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

Burnout in doctors doubles chances of patient safety problems, study finds

Doctors suffering from burnout are far more likely to be involved in incidents where patients’ safety is compromised, a global study has found.
Burned-out medics are also much more likely to consider quitting, regret choosing medicine as their career, be dissatisfied with their job and receive low satisfaction ratings from patients.
The findings, published in the BMJ, have raised fresh concern over the welfare and pressures on doctors in the NHS, given the extensive evidence that many are experiencing stress and exhaustion due to overwork.
A joint team of British and Greek researchers analysed 170 previous observational studies of the links between burnout among doctors, their career engagement and quality of patient care. Those papers were based on the views and experience of 239,246 doctors in countries including the US, UK and others in Africa, Asia and elsewhere globally.
They found that burned-out medics were twice as likely as their peers to have been involved in patient safety incidents, to show low levels of professionalism and to have been rated poorly by patients for the quality of the care they have provided.
Doctors aged 20 to 30 and those working in A&E or intensive care were most likely to have burnout. It was defined as comprising emotional exhaustion, depersonalisation – a “negative, callous” detachment from their job – and a sense of reduced personal accomplishment.
Read full story
Source: The Guardian, 14 September 2022
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All Northern Ireland health trusts missing smear test target

Some women in Northern Ireland are waiting more than three times longer than they should for smear test results.
BBC News NI's Evening Extra programme learned that all health trusts were breaching the target of 80% of samples being reported within four weeks.
The Department of Health (DoH) and Public Health Agency (PHA) said it was due to pressures on pathology services. This included a shortage of available trained staff across the UK to carry out the screening, they said.
Unlike the rest of the UK, each sample in Northern Ireland has to be individually examined by a scientist.
In Great Britain, HPV primary screening is used. This tests the sample of cells taken at the appointment for a virus that can cause cervical cell changes to develop into cancer.
The DoH said it intended to implement this in Northern Ireland and the project involved significant work to reconfigure services.
Read full story
Source: BBC News, 15 September 2022
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Staff warned of ‘harrowing’ care standards review

Trust staff have been warned that an independent investigation into maternity services will be ‘a harrowing read’ with a ‘profound and significant impact’.
The report into services at East Kent Hospitals University Foundation Trust between 2009 and 2020 had been expected to be published on Wednesday 21 September. However, this morning families involved in the investigation received an email saying publication would be postponed to an unknown date in October..  
Next Wednesday, when the report was expected to be released and a statement made to Parliament, has been set aside for all MPs to take an oath of allegiance to King Charles III. 
An email sent to staff at East Kent last week and seen by HSJ said publication would place “significant focus on the trust and all of our services”, and that the trust would make support available to staff as well as former, current and potential patients. The trust will not see the report before publication.
The investigation – led by Dr Bill Kirkup, who also led the Morecambe Bay maternity investigation – was prompted by the death of week-old Harry Richford after a traumatic birth at the trust’s Queen Elizabeth, the Queen Mother, Hospital in Thanet in 2017. Around 200 families are thought to have contacted the investigation team with concerns around maternity care.
Read full story (paywalled)
Source: HSJ, 15 September 2022
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Covid-19: Commission describes “massive global failures” of pandemic response

The global response to the first two years of the Covid-19 outbreak failed to control a pandemic that has led to an estimated 17.7 million deaths to date, a major review has concluded.
The Lancet Commission on lessons for the future from the Covid-19 pandemic, produced by 28 world leading experts and 100 contributors, cites widespread failures regarding prevention, transparency, rationality, standard public health practice, operational coordination, and global solidarity. It concludes that multilateral cooperation must improve to end the pandemic and manage future global health threats effectively.
The commission’s chair, Jeffrey Sachs, who is a professor at Columbia University and president of the Sustainable Development Solutions Network, said, “The staggering human toll of the first two years of the Covid-19 pandemic is a profound tragedy and a massive societal failure at multiple levels.”In its report, which used data from the first two years of the pandemic and new epidemiological and financial analyses, the commission concludes that government responses lacked preparedness, were too slow, paid too little attention to vulnerable groups, and were hampered by misinformation.Read full story
Source: BMJ, 14 September 2022
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Leapfrog Group will measure US hospitals on diagnostic performance in 2024

The Leapfrog Group will add a section to its annual survey in 2024 asking US hospitals to report their progress on evidence-based practices designed to prevent and reduce patient injury and death from diagnostic error and delay.
This Autumn, Leapfrog will pilot test survey questions about a range of diagnostic practices from holding leaders accountable for diagnostic safety to openly communicating diagnostic errors to patients and optimising electronic records to support accurate and timely diagnosis.
Results of the Leapfrog Hospital Survey — completed voluntarily each year by more than 2,300 U.S. hospitals — rate participants’ progress toward Leapfrog’s standards for safety, quality and transparency and are publicly reported. Since 2000, the survey has been the centerpiece of Leapfrog’s mission to “support informed health care decisions and promote high-value care.” The results are also used by hospitals to benchmark their performance to others in the industry.
The addition to the survery is part of a larger push to reduce harm caused by diagnostic error.
Leapfrog is working with the Society to Improve Diagnosis in Medicine (SIDM) on a multi-year project called “Recognizing Excellence in Diagnosis.”
Mark L. Graber, SIDM’s Founder and President Emeritus, expects that including diagnosis in the survey will elevate organizations’ interest in addressing diagnostic error. “Healthcare organizations need to address the harm arising from diagnostic error in their own hospitals.” says Dr. Graber. “The new Leapfrog report gives them ideas on where to start.”
Read full story
Source: Betsey Lehman Center, 14 September 2022
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FBI spotlights cybersecurity risks of outdated medical devices

On Tuesday, the FBI issued a report offering recommendations to address a number of cybersecurity vulnerabilities in active medical devices stemming from outdated software, as well as the lack of security features in older hardware.
Once exploited, the vulnerabilities could impact healthcare facility operations, patient safety, data confidentiality and data integrity. If a cyberattacker takes control, they can direct devices to give inaccurate readings, administer drug overdoses or otherwise endanger patient health.
The FBI noted in its briefing that a mid-year healthcare cybersecurity analysis found that equipment vulnerable to cyberattacks includes insulin pumps, intracardiac defibrillators, mobile cardiac telemetry, pacemakers, and intrathecal pain pumps.
Routine challenges include the use of standardised configurations, specialised configurations – including a substantial number of managed devices on a network – and the inability to upgrade device security features, according to the FBI's announcement.
The agency further adds that research has found an average of 6.2 vulnerabilities per medical device and that 40% of medical devices at the end-of-life stage offer little to no security patches or upgrades.
 
Read full story
Source: Healthcare IT News, 13 September 2022
 
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Rollout of omicron vaccine threatened by ‘flimsy needles’

NHS staff have warned that needles supplied with a Covid vaccine which targets the omicron strain are “not fit for purpose” and could place vaccinators and members of the public at risk.
Dozens of messages shared on an NHS staff forum reveal widespread concerns about the needles supplied with the Moderna SpikeVax vaccine, which are said to bend when vaccinators pierce the top of the vial containing the Covid-19 vaccine doses.
The SpikeVax bivalent vaccine was the first to target both the original and the omicron strain of the virus. It is due to play a key role in the NHS’s autumn Covid vaccination booster programme. 
One pharmacist said: “They [the needles] just are not fit for purpose and as such we are not using them and are using the original needles until a solution is found”.
A UK Health Security Agency spokesperson confirmed the problem, stating: “We are aware that some NHSE sites are experiencing some problems with the use of the new needle and syringe being supplied for administrating the Moderna bivalent vaccine. We are in touch with the supplier about these concerns, including the facilitation of additional training support, but if necessary will also offer an alternative suitable product to avoid any disruption to the vaccination programme.”
Read full story (paywalled)
Source: HSJ, 15 September 2022
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Police prepare for investigation into mental health unit following alleged mistreatment of patients

Police are preparing to investigate alleged mistreatment of patients at a mental health unit. The Edenfield Centre based in the grounds of the former Prestwich Hospital in Bury is at the centre of the claims.
The unit cares for adult patients. The Manchester Evening News understands that action was taken after the BBC Panorama programme embedded a reporter undercover in the unit and then presented the NHS Trust which runs it with their evidence.
A spokesperson for Greater Manchester Police said: "We are aware of the allegations and are liaising with partner agencies to safeguard vulnerable individuals and obtain all information required to open an investigation."
A spokesperson for Greater Manchester Mental Health NHS Foundation Trust said: "We can confirm that BBC Panorama has contacted the Trust, following research it conducted into the Edenfield Centre. We would like to reassure patients, carers, staff, and the public that we are taking the matters raised by the BBC very seriously".
"Immediate action has been taken to address the issues raised and to ensure patient safety, which is our utmost priority. We are liaising with partner agencies and stakeholders, including Greater Manchester Police. We are not able to comment any further on these matters at this stage."
Read full story
Source: Manchester Evening News, 14 September 2022
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Surrey coroner criticises government Covid face mask guidelines after paramedic's death

A coroner has said she does not understand why frontline workers were not required to wear a mask during lockdown after hearing a paramedic had died with Covid. A two-day inquest into the death of Peter Hart, who died on his 52nd birthday, concluded on Tuesday (September 13) with assistant coroner Dr Karen Henderson ruling the father-of-three died of natural causes caused by Covid.
She said on the balance of probabilities he caught the disease while working at East Surrey Hospital, where he died on May 12, 2020. During the onset of the pandemic only healthcare workers tending to those suspected of having Covid-19 were required to wear personal protective equipment (PPE). In accordance with national guidelines, Mr Hart, who was treating patients not suspected of having the virus, did not need to.
“Retrospectively it is difficult to comprehend why the national guidance said PPE did not need to be used for all patients and healthcare workers at the earliest opportunity,” Dr Henderson said. “Although there appears a lost opportunity to ensure maximum protection I make no finding of fact whether this contributed to Mr Hart’s death.
“Patients not suspected to have Covid were not expected to wear face masks. This is in effect a perfect storm and given evidence of Mrs Hart I am satisfied Mr Hart contracted Covid during his work at East Surrey Hospital,” she added.
Read full story
Source: Surrey Live, 13 September 2022
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Muckamore Abbey Hospital: Bid to suspend public inquiry dismissed

A legal bid to suspend the public inquiry into alleged abuse at Muckamore Abbey hospital has been dismissed by a High court judge.
The applicant in the case has been granted anonymity.
They challenged Health Minister Robin Swann's refusal to suspend the public inquiry until criminal proceedings against them had concluded.
Lawyers argued that the applicant's article six right to a fair trail had been jeopardised.
The applicant's lawyers cited "adverse and prejudicial" commentary already in the media.
Rejecting the application the judge, Mr Justice Colton, said that the applicant's article six rights were fully protected within the criminal trial process.
The judge referred to submissions from the applicant's legal team who had argued that if the inquiry recommences as planned this month, it would consider evidence reported by the media which could affect the ability of a jury to act impartially.
The judge told the court there was nothing to suggest that there had been a "virulent media campaign" about the applicant.
Read full story
Source: BBC News, 15 September 2022
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Complaint about ‘misleading’ NHS waiting times figures

Watchdogs have been asked to investigate a Scottish government overhaul of NHS waiting times information after surgeons said that some of the figures were “grossly misleading”.
A complaint has been made to the Office for Statistics Regulation, which ensures that important public data is trustworthy, about a new guide for patients on the NHS Inform website. Concerns have also been raised with Audit Scotland, which monitors public spending and NHS performance.
Last month Humza Yousaf, Scottish health secretary, unveiled the platform claiming that it would reassure patients about waiting times. But the times given reflect only the experience of patients treated over a three-month period.
In orthopaedics, surgeons say, only the most urgent cases are being prioritised while some patients face languishing on waiting lists for years due to lack of capacity.
NHS Inform says that people waited a median of 26 weeks between April and June for orthopaedic care, but surgeons argue that this gives a false impression. Dr Iain Kennedy, new chairman of the British Medical Association in Scotland, said the way the figures have been compiled would suggest that people are still not getting a realistic picture of delays.
Read full story (paywalled)
Source: The Times, 16 September 2022
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Infected blood transfusions killed 1,820 in UK, study estimates

An estimated 1,820 people died in the UK after being given contaminated blood transfusions between 1970 and 1991, a report has found.
The findings were published by the public inquiry into the scandal.
The long period between infection and symptoms appearing makes it difficult to know how many people were infected through a transfusion in the 1970s and 1980s, before it became possible to screen blood donations for the virus.
New modelling for the public inquiry estimated that between 21,300 and 38,800 people were infected after being given a transfusion between 1970 and 1991, with a central estimate of 26,800.
The study, by a group of 10 academics commissioned by the public inquiry, calculated that 1,820 of those died as a result, although the number could be as high as 3,320.
Its findings were based on the rate of hepatitis C infection in the population, the number of blood donations made over that time, the survival rate of the disease and other factors.
It found at least 79 and possibly up to 100 people also contracted HIV through donated blood, based on data provided by the UK Health Security Agency (UKHSA), with most infections between 1985 and 1987.
It said 67 people in that group had now died, although there was no data confirming the causes of death.
The public inquiry into the infected blood scandal began taking evidence in 2019 and is expected to publish its final report in 2023.
Read full story
Source: BBC News, 17 September 2022
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Nurse struck off for failing to dispense morphine

A nurse in Somerset has been struck off after she failed to give morphine to a patient before they underwent surgery.
Amanda-Jane Price had been suspended from front-line duties since the incident in March 2019.
The Nursing and Midwifery Council ruled that Miss Price had been "dishonest" with her colleagues and her ability to practice medicine safely was "impaired".
Miss Price had been a nurse at Musgrove Park Hospital in Taunton since 2018. On 31 March 2019, Miss Price did not administer morphine to an individual in her care, falsely recording in her notes that morphine had been given.
An investigation by the hospital's emergency medicine consultant found that the morphine dose of 6mg had been noted on the patient's chart, but that the drug had not actually been administered.
Miss Price subsequently admitted to falsifying the prescription chart, and to "being consciously aware of her decision".
As a result of Miss Price's actions, the patient underwent an invasive procedure without analgesia, and subsequently complained of being in pain.
The panel concluded that Miss Price was guilty of misconduct and would initially be suspended.
"This was deliberate dishonesty which concealed her failure in clinical issues and caused actual patient harm to a vulnerable victim," the panel concluded.
Read full story
Source: BBC News, 20 September 2022
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Lawyers warned trust that staff could ‘pick and choose’ documents for coroners

An ambulance trust accused of withholding key evidence from coroners was previously warned its staff needed training to ‘understand the real risk of committing criminal offences’ in relation to inquests into patient deaths.
North East Ambulance Service, which has been accused by whistleblowers of withholding details from coroners in more than 90 deaths, was told by its lawyers in 2019 about serious shortcomings in its processes for disclosing information, according to internal documents obtained by a campaigner.
According to the documents, the lawyers said trust staff could “pick and choose” documents to release to coroners “regardless of relevance.”
The following year, an audit report said the issues had not been addressed.
Whistleblowers’ concerns about the trust were first reported by The Sunday Times in the spring, with a review highlighting several cases between 2018 and 2019 where key facts were omitted in disclosures to coroners.
But campaigner Minh Alexander has since obtained new details of warnings that were being made to internally, from lawyers and auditors who were advising the trust.
Read full story
Source: HSJ, 20 September 2022
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Therese Coffey could abolish four hour A&E wait targets under ‘emergency’ NHS plan

Therese Coffey is considering abolishing four-hour A&E waiting time targets as part of her “emergency plan” to tackle the NHS.
The new health secretary is understood to be looking at a range of measures to address the growing crisis in the NHS, understood to be announced next Thursday.
But a source close to the discussions told The Independent getting rid of the four-hour waits – first suggested in March 2019 – would have to be given the green light by the new prime minister Liz Truss.
The announcement will focus on the health secretary’s “ABCD” priorities – standing for “ambulances, backlog, care, dentists and doctors” – with improvements to mental health services as an addition.
Policies also being looked at include more call handers for ambulances, more diagnostic community centres, speeding up the hospital building programme, reducing “bureaucratic” burdens on GPs, improving direct access to counselling services for patients and “robust” management of the national dentists’ contract.
There is concern among those involved that the move would see the four-hour wait replaced by a new target, which could be as difficult as the current target to achieve.
Read full story
Source: The Independent, 18 September 2022
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Britons of black and south Asian origin with dementia die younger, study finds

Britons of black and south Asian origin with dementia die younger and sooner after being diagnosed than white people, research has found.
South Asian people die 2.97 years younger and black people 2.66 years younger than their white counterparts, according to a study by academics from University College London and the London School of Hygiene and Tropical Medicine.
A team led by Dr Naaheed Mukadam, from UCL’s division of psychiatry, reached their conclusions after studying health records covering the 21 years between 1997 and 2018 of 662,882 people across the UK who were aged over 65.
They found that:
 Dementia rates have increased across all ethnic groups.  Black people are 22% more likely to get dementia than their white peers.  Dementia is 17% less common among those of south Asian background. But they have voiced concern about also discovering that south Asian and black people are diagnosed younger, survive for less time and die younger than white people.
“The earlier age of dementia diagnosis in people of black and south Asian [origin] … may be related to the higher prevalence of some risk factors for dementia such as, in older south Asians, fewer years of education, and in both groups hypertension [high blood pressure], diabetes and obesity,” they write in their paper, published in the medical journal Alzheimer’s & Dementia.
Read full story
Source: The Guardian, 18 September 2022
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