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Patient Safety Learning



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  1. Content Article
    In this longitudinal study, medication errors in the clinic, pharmacy, or at home among children with leukaemia or lymphoma over a 7-month period were common, and 10% suffered harm because of errors. Children on >13 medications had significantly more serious medication errors than those on fewer medications. Physician reviewers judged that improved communication among caregivers and between caregivers and clinicians may have prevented the most harm (66%). Improvements addressing communication with and among caregivers should be codeveloped with families and based on human-factors engineering.
  2. News Article
    The independent data watchdog has called for greater clarity from NHS England on how it will ensure there are “as strong… if not stronger” safeguards on health and care data following its takeover of NHS Digital. NHS Digital – whose role included controlling access to large amounts of NHS data – became part of NHS England on 1 February, and its teams and functions are due to merge in coming months. In an interview with HSJ, national data guardian Nicola Byrne said the merger creates “an inherent tension in having one organisation be both data custodian and the organisation seeking to access the data”, although it “makes sense in terms of streamlining and efficiencies”. Concerns have been raised about the merger’s information governance implications by campaign group medConfidential, the British Medical Association and politicians. These include that there would be less transparency over the handling of data, and that NHSE would be “marking its own homework” as both controller of, and a major user of, data. Read full story (paywalled) Source: HSJ, 8 February 2023
  3. News Article
    A Norfolk surgeon who left two patients with life-changing injuries has received a formal warning by a disciplinary panel. Camilo Valero Valdivieso was found guilty of "serious misconduct" by an independent medical panel after two operations went wrong in six days. One of his patients, Paul Tooth, 65, said his life was "a constant struggle" since his operation in January 2020. However, the panel found the surgeon had "learned from these events". The findings from the Medical Practitioners Service (MPTS) panel said that his actions had "risked damaging public confidence in the profession". It heard that he twice "misinterpreted the anatomy" - on one occasion severing a patient's gallbladder. The panel also concluded Mr Valero's fitness to practise was not currently impaired, allowing him to continue working. Read full story Source: BBC News, 7 February 2023
  4. News Article
    A mother who has seen her suicidal 12-year-old daughter shuttled between placements and then held in a locked and windowless hospital room says she is frightened for her child’s life. Since going into care in Staffordshire nine months ago, Becky (not her real name) has attempted to take her own life on several occasions. Her case throws fresh light on the chronic nationwide shortage of secure accommodation for vulnerable children. “I am constantly told there is nowhere for her,” said her mother, who cannot be identified for legal reasons. “I fear I’ll soon be arranging her funeral due to the systemic failings in health and social care.” Becky has been alone in a locked hospital room since 27 January. The room has no window or access to the outdoors, no furniture except for a bed, and she is permitted no belongings. All human contact is conducted through a hatch. The child’s court-appointed guardian told the high court at a hearing to discuss Becky’s case that she considered “the risk to Becky’s life to be catastrophic”. Read full story Source: The Guardian, 7 February 2023
  5. News Article
    NHS waiting lists are unlikely to fall in 2023, and the backlog is unlikely to be significantly tackled until mid-2024 despite being one of Rishi Sunak’s priorities for this year, research suggests. The NHS has struggled to increase the number of people it is treating from its waiting lists each month due to ongoing pressures from Covid-19, although there have been signs of improvement in the past month, analysis from the Institute for Fiscal Studies (IFS) has found. Max Warner, an IFS economist and one of the report’s authors, said that although the NHS had made “real progress” to reduce the number of patients waiting a very long time for care, efforts to increase overall treatment volumes had “so far been considerably less successful”. The NHS Providers’ chief executive, Julian Hartley, urged the government to introduce a fully funded workforce plan and to talk to unions about pay for this financial year as strikes were causing huge disruption to services, and risked undoing hard-won progress made on care backlogs. “Mounting pressures on acute, ambulance, mental health and community services, such as chronic workforce shortages, could hamper efforts to cut the backlog further if left unchecked,” he said. Read full story Source: The Guardian, 8 February 2023
  6. Content Article
    Key points The 2022 Autumn Statement saw the Chancellor promise an extra £3.3bn for the NHS and £1.4bn for capital investment in 2023/24 and 2024/25. In cash terms, spending in 2024/25 will be almost £14bn higher than in 2022/23. Much of this additional spending will be needed to meet inflation. After accounting for inflation, real-terms funding in 2024/25 will be £6bn higher than in 2022/23. This means that in real terms, core day-to-day spending on the NHS will rise by 2% a year by 2024/25, while capital spending will grow by just 0.2%. Overall, the Department of Health and Social Care’s funding settlement will increase by 1.2% a year in real terms over the next 2 years. This is higher than planned at the last Spending Review but far below the 3.6% long-term average growth rate. The NHS continues to face rising cost pressures that will erode the spending power of this settlement, with pay being the most significant. Health service inflationary pressures may be higher than the government estimates through the central GDP deflator forecast. The different methods used to estimate inflation for the whole economy show that the buying power of this settlement is uncertain. The unknown outcome of future pay negotiations and volatility in the cost of other key inputs add further uncertainty around the actual cost pressures the health care sector will face.
  7. Event
    Hear about the work undertaken on digital storytelling via the NHS England cancer alliances and how they have been used to improve services. There will also be a session by Macmillian Cancer Care on digital storytelling project which shares peoples experiences of cancer diagnosis and treatment. Register
  8. Event
    Here at Solent, we have fundamentally changed the way we work with local people and communities. We want to ensure that the way we develop, design and improve our services is based on what really matters most to people who use them, not that we believe as health professionals is important. We now actively recognise and celebrate the strengths of our community, as people with exceptional knowledge, skills and expertise, that which sadly often goes untapped by providers of health and care services. By working with the Touch Network, we are enabling people to unlock stories about difficult times. This helps us understand what we do well, and what we need to change to ensure people who use our services have a positive experience of care. Do join us, Debs Carter, Founder of Touch Network and Sarah Balchin, Director of Community Engagement and Experience, to hear our story of sharing and learning. Register
  9. News Article
    Thousands of patients are being recalled for urgent eye checks after regulators raised safety concerns related to a product used in cataract surgery. It is thought around 20 trusts have suspended use of the EyeCee One lenses, after the Medicines and Healthcare Products Regulatory Agency warned of links to higher pressure in the eye, which can cause lost vision. The MHRA has issued an alert ordering trusts to recall patients who have had surgery since October, and estimates between 2 and 4 per cent of patients could have complications. The watchdog stressed reduced vision would only occur if patients were not treated. It is thought the complications could be down to the way the implant was being used in surgery, rather than the product itself. Read full story (paywalled) Source: HSJ, 7 February 2023
  10. Content Article
    Actions for ophthalmology, ophthalmic theatres, and Medical Devices Safety Officers. To be completed 26 January 2023 Please take the following actions immediately: Nominate a lead person to take responsibility for completing these actions. Note – we recommend including colleagues in purchasing, supplies, and the Medical Device Safety Officer (MDSO). Identify if your organisation uses these IOLs Stop using these impacted products immediately Quarantine these impacted IOLs until further notice. Consider using a suitable alternative product if available following local risk assessment Immediately notify any other departments who need to be aware of this notice.
  11. News Article
    East Kent Hospital University Foundation Trust has been criticised for failures in services by the Care Quality Commission, after an unannounced inspection last month, years after major problems began to come to light. The Care Quality Commission has highlighted: Issues with processes for fetal monitoring and escalation at the William Harvey Hospital, Ashford. There had been “incidents highlighting fetal heart monitoring” problems in September and October, and the trust’s measures to improve processes were not “embedded and understood by the clinical team”; Slow maternity triage, due to staffing problems, and infection control problems at the William Harvey. The trust is reviewing how issues with infection prevention and control and cleanliness were not identified or escalated; and Fire safety issues at the Queen Elizabeth, the Queen Mother Hospital, in Thanet with problems linked to fire doors and an easily accessible secondary fire escape route. Three years ago issues with reading and acting on fetal monitoring were highlighted at the inquest into baby Harry Richford, whose poor care by the trust led to an independent inquiry into widespread failings in its maternity services, led by Bill Kirkup. Read full story (paywalled) Source: HSJ, 6 February 2023
  12. News Article
    A draft NHSE statement suggests mental trusts could be asked to eradicate features of the ‘serenity integrated mentoring’ (SIM) care model from clinical practice, following a whirlwind of concerns in 2021 and an investigation by national clinical director Tim Kendall. A core feature of SIM is to place a police officer within a healthcare team charged with supporting patients who frequently attend emergency services in crisis, and creating crisis plans. The draft position statement produced by NHSE, which the regulator said is not its final version and is subject to changes, says SIM should not be used. It also proposes the eradication of the following practices from any equivalent care model: Police involvement in delivery of therapeutic interventions in planned, non-emergency, community mental healthcare; The use of coercion, sanctions (criminal or otherwise), withholding care and otherwise punitive approaches; and Discriminatory practices and attitudes towards patients who express self-harm behaviours, suicidality and/or those who are deemed “high intensity users”. The statement, which is the first indication of NHSE’s position on the SIM model but not its final stance, also suggests Professor Kendall will be seeking assurance from trust medical directors that SIM or similar models, and the above three features of concern, are no longer used. A full policy and public statement on the model is expected by the spring. The StopSIM coalition, whose campaigning prompted the NHSE review, said: “Unless and until the full policy is freely available to service users and the public, service users are not equipped to protect themselves against the dangers of SIM and similar approaches". Further reading on the hub: The High Intensity Network (HIN) approach and SIM model for mental health care and 'high intensity users' – views and discussion
  13. News Article
    A record number of eating disorder patients are not getting the life-saving treatment they need due to lengthy waits, leaked NHS data shows. More than 8,000 adults are waiting to be seen for therapy, according to internal figures from NHS England – the highest figure recorded since data collection began in 2019. In March 2021, there were around 6,000 adults waiting, while it was less than 2,000 in March 2019. One leading doctor warned that delays were leading to avoidable deaths, while multiple coroners investigating the deaths of nine patients since 2021 have repeatedly called on the NHS and ministers to improve services to prevent more. An investigation by The Independent can also reveal that long waits have led to a woman, 24, taking her own life while waiting two years for appropriate care, and patients being admitted to hospital because their conditions became so severe they developed life-threatening physical conditions. Dr Agnes Ayton, the Royal College of Psychiatrists’ lead for adult eating disorders, said long waits meant patients were “dying avoidably” because under-resourced services were forced to turn them away or leave them waiting for years. Anorexia has the highest morality rate of any psychiatric disorder. “One important thing is eating disorders are treatable, people can get better with time and treatment. We shouldn’t accept anorexia has the highest mortality rate because a lot of these deaths are avoidable and treatable. We should be aiming to provide high-quality care,” she said. Read full story Source: The Independent, 6 February 2023 Further reading on the hub: People with eating disorders should not face stigma in the health system and barriers to accessing support in 2022 Eating disorders: challenges of the pandemic