Skip to content
the hub has moved to a new software platform. You will need to login using your email address. Find out more here.

News

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

County Durham and Darlington improves patient safety with AI

County Durham and Darlington NHS Foundation Trust has created and implemented an artificial intelligence (AI) model to protect patients from acute kidney injury (AKI).
The trust’s AI-driven model helps healthcare staff to identify patients who are at risk from AKI and to swiftly respond with treatment. The technology uses risk stratification digital tools that staff are able to access through an app. These are combined with care processes developed at the trust and which involve a new specialist nurse team, preventive specialist intervention, assessment and follow-up.
Its implementation at County Durham and Darlington has led to a reduction in both hospital-acquired and community AKI. Overall, the incidence of AKI within the trust fell from 6.5% between March and May 2020, to 3.8% during the same period in 2021. The most significant reduction was seen in hospital-acquired AKI – which fell by more than 80%.
Jeremy Cundall, medical director for County Durham and Darlington NHS Foundation Trust and executive lead for the project, said: “The partnership has resulted in patients being detected earlier – preventing AKI from occurring or mitigating the worsening of existing AKI. Accordingly, patients have been more effectively triaged to the right pathways of care including referral and transfer to tertiary renal units where appropriate.”
Claire Stocks, early detection, resuscitation and mortality lead nurse for County Durham and Darlington NHS Foundation Trust, said: “This work has been a project very much about using collaborative partnerships to enhance patient safety and quality. An idea that was developed in a ‘cupboard conversation’ is now a fully operational specialist nurse service. Utilising digital innovations supports rapid triage, early detection and treatment to improve outcomes.”
In addition to the improvements in patient safety, the technology has delivered cost savings for the trust too. County Durham and Darlington saved more than £2million in direct costs from reductions in AKI incidence. The improved transfer of patients has also released ICU capacity, vital at a time when the NHS is dealing with a growing national backlog for elective surgery.
Read full story
Source: Digital Health, 27 July 2022
Patient Safety Learning

Mesh surgeon fails in bid to stop legal action against trust being made public

A leading colorectal surgeon whose former employer, North Bristol NHS Trust, faces negligence claims from dozens of his ex-patients has failed in his bid to keep legal action he is taking against the trust a secret.
A review by the trust found that 203 women on whom the surgeon Tony Dixon performed pelvic mesh procedures between 2007 and 2017 came to harm. The trust faces legal claims from many of them.
Trust board members were told in May that the trust had notified the 203 women that “although their laparoscopic ventral mesh rectopexy operation was carried out satisfactorily, they should have been offered alternative treatments before proceeding to surgery,” and that those patients were defined as suffering “harm.”
Dixon sued the trust in the High Court to try to stop it releasing two documents to solicitors acting for ex-patients, as part of the disclosure process in litigation. 
Read full story (paywalled)
Source: BMJ, 27 July 2022
Patient Safety Learning

What the Fuller Stocktake report means for primary care and digital technology

The recent publication of the Fuller Stocktake report sets out a new vision for the role of primary care in integrated care systems. With primary care the bedrock of the NHS and at “the heart of communities”, the paper’s recommendation to similarly establish it at the centre of new ICS systems and foster greater collaboration is a welcome one that has been greeted positively in many quarters.
However, a key priority underpinning many of the recommendations made is the need to create sustainable primary care for the future. Within this, there is a challenge to tackle “inadequate access to urgent care” which the report argues is having a direct impact on general practice’s ability to provide continuity of care to patients who need it most as well as overall primary care capacity. Referred to as being two sides of the same coin, this stark recognition of current workload and workforce challenges in general practice alongside their wider contributing factors is both timely and welcome.
Read full story (paywalled)
Source: HSJ, 27 July 2022
Patient Safety Learning

Stick-on ultrasound patch hailed as revolution in medical imaging

A stick-on patch that can take an ultrasound scan of a person’s insides as they go about their daily life has been hailed as a revolution in medical imaging.
The wearable patch, which is the size of a postage stamp, can image blood vessels, the digestive system and internal organs for up to 48 hours, giving doctors a more detailed picture of a patient’s health than the snapshots provided by routine scans.
In laboratory tests, researchers used the patches to watch people’s hearts change shape during exercise, their stomachs expand and shrink as they drank and passed drinks, and their muscles pick up microdamage when weightlifting.
Prof Xuanhe Zhao at Massachusetts Institute of Technology, who led the research team, said the patches could “revolutionise” medical imaging because existing scans are very brief, sometimes lasting only seconds, and usually have to be performed in hospitals.
Ultrasound scans are extremely common, with NHS England performing more than 8m last year. But the technique has major limitations, requiring highly trained sonographers to place and orient the probes on patients’ bodies to get high-quality images. For this reason, most ultrasound scans are brief and performed on patients who are required to keep still while the images are taken.
Wireless patches could sidestep some of these problems, as they can be fixed in position and left to take images for hours, and even days, at a time, the researchers say. Beyond scanning organs for early signs of disease, the “set and forget” patches could monitor bladder function, tumours, and the development of foetuses in the womb.
Read full story
Source: The Guardian, 28 July 2022
Patient Safety Learning

Grim figures reveal the scale of healthcare decline worldwide

Startling numbers from around the world give grim statistical support for the argument that healthcare quality has not only stalled, but is in worrying retreat. 
Nearly 15 million deaths have been attributed to Covid-19 worldwide. All countries have seen waiting times increase and deaths from cardiac conditions and cancer rise. Mental health problems have been exacerbated, while the frailty of some elderly care services has left families unsupported. The global workforce crisis has been exposed, health inequalities amplified, and life expectancy arrested. Government debt has soared, and livelihoods have been lost. 
In a new report, health systems leaders from across the world – including the UK, Australia, India, Singapore, Canada, the USA and Europe – raise the alarm.
There has been a decline in the focus on quality by the leadership of health systems all over the world with an opportunity cost in terms of patient outcomes, safety issues and people’s experience of healthcare.
How do we shift from firefighting to a focus on quality of care?
Dr Mark Britnell, chair of the Beamtree Global Impact Committee report, makes a simple argument: the only way to reverse the retreat from quality is to march steadfastly towards it. 
Read full story (paywalled)
Source: The Telegraph, 26 July 2022
Patient Safety Learning

Ex-health secretaries call for urgent blood scandal pay-outs

Three former health secretaries have called on the government to urgently pay compensation to victims of the contaminated blood scandal.
The chairman of the public inquiry into the scandal, Sir Brian Langstaff, has recommended that each victim should receive a provisional sum of £100,000.
One woman who developed hepatitis C from infected blood told the BBC the news was "incredibly significant".
The government has said it will urgently consider any recommendations.
Former health secretaries Andy Burnham, Jeremy Hunt and Matt Hancock told the BBC it was important to act quickly because the life expectancy of many victims had been shortened by infections they had contracted.
A lawyer representing about 15,000 claimants also argued that victims should receive compensation "immediately". Des Collins said payment must be made within "days or weeks", and he would step up pressure from Monday.
Read full story
Source: BBC News, 31 August 2022
Patient Safety Learning

Fears for patients as '111' calls abandoned - Government called to 'get a grip' on issue

A call to NHS 111 was abandoned every 10 seconds between 2020 and 2021, figures show. Millions of callers to the helpline hung up at a time when demand for the NHS was at its highest.
In 2020, 2,490,663 calls were abandoned, while in 2021 this figure increased to 3,531,186. And 1,174,159 gave up on the line from January to May this year. Callers in Devon take an average of 11 minutes to get through to the NHS 111 service, according to Liberal Democrat research.
Daisy Cooper, Lib Dem spokeswoman for health and social care, said: "Ambulance services are being stretched to breaking point, hospitals are reaching full capacity and now people cannot get through to NHS 111. We have called on this government time and time again to get a grip on this issue by recruiting more NHS 111 call handlers now."
"The longer they delay, the longer they are leaving people in pain and distress."
Helen Hughes, of the Patient Safety Learning charity, said: "These figures represent a serious safety concern. Each call is a potential missed opportunity for patients to receive timely medical advice that may prevent future harm."
"With the ongoing severe pressures faced by ambulance services and hospitals this summer, patients are increasingly being signposted to NHS 111 for advice on non-life threatening conditions."
"However, it can only relieve the pressure on other areas of the health service if NHS 111 has the capacity and resources to meet rising demand. The NHS leadership needs to urgently assess the reasons for this high number of abandoned calls."
Read full story
Source: Express, 31 July 2022
Patient Safety Learning

NHS to use AI to identify people at higher risk of hepatitis C

The NHS is to use artificial intelligence to detect, screen and treat people at risk of hepatitis C under plans to eradicate the disease by 2030.
Hepatitis C often does not have any noticeable symptoms until the liver has been severely damaged, which means thousands of people are living with the infection – known as the silent killer – without realising it.
Left untreated, it can cause life-threatening damage to the liver over years. But with modern treatments now available, it is possible to cure the infection.
Now health chiefs are launching a hi-tech screening programme in England in a fresh drive to identify thousands of people unaware they have the virus.
The scheme, due to begin in the next few weeks, aims to help people living with hepatitis C get a life-saving diagnosis and access to treatment before it is too late.
The NHS will identify people who may have the virus by using AI to scan health records for a number of key risk factors, such as historical blood transfusions or an HIV diagnosis.
Anyone identified through the new screening process will be invited for a review by their GP and, if appropriate, further screening for hepatitis C. Those who test positive for the virus will be offered treatment available after NHS England struck a deal with three major pharmaceutical companies.
Prof Graham Foster, national clinical chair for NHS England’s hepatitis C elimination programmes, said the scheme “marks a significant step forward” in the fight to eliminate the virus before 2030. It will “use new software to identify and test patients most at risk from the virus – potentially saving thousands of lives”, he added.
Read full story
Source: The Guardian, 31 July 2022
Patient Safety Learning

NHSE leak reveals 1m patients on hidden waiting list

More than a million people – including hundreds of thousands of children – are on an unpublished national waiting list for community health services, according to NHS England documents leaked to HSJ.
They reveal that just over 75,000 children are waiting to access community paediatric services, including children needing help with developmental delay, long-term health conditions and additional needs; and there is a backlog of more than 74,300 young people for speech and language therapy.
More than 321,000 adults are on the list waiting for musculoskeletal services, mostly physiotherapy such as for back and joint pain; while 120,000 are waiting for podiatry.
HSJ understands the lack of national support for long waits for most community and mental health care – in contrast to billions of government funding and a major recovery programme for elective consultant-led treatment – has been raised at a senior level in NHS E in recent weeks. One senior leader told HSJ the discrepancy was “immoral”. 
Read full story (paywalled)
Source: HSJ, 1 August 2022
Patient Safety Learning

Trust begins ‘most ambitious’ outpatients project in NHS

A large acute trust is carrying out a major expansion of patient-initiated follow-up (PIFU) appointments, which is said to be “the most ambitious” project of its kind in the NHS.
Norfolk and Norwich University Hospitals Foundation Trust has categorised around half of its outpatient follow-up list as “possible or probable opportunities” for patient-initiated pathways.
NNUH wants to make PIFU the “default model” for patients who are not on active pathways, and where it is safe to do this.
Its project is being closely watched by national leaders and has already drawn praise from NHS England’s director of elective recovery, Rob Stones, during a webinar last month. It is understood to be more ambitious than NHSE’s official PIFU pilot projects.
NHSE’s elective chief, Sir Jim Mackey, has said he wants to expand PIFU pathways on an “industrial” scale.
Read full story (paywalled)
Source: HSJ, 29 July 2022
Patient Safety Learning

Doctors are concerned about the risk of hospital-acquired Covid-19

People who go to hospital for non-covid treatment are at higher risk of the virus compared with the general public, which is why high levels of hospital-acquired Covid-19 in England are worrying some doctors.
They fear that the coronavirus is becoming a potential hazard of a hospital stay for older or vulnerable people, in a similar way to “superbugs” such as methicillin-resistant Staphylococcus aureus (MRSA).
People who go to hospital for non-covid-19 treatment are at higher risk from the virus compared with the general public, says Tom Lawton, an intensive care doctor in Bradford, UK.
Read full story (paywalled)
Source: The New Scientist, 21 July 2022
Patient Safety Learning

Trusts reveal thousands of new 12-hour waits

Several trusts have now started reporting thousands of 12-hour waits in their emergency departments, representing a huge difference to the numbers published nationally under a slightly different measure.
This year, trusts have started submitting data to NHS England on the number of patients waiting over 12 hours from time of arrival in ED, until discharge, admission or transfer. Many trusts are now reporting these statistics in their public board reports.
This is a slightly different measure to the publicly reported “trolley wait” figures, which count waits of over 12 hours from decision to admit until admission.
Experts have long argued the trolley wait measure does not capture the true problem of ED overcrowding and delayed care. The new data captures a far higher number of patients and has not been published nationally by NHSE.
Read full story (paywalled)
Source: HSJ, 2 August 2022
Patient Safety Learning

Staff falsified records night man died, inquest hears

Staff at a mental health trust, run by Norfolk and Suffolk NHS Foundation Trust, falsified records that they had checked on a vulnerable patient the night he died, an inquest has heard.
Eliot Harris was found dead in his room at Northgate Hospital in Great Yarmouth, Norfolk, in April 2020. A police witness statement detailed how CCTV footage contradicted 19 log entries.
Mr Harris, 48, was admitted to hospital after the care home where he was a resident requested an urgent mental health assessment, an inquest into his death at Norfolk Coroner's Court heard.
He had been diagnosed with paranoid schizophrenia, had a history of epileptic seizures and had not been taking his medication.
Mr Harris was deemed to be high risk and was supposed to be on regular checks four times an hour.
In a witness statement read out in court, Det Sgt Nick Appleton described how police had cross referenced logs of his observations with CCTV recordings.
Det Sgt Appleton listed 19 instances in which the observation record was signed by a staff member that night, indicating Mr Harris had been checked, but was not backed up by the CCTV record.
He identified a number of "points of concern" in his evidence in which falsifying logs was "normal" and "standard practice" on wards.
Read full story
Source: BBC News, 1 August 2022
Patient Safety Learning

Cancer patient's 31-hour 'cattle market' A&E wait

A cancer sufferer who says she faced a wait of 31 hours in A&E has compared the emergency department to "a cattle market".
Tracy Summerson, who had nausea and a fever, was eventually admitted to Lincoln County Hospital last week. Ms Summerson said there were more than 30 other patients who waited a similar amount of time.
The hospital said despite long waits, those who needed immediate care were "able to be seen and looked after".
Ms Summerson, from Scopwick near Metheringham, described the scene as "just crammed, you were like cattle in a market".
Ms Summerson, who has stage four malignant melanoma, said: "There was people coming with sick bowls being sick next to you.
"When you are immune-suppressed you're supposed to go in a side room out of germs way, but they needed all the rooms for consultations."
The family of an 83-year-old woman also contacted the BBC to say she waited more than 40 hours in a wheelchair in her nightdress after being taken to the hospital with a suspected brain bleed.
The trust added: "We continue to see an increasing demand on our urgent and emergency care services coupled with patients staying much longer in our hospitals than previously experienced."
Read full story
Source: BBC News, 1 August 2022
Patient Safety Learning

NHS must learn to love smart IV pumps to avoid drug errors

Hospitals must start using “smart” intravenous (IV) infusion technology to its full potential if they are to prevent dangerous drug errors, University of Manchester researchers have found.
‘Smart pumps’-  which automatically calculate the dose and rate of different drugs before they are pumped into a vein  - prevent potentially fatal errors by stopping the administration of the wrong rate.
But according to the study published in BMJ Open Quality, though the technology probably saved the lives of 110 people in two Trusts over a year, it has largely failed to be adopted by hospitals.
Though many IV pumps used in hospitals have a smart capability, most trusts do not utilise the functionality because they are difficult to configure and maintain.
Smart pumps are usually configured by a pharmacist and checked by a consultant or senior nurse. Conventional pumps, however, are set by ward staff who calculate and input infusion rates themselves - increasing the risk of drug errors.
The risks are illustrated by previous work from the Manchester team, who demonstrated that 1 in 10 IV drug administrations are associated with an error, and up to 1 in 10 of those were associated with harm.
Read full story
Source: University of Manchester, 1 August 2022
Patient Safety Learning

‘Apocalyptic’ A&E waits that could be driving 1,000 patient deaths a month

A&E waits are now “apocalyptic” and “worse than ever imagined” leaked NHS data shows, and could be driving 1,000 patient deaths a month, The Independent can reveal.
Almost 700,000 people have waited more than 12 hours in A&E in the first seven months of 2022, according to leaked NHS data.
The “hidden” monthly trolley waits, not published in national data, have more than doubled this year in comparison to 2019.
Dr Katherine Henderson, President of the Royal College of Emergency Medicine, warned data shows trolley waits are “worse than ever imagined” and said it is “scandalous” the real figures are not published despite promises.
Dr Henderson warned the deterioration in A&E waiting times is the result of “decades of underfunding” and “unheeded warnings” over staffing and social care.
In one message to staff in Nottinghamshire, seen by The Independent, hospital leaders said last week patients were waiting more than 40 hours for beds in A&E, while some areas of the hospital were running on a 1:14 staffing ratios and patients were waiting at home with no care.
Read full story
Source: The Independent, 1 August 2022
Patient Safety Learning
Registered address: Patient Safety Learning, China Works SB203, 100 Black Prince Road Vauxhall, London, SE1 7SJ

Account

Navigation

Search

Search

Configure browser push notifications
Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.