be provided with each prescription could reduce the amount of unused opioid analgesics in patients' homes. Data show educating patients about disposal options may increase the disposal rate of unused opioids and that providing a disposal option along with education could further increase that rate.
Mail-back envelopes have several favorable characteristics. They do not require patients to mix medications with water, chemicals or other substances nor use other common at-home disposal techniques. Opioid analgesics sent back to Drug Enforcement Administration-registered facilities in mail-back envelopes do not enter the water supply and landfills (instead, they are incinerated). The nondescript mail-back envelopes provided would be postage paid, offering patients a free disposal option. Additionally, there are long-standing regulations and policies in place to ensure that mail-back envelopes are fit for that purpose and can safely and securely transport unused medicines from the patient's home to the location where they will be destroyed.
"The FDA is committed to addressing the opioid crisis on all fronts, including exploring new approaches that have the potential to decrease unnecessary exposure to opioids and prevent new cases of addiction. Prescribing opioids for durations and doses that do not properly match the clinical needs of the patient not only increases the chances for misuse, abuse and overdose, but it also increases the likelihood of unnecessary exposure to unused medications," said FDA Commissioner Robert M. Califf, M.D. "As we explore ways to further address this issue more broadly, the mail-back envelope requirement under consideration for these unused medications would complement current disposal programs and provide meaningful and attainable steps to improve the safe use and disposal."
Read full story
Source: Cision, 20 April 2020
Patient Safety Learning

York eating disorder clinic served unsafe food

A hospital for adults with eating disorders has been rated inadequate after inspectors found the provision of food was "unsafe and unacceptable".
A Care Quality Commission (CQC) report of the Schoen Clinic in York said some patients were given mouldy bread and one was served food containing plastic.
Concerns were also raised around lack of staff and patient safety, though wards were clean and well-equipped.
Schoen Clinic Group said issues raised in the report "were quickly addressed".
Following the inspection in January the hospital has been placed in special measures and will be visited again in six months.
Brian Cranna, CQC's head of hospital inspection, said: "The standards of care we found at Schoen Clinic York were putting patients at risk and so we have taken urgent enforcement action, which means the service must improve if it's to retain its registration."
According to the report patients were put at risk of "physical and psychological harm due to unsafe and unacceptable food provision".
Read full story
Source: BBC News, 21 April 2022
Patient Safety Learning

NHS set to miss key targets in fight against antibiotic-resistant infections

The NHS is falling behind in the race to tackle antibiotic-resistant infections, with the service set to miss two key targets. 
As part of the government’s 2019 five-year-action plan to tackle the growth in antimicrobial resistance (AMR), the NHS was set the target of reducing the number of healthcare-associated bloodstream infections of three gram-negative bacteria by 25% by March this year, and 50% by the end of March 2024.
Infections caused by E. coli, pseudomonas aeruginosa and klebsiella can cause urine or wound infection, blood poisoning or pneumonia. The AMR action plan said: “In the UK, the biggest drivers of resistance [include] a rise in the incidence of infections, particularly gram-negatives.”
Last week, health and social care secretary Sajd Javid stressed the continuing importance of the issue, stating that antimicrobial resistance is “one of the biggest health threats facing the world”.
Analysis by HSJ has shown there has been only a small decline in the numbers of cases involving the three bacteria since monitoring started. The baseline for measuring the reduction was 2016-17, when there were 23,037 healthcare associated infections related to the bacteria.
Read full story (paywalled)
Source: HSJ, 21 April 2022
Patient Safety Learning

Study reveals clues to cancer causes and potential for personalised treatment

Analysis of thousands of tumours has unveiled a treasure trove of clues about the causes of cancer, representing a significant step towards the personalisation of treatment, a study suggests.
Researchers say that for the first time it is possible to detect patterns – called mutational signatures – in the DNA of cancers.
These provide clues including about whether a patient has had past exposure to environmental causes of cancer such as smoking or UV light, for example.
This is important as these signatures allow doctors to look at each patient’s tumour and match it to specific treatments and medications.
Dr Andrea Degasperi, research associate at the University of Cambridge and first author, said: “Whole genome sequencing gives us a total picture of all the mutations that have contributed to each person’s cancer.
“With thousands of mutations per cancer, we have unprecedented power to look for commonalities and differences across NHS patients, and in doing so we uncovered 58 new mutational signatures and broadened our knowledge of cancer.”
The findings are now being incorporated into the NHS as researchers and clinicians now have the use of a digital tool called FitMS that will help them identify the mutational signature and potentially inform cancer management more effectively.
Read full story
Source: The Independent, 21 April 2022
You may also be interested to read hub blog: Genetic profiling and precision medicine – the future of cancer treatment
Patient Safety Learning

Women struggling to ‘sleep and work competently’ amid England’s HRT shortages

Women are being left unable to sleep or work competently because of the shortages of hormone replacement therapy (HRT) products used to treat symptoms of the menopause, the former cabinet minister, Caroline Nokes, has said.
Millions of women go through the menopause every year, with many experiencing symptoms that can be severe, such as low mood, anxiety, hot flushes and difficulty sleeping, and have a negative impact on everyday life. The number of prescriptions for HRT in England has doubled in the last five years to more than 500,000 a month.
But the rise in prescriptions has come amid several years of HRT shortages, with pharmacists often unable to fulfil prescriptions. Shortages have been blamed on manufacturing and supply issues, and have been exacerbated by the growing numbers of women seeking the products.
Speaking in the Commons on Thursday, Nokes, chair of the women and equalities committee, called for an urgent debate on the issue to ensure women “can get the supplies that we need”.
In October, the government announced that the cost of repeat prescriptions for HRT would be significantly reduced in England.
In the Commons on Thursday, Labour MP Nick Smith asked Spencer why there was “no date yet for the HRT prescription changes in England”. Spencer said it was “something the health secretary is looking at, at this moment in time”.
Read full story
Source: The Guardian, 21 April 2022
Patient Safety Learning

Nearly half of those recovering from coronavirus infection endure ‘long Covid’ symptoms, study finds

An analysis of data from 50 studies looking at 1.6 million people suggests that as much as 43% of those infected with the coronavirus experienced post-Covid conditions, pointing to the need for better diagnosis and care for “long Covid” patients.
Post-Covid conditions are clinically defined by the World Health Organization (WHO) as mid- and long-term symptoms – also known as Long Covid – occurring in individuals after infection with the SARS-CoV-2 virus.
The research, published this week in the Journal of Infectious Disease, assessed 23 symptoms reported across 36 of the studies and found that shortness of breath, sleep problems, and joint pain was widely reported by those who had recovered from the novel coronavirus infection.
Researchers say fatigue (23%) and memory problems (14%) were the most common symptoms of individuals experiencing post-Covid conditions.
While about 34% of non-hospitalised coronavirus patients report lingering post-Covid symptoms, scientists say this rate jumps to over 50% for hospitalised Covid patients.
“Long Covid is quite common overall and across geographic regions, sex and acute COVID-19 severity. Knowing this, providers should take proactive approaches such that their patients are well-supported when experiencing long-term health effects of Covid-19,” scientists wrote in the study.
Read full story
Source: The Independent, 21 April 2022
Patient Safety Learning

Make publishing NHS workforce planning forecasts a legal duty

Despite workforce being the biggest challenge facing the health service, the Health and Care Bill provides no clarity on the numbers of staff this country needs, says Andrew Goddard in a HSJ article.
The Health and Care Bill returned to the Commons this week – as did the question of workforce planning. At the end of the spring term, MPs voted to reject an amendment to the bill which would have required the secretary of state to publish independent assessments of current and future workforce numbers every few years.
The following week, the House of Lords – led by Baroness Cumberlege, with support from Baroness Harding, Lord Stevens of Birmingham and other cross-party peers – voted to put a revised version of the amendment back in.
This particular game of ping pong about how we should plan the NHS and social care workforce is an important one. Workforce is not only a blindspot in the bill – it is a blindspot in the government’s ambitions for health and care.
A lack of staff risks undermining the true potential of the Health and Social Care Levy because there will be too few staff to carry out the additional checks and diagnostic procedures promised. The new diagnostic hubs are to be staffed with existing NHS colleagues.
Workforce shortages hampered our response to the pandemic and are already having a significant impact on our response to the backlog. They were also identified in the Ockenden Report as a driving factor in the avoidable deaths of 201 babies.
It is concerning then, that despite workforce being the biggest challenge facing the health service, the Health and Care Bill provides no clarity on the numbers of staff this country needs.
Read full story (paywalled)
Source: HSJ, 22 April 2022
Patient Safety Learning

Government progress against commitments made on workforce to be evaluated

The Health and Social Care Committee examines the Government’s progress against its pledges on the health and social care workforce and will be the focus of a new independent evaluation by the Health and Social Care Committee’s Expert Panel.
Professor Dame Jane Dacre, Chair of the Expert Panel, said:
“We’ll be looking at commitments the Government has made on workforce – the people who deliver the health and social care services we rely on.
“We’ve identified a recurrent theme in our evaluations to date – whether in maternity, cancer or mental health services, progress is dependent on having the right number of skilled staff in the right place at the right time. Shortages have a real impact on the delivery of services and undermine achievements.
“Our panel of experts will evaluate progress made to meet policy pledges in this crucial area - whether it’s about getting workforce planning right, training, or ensuring staff well-being.”
The Expert Panel will focus on three areas:
Planning for the workforce – including how targets are set, recruitment, and retention. Building a skilled workforce – including incorporating technology and professional development of staff. Wellbeing at work – including support services for staff, and reducing bullying rates. Four specialists have been appointed for this evaluation, bringing their subject specific expertise and experience. They will work alongside the core members of the Expert Panel in identifying a set of Government commitments on workforce and evaluate progress made against them.
The findings will support the work of the Health and Social Care Committee which is carrying out a separate inquiry: Workforce: recruitment, training and retention in health and social care.
Read full story
Source: UK Parliament, 20 April 2022
Patient Safety Learning

MPs launch survey on body image and mental health

A survey looking at the effect of body image on physical and mental health has been launched by MPs in England.
It also asks whether people have used the NHS to deal with body image issues and how successful services have been.
The Health and Social Care Committee will use the survey as part of its ongoing inquiry into the impact of body image.
The committee will hold another parliamentary evidence session on Tuesday. This session will hear from doctors, researchers and people with Body Dysmorphic Disorder.
Questions in the survey cover a range of topics, including whether thoughts and feelings on body image negatively impact quality of life, and which aspects of life are affected the most.
Jeremy Hunt, chairman of the Health and Social Care Committee, said: "Worries about body image can become enormously distressing, particularly for young people.
"To support our inquiry into body image, we're asking people to take part in a survey about how concerns about body image can affect their physical and mental health," he added.
"We want to hear about their experiences of accessing NHS services in relation to body image, whether people know where to go to get help, and whether they feel any stigma in seeking support for health issues relating to body image."
Read full story
Source: BBC News, 25 April 2022
Patient Safety Learning

Pharmacists in England face abuse from patients due to drug shortages

Pharmacy staff in England are facing growing abuse and aggression from patients frustrated that drug shortages mean they cannot get their usual medications, a survey reveals.
The hostility, including swearing and spitting, comes as availability of medicines is becoming more uncertain as a result of Brexit, the Covid pandemic and ingredient supply problems. Hormone replacement therapy drugs are in short supply in many places, affecting women undergoing menopause, for example.
Half of pharmacists and counter staff say the unpredictability is causing problems for customers managing their health, according to research by the Pharmaceutical Services Negotiating Committee (PSNC), which represents community pharmacies in England.
The PSNC’s survey of 1,132 staff from and 418 bosses of 5,000 pharmacies found:
75% of pharmacies have seen patients turn aggressive when told they cannot have the medication they have been prescribed. 49% of staff say patient abuse is undermining their mental wellbeing. 51% believe supply chain issues affect patients every day. “It is really worrying to hear that pharmacy staff are so routinely facing aggression from patients,” said Janet Morrison, the PSNC’s chief executive. “Pharmacists tell us anecdotally that this can include verbal abuse, swearing, spitting and threatening to report staff to regulators.
“Many community pharmacies are having to deal with medicine supply issues on a daily basis. This adds pressures on to already busy pharmacy teams and can also be worrying for patients if they have to wait longer for the medicines that they need.”
Patients were left “frustrated and inconvenienced” by drug shortages, she added.
Read full story
Source: The Guardian, 25 April 2022
Patient Safety Learning

NHS orders new chair of review into baby deaths

The NHS has ordered a new chair for the Nottingham maternity scandal review which is looking into hundreds of cases of alleged poor care.
In a letter published late on Friday the NHS said there needed to be “urgent” changes to the way the review was being carried out and this included appointing a former NHS trust chair Julie Dent to lead the review.
More than 100 bereaved families wrote to the health secretary Sajid Javid on 7 April calling for the review, to be overhauled and the chair Cathy Purt, to be replaced by Donna Ockenden who chaired the Shrewsbury maternity scandal inquiry.
The Nottingham review, dubbed an “independent thematic review”, was launched in July 2021 and is being led by local NHS commissioners and NHS England.
It was announced after The Independent and Channel 4 revealed millions had been paid out by the trust over 30 baby deaths and 46 incidents of babies left permanently brain damaged by Nottingham University Hospitals Foundation Trust.
Sir David Sloman, the NHS chief operating officer, said in his letter on Friday: “Following discussions at both a regional and national level, it is clear that urgent changes to how the review is being delivered need to be made. A new chair needs to lead this review with sufficient senior experience to address the concerns and challenges faced at Nottingham University Hospitals, to speed up the process and to deliver a review that can bring about real change for women and babies in Nottingham.
“It has therefore been agreed that the review will now have enhanced national oversight by NHS England and NHS Improvement and I am pleased to announce that Julie Dent CBE has agreed to take on the role of chair for this review and she will begin this work with immediate effect.”
Read full story
Source: The Independent, 23 April 2022
Patient Safety Learning

Women asked if bladder drug should be available to buy

A pill to help treat an overactive bladder - which affects millions of women - could soon be available to buy in the UK without prescription.
The Medicines and Healthcare products Regulatory Agency (MHRA) wants women and doctors to submit their views.
Aquiette tablets treat the "urge to pee" condition which can cause frequent toilet trips and distressing accidents. Symptoms include having to urinate at least eight times a day and more than once during the night.
It would be the first time a medicine for the treatment of overactive bladder would be available without prescription.
Dr Laura Squire, from the MHRA, said: "For many women, an overactive bladder can make day-to-day living extremely challenging.
"It can impact on relationships, on work, on social life, and it can lead to anxiety and depression.
"Fortunately there are treatments around, and from today you will have a chance to have your say on whether one of those treatments, Aquiette, can be available for the first time without a prescription."
Minister for Women's Health Maria Caulfield said: "When it comes to sensitive issues such as bladder control, speaking to a GP may act as a barrier for some women to seek help.
"Reclassification of Aquiette would enable women to access vital medication without needing a prescription."
The Commission on Human Medicines has been consulted and has advised that it is safe for Aquiette to be made available over-the-counter at UK pharmacies.
The consultation will run for three weeks, closing on 6 May, 2022.
Read full story
Source: BBC News, 23 April 2022
Patient Safety Learning

‘I thought she’d be safe’: a life lost to suicide in a place meant for recovery

"I thought she would be safe at Chadwick Lodge,” said Natasha Darbon, recalling how she felt in April 2019 when her 19-year-old daughter, Brooke Martin, was admitted to the mental health hospital in Milton Keynes.
Eight weeks later, Brooke took her own life.
The jury at the inquest found that Brooke’s death could have been prevented and that the private healthcare provider Elysium Healthcare, which ran the hospital, did not properly manage her risk of suicide. It also found that serious failures of risk assessment, communication and the setting of observation levels contributed to her death. Elysium accepted that had she been placed on 24-hour observations, Brooke would not have died.
In 2018, Brooke, who was autistic, was repeatedly sectioned under the Mental Health Act because of her escalating self-harm and suicide attempts. After a spell in an NHS facility in Surrey she moved to Chadwick Lodge, which specialises in treating personality disorders.
After a few weeks there, Brooke was doing well and staff were pleased with her progress. She was due to move to Hope House, a separate unit at the hospital, to start more specialist therapy for emotionally unstable personality disorder, and was keen to make the switch.
But then the teenager’s mental health deteriorated again. On 5 June 2019 she tried to kill herself. Five days later she was seen twice that evening secretly handling potential ligatures, but no appropriate action was taken. A few minutes later she was found unresponsive in her room. She received CPR but died the next day in Milton Keynes university hospital.
After hearing the evidence about the care Brooke received in her final days, Tom Osborne, the coroner at the inquest, took the unusual step of issuing a prevention of future deaths notice. He sent it to Sajid Javid, the health secretary, and to Elysium Healthcare, as the owner of Chadwick Lodge.
It set out the detailed criticisms that the jury had made of Elysium’s interaction with Brooke after her attempt to take her own life on 5 June. They cited the hospital’s failures to communicate information regarding Brooke’s suicide attempt, to search her room after she was found handling potential ligatures on the night she died, and to place Brooke on constant observations afterwards.
Read full story
Source: The Guardian, 24 April 2022
Patient Safety Learning

Sajid Javid to review gender treatment for children

Health Secretary Sajid Javid is to review what immediate changes can be made to gender treatment services for children in England.
This could include changing the law to let the independent Cass review have access to an NHS database of young people who already received treatment.
It comes ahead of the review's report, due later this year.
This week Mr Javid told MPs services in this area were too affirmative and narrow, and "bordering on ideological".
He is now thought to be planning an overhaul of the Gender Identity Development Service (GIDS), which is run by the Tavistock and Portman NHS Foundation Trust, with clinics in London and Leeds.
The trust has defended itself, saying while there is a need for change, doctors already take into account the wider physical and mental health of children who are referred there.
The health secretary has been considering changing the law to allow a review of GIDS being led Dr Hilary Cass, former president of the Royal College of Paediatrics and Child Health, to access a database of children who were treated by GIDS to see if any later regretted having treatments, such as puberty blockers. It is unclear how the process of giving access to the information would work.
Read full story
Source: BBC News, 24 April 2022
Patient Safety Learning

Abbigail Smith: Woman’s death prompts fresh calls for public inquiry into scandal-hit mental health trust

The death of a young woman a day after she was discharged from a mental health facility has sparked renewed calls for a public inquiry into a scandal-hit trust.
Abbigail Smith, 26, who had autism and learning difficulties, was found dead in a park in Essex in February, 24 hours after she was allowed to leave the Linden Centre run by the Essex Partnership University Hospitals Foundation Trust (EPUT).
The trust has launched an investigation into the care she received before she died, according to a letter seen by The Independent, and Essex Coroner’s Court will examine her death.
The Independent can reveal 97 patient deaths have been declared by the trust between February 2021 and February 2022 under the national patient safety alert system.
The trust is already facing an independent inquiry into 1,500 patient deaths between 2000 and 2020. Deaths after December 2020 will not be looked at by that inquiry.
At least 68 families have called for a public inquiry into mental health services in Essex, led by Melanie Leahy, whose son Matthew died at the Linden Centre in 2012.
Nina Ali, a solicitor at Hodge Jones & Allen, which is supporting the Wolffs and other families, told The Independent: “It is worrying that the government has and continues to completely ignore the call led by Melanie Leahy, now supported by some 68 families and individuals, for the current independent inquiry to be converted to a full statutory inquiry on the basis that the current inquiry – which lacks the statutory power to compel relevant documentary evidence to be obtained and to compel witnesses to attend and give their evidence under oath – will ultimately prove to be a complete waste of time and money.”
Read full story
Source: The Independent, 25 April 2022
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