Patient Safety Learning

Reports that medical errors are the third leading cause of death in the US have led the Institute of Medicine and several state legislatures to suggest that data from patient safety event reporting systems could help health care providers better understand safety hazards and, ultimately, improve patient care. "Tens of thousands of these safety report databases provide a free text field that does not constrain the reporter to fixed, predefined categories," said Srijan Sengupta, Assistant Professor of Statistics in the College of Science and a faculty member at the Discovery Analytics Center. Sengupta has received an $815,218 Research Project Grant (R01) from the National Institutes of Health (NIH) to develop novel statistical methods to analyze such unstructured data in safety reports. "Detailed information that spans multiple categories can be more valuable than identifying an event by just checking off a category," he said. Read full story Source: EurekAlert, 13 November 2019

Existing claims that locum GPs present a greater risk of harming patients are unfounded, according to new research published in the Journal of the Royal Society of Medicine. It found that there is little evidence that locum doctors, including GPs, have a 'detrimental' impact on patient care delivery. Researchers from the University of Manchester looked at 42 international papers, including 24 from the UK, on the impact of locum doctors working in various healthcare settings to determine whether this group is more likely to harm patients than permanent doctors. Previous reports highlight longstanding and growing concerns about the quality, safety and cost of locum doctors among a range of stakeholders such as policymakers, employers, regulators and professional bodies. These include locum GPs being less aware of local policies and less familiar with the patient's healthcare history and lacking commitment. However, the researchers found there is 'very limited evidence' to support claims that these healthcare professionals deliver lower quality of care than their permanent counterparts. Read full story (registration required) Source: Pulse, 12 November 2019

A new £700,000 computer system has been deployed in an intensive care unit at Aberdeen Royal Infirmary. The new Philips system will replace bedside charts, freeing up clinical time and improving patient safety at the NHS Grampian hospital. ICU clinical director Dr Iain MacLeod said: “At the heart of this change is patient safety. The system records physical measurements like blood pressure and heart rate as well as blood results and parameters from the various machines used in ICU, such as dialysis machines and ventilators." “It will also save on staff time. Currently medical staff members waste lots of time transcribing blood results from a computer onto sheets of paper. The new system allows this to happen automatically. That’s great from a timesaving point of view but more importantly there will be a reduction of errors that can happen when writing something down.” Read full story Source: FutureScot, 11 November 2019

Thousands of bowel cancer cases are being missed due to “unacceptable” testing failures, research in the BMJ shows. The UK research found that some providers carrying out colonoscopies were three times as likely as others not to spot signs of disease. At the worst units, almost one in ten cases which turned out to be bowel cancer were not picked up during the tests, the study led by the University of Leeds found. Researchers said that almost 4,000 more cases could have been prevented or treated sooner had there been better screening over a nine year period tracked. Researcher Roland Valori, Consultant Gastroenterologist from Gloucestershire Hospitals NHS Foundation Trust, said: “We are seeing unacceptable variation in post colonoscopy bowel cancers between providers in the English NHS and this variation in quality needs to be addressed urgently.” Read full story Source: The Telegraph, 2019

A privately run mental health unit has been banned from admitting new patients after inspectors found numerous safety failings, one of which led to a resident dying by hanging. The Care Quality Commission (CQC) has stopped the Cygnet Acer Clinic, in Chesterfield, Derbyshire, from accepting new inpatients. It declared that the facility was “not safe” for people to use. Inspectors found that clinic patients had opportunities to hang themselves, and the unit had soaring levels of patient self harm, and a huge shortage of trained staff. The CQC’s report is one of the most damning it has issued about poor and unsafe care affecting vulnerable and potentially suicidal patients in a mental health facility. Read full story Source: The Guardian, 13 November 2019

Fragmented patient data can lead to redundant and unnecessary care, potentially harming individuals. Thought leaders are calling for standardised methods to identify patients and minimise potential harm. At a recent US Food and Drug Administration conference for improved data standards, Shaun Grannis, Regenstrief Institute Vice President of Data and Analytics, advocated for standards that promote better patient matching. “Any time you lack complete information to make the best decision possible, there's an opportunity for error,” Grannis said. “Patient matching is a safety issue. Patient identification is paramount to making sure that patients receive appropriate, safe care.” Grannis noted that patient data is currently fragmented across healthcare systems. Patients often do not receive care at just one facility or in one health system. “They’re going to be identified differently across organizations. You might go to your primary care doctor or they refer you to a specialist who’s outside of your system, so your data is fragmented,” he continued. Disjointed data can make it difficult for providers to make decisions about patient care. Without a complete picture of the patient’s medical history, it is more challenging for clinicians to make care decisions. Read full story Source: EHR Intelligence, 12 November 2019

Dozens of doctors from across Greater Manchester have warned health bosses plans to reform cancer services in the city will put patients at risk and destabilise smaller hospitals. In a letter, seen by The Independent, to the head of the devolved NHS and social care system for the city, almost 40 urological consultants called on the NHS to abandon its plans. NHS leaders are aiming to centralise hundreds of bladder and kidney cancer operations a year at the University Hospital of South Manchester but the doctors warn this will make their roles in smaller district general hospitals harder to recruit to and leave patients who need input from urologists at a disadvantage. Ultimately they fear the reorganisation could put services at smaller hospitals such as emergency care, gynaecology, trauma and obstetrics at risk because of the role urologist play in their delivery. The letter added: “The inevitable consequences of centralisation of complex urological cancer services on a single site will result in an inability to provide a safe sustainable comprehensive service to large areas of the city, particularly those areas which are already under resourced with regard to access to care and which have the highest levels of social deprivation." Read full story Source: The Independent, 12 November 2019