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

US abortion laws spark profound changes in other medical care

A sexual assault survivor chooses sterilization so that if she is ever attacked again, she won’t be forced to give birth to a rapist’s baby. An obstetrician delays inducing a miscarriage until a woman with severe pregnancy complications seems “sick enough.” A lupus patient must stop taking medication that controls her illness because it can also cause miscarriages.
Abortion restrictions in a number of states and the Supreme Court’s decision to overturn Roe v. Wade are having profound repercussions in reproductive medicine as well as in other areas of medical care.
“For physicians and patients alike, this is a frightening and fraught time, with new, unprecedented concerns about data privacy, access to contraception, and even when to begin lifesaving care,” said Dr. Jack Resneck, president of the American Medical Association.
Even in medical emergencies, doctors are sometimes declining immediate treatment. In the past week, an Ohio abortion clinic received calls from two women with ectopic pregnancies — when an embryo grows outside the uterus and can’t be saved — who said their doctors wouldn’t treat them. Ectopic pregnancies often become life-threatening emergencies and abortion clinics aren’t set up to treat them.
It’s just one example of “the horrible downstream effects of criminalizing abortion care,″ said Dr. Catherine Romanos, who works at the Dayton clinic.
Read full story
Source: AP News, 16 July 2022
Patient Safety Learning

Hospital has left my daughter in ME agony, claims mother

A mother has said an NHS hospital failed to offer her daughter adequate pain relief in a pattern of poor treatment that left the teenager suicidal.
Ella Copley, 17, from Tingley, West Yorkshire, has suffered from ME (myalgic encephalomyelitis), sometimes known as chronic fatigue syndrome, for seven years. She has been in Leeds General Infirmary since March, when she was taken there by ambulance with an infection later diagnosed as sepsis.
Her mother, Joanne McKee, 49, said the treatment Ella had received “feels like neglect and abuse”. She has posted videos on social media of the teenager screaming in pain when medicine is given by nasogastric tube. “I don’t think they believe that her pain is real at all,” she said.
McKee said doctors had told Ella she was “hypersensitive”, and suggested that she stroke a piece of material against her skin as part of a desensitisation programme. “I have just never, ever known anything so dismissive,” McKee said.
In an interview with Times Radio, she added: “No one has any understanding of her conditions. That really is the issue."
The charity Action for ME has written a letter to the hospital’s chief executive raising concerns over Ella’s case. In it, Sonya Chowdhury, chief executive of the charity, said she was “aware of several other situations that bear similarity with Ella’s illness and care”.
Questions have been raised over the treatment of Maeve Boothby-O’Neill, who died in October last year. Her death will be the subject of an inquest in Exeter next month.
Read full story (paywalled)
Source: The Times, 18 July 2022
Patient Safety Learning

Half of all deaths of people with a learning disability ‘avoidable’

Nearly half (49%) of all deaths of people with a learning disability in 2021 were deemed to be avoidable, a major annual report has found.
By comparison, just 22% of deaths were classified as avoidable among the overall general population in 2020.
A new report, led by King’s College London and produced for NHS England – identified that of those avoidable deaths among people with learning disabilities, 65.5% died in hospital.
The learning from life and death reviews programme (LeDeR) report also revealed that the Midlands and North West showed the greatest difference in avoidable to unavoidable deaths at 53%, compared to 48% in London.
And when looking at individual long-term conditions, 8% of avoidable deaths were related to cancer, 17% to diabetes, 14% to hypertension, and 17% to respiratory conditions.
It also found that:
More than 50% of people with a learning disability died in areas rated as some of the most deprived in England Around six out of 10 people with a learning disability die before age 65, compared to 1 in 10 from the general public On average, men with a learning disability die 22 years younger than men from the general population. Read full story
Source: Healthcare Leader, 18 July 2022
Patient Safety Learning

First Women's Health Strategy for England to tackle gender health gap

Women and girls across England will benefit from improved healthcare following the publication of the first ever government-led Women’s Health Strategy for England today.
Following a call for evidence which generated almost 100,000 responses from individuals across England, and building on 'Our Vision for Women’s Health', the strategy sets bold ambitions to tackle deep-rooted, systemic issues within the health and care system to improve the health and wellbeing of women, and reset how the health and care system listens to women.
The strategy includes key commitments around:
New research and data gathering. The expansion of women’s health-focused education and training for incoming doctors. Improvements to fertility services. Ensuring women have access to high-quality health information. Updating guidance for female-specific health conditions like endometriosis to ensure the latest evidence and advice is being used in treatment. To support progress already underway in these areas, the strategy aims to:
Provide a new investment of £10 million for a breast screening programme, which will provide 25 new mobile breast screening units to be targeted at areas with the greatest challenges in uptake and coverage. This will: - provide extra capacity for services to recover from the impact of the coronavirus (COVID-19) pandemic - boost uptake of screening in areas where attendance is low - tackle health disparities - contribute towards higher early diagnosis rates in line with the NHS Long Term Plan. Remove additional barriers to IVF for female same-sex couples. There will no longer be a requirement for them to pay for artificial insemination to prove their fertility status and NHS treatment for female same-sex couples will start with 6 cycles of artificial insemination, prior to accessing IVF services, if necessary. Improve transparency on provision and availability of IVF so prospective parents can see how their local area performs to tackle the ‘postcode lottery’ in access to IVF treatment Recognise parents who have lost a child before 24 weeks through the introduction of a pregnancy loss certificate in England. Ensure specialist endometriosis services have the most up-to-date evidence and advice by updating the service specification for severe endometriosis, which defines the standards of care patients can expect. This sits alongside the National Institute for Health and Care Excellence (NICE) review of its guideline on endometriosis. Read full story
Source: Gov.UK, 20 July 2022
Patient Safety Learning

NHS ‘shouting into the void’ with covid concerns

NHS leaders have sometimes been “shouting into the void” about their fears of the health service being overwhelmed by Covid because of the absence of a single national command centre for the pandemic response, a new report argues.
The Tony Blair Institute for Global Change has published a report which recommends short and long term actions for dealing with Covid and future health emergencies. 
It says the government should have previously, and should now, set up “a national centre for response” to have overriding national responsibility for managing Covid and future crises.
The government should also shift away from traditional methods of communication, to instead listen to “communities… beliefs and fears” about Covid, and adjust messages to respond to these.
The report has been authored by the institute’s head of health Henry Dowlen, who was seconded to work on several pandemic projects such as a setting up a Nightingale Hospital and coordinating regional and national response work.
He said that if government did not change course then the NHS, along with other services and parts of society, would remain in a “vicious cycle” of operational problems.
Read full story (paywalled)
Source: HSJ, 20 July 2022
Patient Safety Learning

Bereaved families demand ‘core’ role in UK Covid inquiry as ‘investigative’ phase begins

Families who lost loved ones during the pandemic have demanded to play a central role in the UK’s Covid-19 inquiry, which launches its investigative phase tomorrow.
The inquiry has already consulted with different groups, businesses, academics and officials from a variety of sectors involved in the pandemic response to review which areas warrant scrutiny and how to structure proceedings.
This includes Covid-19 Bereaved Families for Justice, a campaign group of over 6,000 people who have lost a loved one to coronavirus.
The group has repeatedly sought assurances from the inquiry it will be granted a ‘core participant’ status once applications open. This which would allow families to give evidence, ask questions during proceedings, access all disclosed documents, and recommend people to be interviewed.
However, Elkan Abrahamson, a lawyer who is representing the group in the inquiry, said it was unclear how the inquiry would select core participants and expressed concern that the bereaved families won’t play a central role.
“The feeling from the bereaved at the consultation stage was that the chair was sympathetic. They were happy with how that went,” Mr Abrahamson said.
“[But] given we represent the largest group of bereaved in the UK, we’re not experiencing a sense of co-operation that we would normally expect to have reached by this stage. Their lawyers are happy to meet with us, but the questions we ask them aren’t being properly answered.”
Read full story
Source: The Independent, 20 July 2022
Patient Safety Learning

Patient safety issues with VA Cerner EHR caused harm to veterans, federal watchdog says

A new patient medical records system at a Spokane Veterans Affairs hospital in the US has caused nearly 150 cases of patient harm, according to a federal watchdog agency.
An inspection by the VA Office of the Inspector General (OIG) found that a new Cerner electronic health record (EHR) system, now owned by Oracle, failed to deliver more than 11,000 orders for specialty care, lab work and other services at Mann-Grandstaff VA Medical Center, the first VA facility to roll out the new technology.
The OIG review found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of the intended care or service location, effectively causing the orders to disappear without letting clinicians know they weren't delivered.
The intent of the unknown queue is to capture orders entered by providers that the new EHR cannot deliver to the intended location because the orders were not recognized as a “match” by the system, according to the VA watchdog.
From facility go-live in October 2020 through June 2021, the new EHR failed to deliver more than 11,000 orders for requested clinical services.
Those lost orders, often called referrals, resulted in delayed care and what a VA patient safety team classified as dozens of cases of "moderate harm" and one case of "major harm."
The clinical reviewers conducted 1,286 facility event assessments and identified and classified 149 adverse events for patients.
Read full story
Source: Fierce Healthcare, 20 July 2022
Patient Safety Learning

Nurse struck off after medication lies

A nurse who recorded she had given medication to care home residents when in fact she had delegated the task to unqualified staff has been struck off.
Adelaide Maloane was working a night shift at Somerleigh Court in Dorchester, Dorset, in August 2019 when the incident took place.
Ms Maloane delegated giving 16 medicines to residents to an unqualified healthcare assistant at the home.
The Nursing and Midwifery Council said Ms Maloane had "failed to acknowledge the seriousness of her misconduct and dishonesty and the implications of her actions for residents, colleagues and the reputation of the nursing profession".
Read full story
Source: BBC News, 21 July 2022
Sam

Prehab: Getting patients fit for cancer treatment

Roy Cairns, 58, was diagnosed with liver cancer in 2019. Twelve months later a tumour was found on his lung.
Mr Cairns said taking part in the cancer prehab programme piloted by the Northern Ireland's South Eastern Health Trust after his second diagnosis was a "win-win", not only for himself but also his surgeons.
"I think when you get that diagnosis you are left floundering and with prehab the support you get gives you focus and a little bit of control back in your life," he said.
Prehabilitation (prehab) means getting ready for cancer treatment in whatever time you have before it starts.
Mr Cairns is one of 175 patients referred to the programme which involves the Belfast City Council and Macmillan Cancer Support.
Dr Cherith Semple said the point of the programme is to " improve people's physical well-being as much as possible before treatment and to offer emotional support at a time that can be traumatic".
Dr Semple, who is a leader in clinical cancer nursing, said this new approach to getting patients fit prior to their surgery was proving a success, both in the short and long-term.
She said: "We know that it can reduce a patient's hospital stay post-surgery and it can reduce your return to hospital with complications directly afterwards."
Read full story
Source: BBC News, 20 July 2022
Sam

25% of BAME non-executive directors in NHS ‘have seen discrimination’ at work

A quarter of Black, Asian and minority ethnic (BAME) non-executive directors of NHS trusts have seen or experienced discrimination in the course of their work, a report reveals.
While almost four out of five (79%) of these BAME non-executives said they challenged such behaviour when they encountered it, only half (50%) said that led to a change of policy or behaviour.
The other half felt they had been ‘fobbed off’ or subjected to actively hostile behaviour for having spoken up,” says a report commissioned by the Seacole Group, which represents most of the BAME non-executive board members of NHS trusts in England.
It adds: “This level of discrimination is unacceptable anywhere and even more so in the boardrooms of NHS organisations. Too many Black, Asian and other ethnic NEDs (non-executive directors) are being subjected to it and left to deal with it on their own.”
Read full story
Source: The Guardian, 21 July 2022
Sam

Hormone replacement therapy to be offered over the counter in UK

Hormone replacement therapy is to be offered over the counter for the first time in the UK after the medicines watchdog gave the green light.
Millions of women go through the menopause every year, with the majority experiencing some symptoms that can be severe and have a negative impact on everyday life.
In a landmark move hailed as a “huge step forward” for women’s health, the first type of HRT to become available at pharmacies without a prescription will be Gina 10 microgram vaginal tablets (containing estradiol).
The Medicines and Healthcare products Regulatory Agency (MHRA) said the vaginal tablets would be available for post-menopausal women from September after a safety review.
Maria Caulfield, the minister for women’s health, said: “Menopause affects hundreds of thousands of women every year, but for some its symptoms can be debilitating and for many they can be misunderstood or ignored.
“Making Gina available over the counter is a huge step forward in enabling women to access HRT as easily as possible, ensuring they can continue living their life as they navigate the menopause.”
Read full story
Source: The Guardian, 20 July 2022
 
 
Sam

Catheter pilot scheme sees infections fall by 100%

A pilot scheme to reduce infections following catheter insertions has shown a 100% fall within a hospital trust.
NHS Supply Chain is now encouraging acute trusts in England to take advantage of the scheme which has shown to not only reduce infection rates but shorten patient length of stay and save clinicians’ time.
Catheter associated urinary tract infections (CAUTIs) are not uncommon and can cause patients significant pain, discomfort, confusion and anxiety for family and friends. They further impact healthcare with increased antibiotic use, prolonged hospital stays, increased clinical activity and risk of complaints and litigation. 
University Hospitals of North Midlands NHS Trust had audited its urethral catheterisation practice, and the way catheterised patients w19 July ere cared for in clinical areas. The audit highlighted a wide variation in care delivery leading to inconsistent outcomes for patients and staff.
After reviewing the available options, the University Hospitals of North Midlands NHS Trust decided to pilot the BARD® Tray which contains all the essential items to catheterise or re-catheterise a patient in one pack and includes the catheter with a pre-connected urine drainage bag. This unique ‘closed system’ prevents ingress of bacteria and helps avoid catheter related infection. 
NHS Supply Chain: Rehabilitation, Disabled Services, Women’s Health and Associated Consumables worked alongside supplier Beckton Dickinson to provide the tray products required by the trust.
During the three-month pilot, catheter related infection rates fell by 100% at the trust which coincided with a reduction in complaints and a reduced length of hospital stay for patients. Clinicians reported that the pack was intuitive and saved around five minutes per catheterisation, which during the pilot process meant saving 83 hours from 1,000 catheterisation procedures.
While the BARD® Tray was more expensive than the individual components that were currently purchased, the pilot study demonstrated the clinical and financial value that was delivered by the tray being implemented across an organisation. The overall cost of components is slightly cheaper, but due to reduced catheterisations, consumables spend fell by 24%.
Read full story
Source: NHS Supply Chain, 19 July 2022
Sam

London NHS trust cancels operations as IT system fails in heatwave

One of the NHS’s biggest hospital trusts is facing major problems after its IT system failed because of the extreme temperatures earlier this week.
Guy’s and St Thomas’ trust (GSTT) in London has had to cancel operations, postpone appointments and divert seriously ill patients to other hospitals in the capital as a result of its IT meltdown.
The situation means that doctors cannot see patients’ medical notes remotely and are having to write down the results of all examinations by hand. They are also unable to remotely access the results of diagnostic tests such as X-rays and CT and MRI scans and are instead having to call the imaging department, which is overloading the department’s telephone lines.
GSTT has declared the problem a “critical site incident”. It has apologised to patients and asked them to bring letters or other paperwork about their condition with them to their appointment to help overcome doctors’ loss of access to their medical history.
One doctor at GSTT, speaking on condition of anonymity, said: “This is having a major effect. We are back to using paper and can’t see any existing electronic notes. We are needing to triage basic tests like blood tests and scans. There’s no access to results apart from over the phone, and of course the whole hospital is trying to use that line.
“Frankly, it’s a big patient safety issue and we haven’t been told how long it will take to fix. We are on divert for major specialist services such as cardiac, vascular and ECMO.”
Read full story
Source: The Guardian, 21 July 2022
Patient Safety Learning

Gloucestershire maternity service failures 'putting women and babies at risk'

A shortage of maternity staff is putting women and babies at risk in Gloucestershire, inspectors have said.
The county's maternity services have been downgraded by two levels, from good to inadequate, by the Care Quality Commission (CQC).
Its report highlighted staff shortages, missed training, exhaustion among workers and concerns over equipment.
Gloucestershire Hospitals NHS Foundation Trust issued an apology and said improvements have been made.
CQC inspectors visited maternity wards, birth units and community midwives in Gloucester, Cheltenham and Stroud in April after receiving concerns about the "culture, safety and quality of services".
They found the service did not have enough midwifery staff with the "right qualifications, skills, training and experience to keep women safe from avoidable harm or to provide the right treatment all the time".
Read full story
Source: BBC News, 22 July 2022
Patient Safety Learning

NHS waits force patients to pay for private ops

Long NHS waiting times appear to be pushing people into paying thousands of pounds for private treatment.
There were 69,000 self-funded treatments in the UK in the final three months of last year - a 39% rise on the same period before the pandemic.
Experts said it was a sign of how desperate people had become.
The BBC has seen evidence of people taking out loans and resorting to crowdfunding to pay for private treatment.
The figures from the Private Healthcare Information Network (PHIN) do not include those who have private insurance - instead they are the people paying the full cost of treatment themselves, leaving them liable for huge bills.
Patient groups warned there was a risk of a two-tier system being created, with the poorest losing out because they were the least likely to be able to afford to pay for treatment.
Patient watchdog Healthwatch England said waits for treatment were one of the most common concerns flagged by patients, and warned the situation risked "widening health inequalities".
Chief executive Louise Ansari said for most people going private "simply isn't an option", especially with the cost-of-living crisis.
"People on the lowest incomes are the most likely to wait the longest for NHS treatment. This leads to a worse impact on their physical health, mental health and ability to work and care for loved ones."
Read full story
Source: BBC News, 21 July 2022
Patient Safety Learning

NHSE tries to put £2.3bn cap on agency staff spend

NHS England is introducing a new ceiling on the amount spent within each integrated care system on agency staff — cutting it by at least 10% in each area in one year — as part of a drive to find further savings across the health service.
Integrated Care Services (ICSs) have been told to cut spending on temporary staff by providers in their area by at least 10%, or £257m, on 2021-22 levels, taking expenditure down to a total of £2.3bn nationally. A letter to finance directors sent today, seen by HSJ says: “This will mean that some systems will need to go beyond their current financial plans to reduce agency expenditure.”
The move is part of a wider efficiency crackdown from NHS England, with further national control measures to be introduced over the next 18 months. HSJ understands that the renewed drive will focus on five other areas in addition to agency spend: medicines, pathway redesign, corporate services, procurement and specialised commissioning.
The extra savings ask comes on top of ICSs already committing to £5.5bn in efficiencies over 2022-23, which Nuffield Trust CEO Nigel Edwards said was “not a credible savings target”.
Read full story (paywalled)
Source: HSJ, 20 July 2022
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