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Patient Safety Learning


News posted by Patient Safety Learning

  1. Patient Safety Learning
    The NHS will start publishing “hidden” figures on A&E waiting times following several leaks reported by The Independent.
    After unveiling its emergency care plan on Monday, NHS England confirmed it would release internal data each month - currently only made public once a year - showing how many people are waiting for longer than 12 hours after arriving at an emergency department.
    The Independent has published several leaks of this data, which shows that these waiting times can be up to five times higher than publicly available NHS figures. Official monthly figures only count the number of hours patients wait after a decision to admit them has been made, and so mask the true scale of the problem.
    The move comes after health secretary Steve Barclay said the NHS would, from April, publish this “real” number in a bid for “greater transparency.”
    Writing in The Telegraph, he said: “Too much of the debate about A&E and ambulance services is based on anecdotal evidence. I want NHS managers and the wider public to have access to the same facts from the front line, starting with publishing the number of 12-hour waits from the time of arrival in A&E from April.”
    Read full story
    Source: The Independent, 31 January 2023
  2. Patient Safety Learning
    The Covid-19 pandemic cannot continue being blamed for poor cancer care, a charity boss has said.
    Judi Rhys, of Tenovus Cancer Care, said urgent action was needed to save lives when more people than ever are living with cancer in Wales.
    It comes as the Wales Cancer Network publishes a three-year plan to improve cancer outcomes and patient experience.
    But the group's clinical director warned the immediate priority would be maintaining current services.
    Prof Tom Crosby, clinical director for Wales Cancer Network, which was tasked by Wales' health minister to draw up the improvement plan, said the biggest pinch point at the moment was access to diagnostics.
    "We're absolutely trying to shorten overall times for patients coming into the system being diagnosed and then being treated," he said.
    On average in November, people suspected of having cancer had to wait 17 days for a first appointment and 23 days for a first test.
    It was an average 31 days from point of suspicion to being told if they had cancer or not and an average 24 days from point of diagnosis to treatment starting.
    "We hope that this year we will develop the first regional diagnostic centre and that is likely to be in south-east Wales," Prof Crosby said.
    Read full story
    Source: BBC News, 31 January 2023
  3. Patient Safety Learning
    All three acute trusts in an integrated care system are failing to meet national requirements to tackle health inequalities after being overwhelmed by emergency and elective care pressures.
    A report by Devon Integrated Care Board found progress on addressing variation in poor health outcomes had “slipped due to capacity issues.” Both Royal Devon University Healthcare Foundation Trust and Torbay and South Devon FT were rated “red” for a lack of headway.
    All trusts were told by NHSE in 2021 to undertake a range of actions as part of work to reduce health inequalities during 2022-23.
    These included publishing analyses of waiting times disaggregated by ethnicity and deprivation, using the waiting list data to identify disparities between different patient groups, and measuring access, experience and outcomes for patients from a deprived community or an ethnic minority background.
    Sarah Sweeney, interim chief executive of National Voices, which represents health and care charities and patients, said she was “really concerned to see that some ICSs are not making as much progress on reducing health inequalities as expected and hoped”.
    “These inequalities are completely unjust and preventable,” she said. 
    Read full story (paywalled)
    Source: HSJ, 30 January 2023
  4. Patient Safety Learning
    A dementia home care agency spent as little as three and a half minutes on taxpayer-funded care visits and filed records claiming far more care was given, according to evidence seen by the Guardian.
    The hasty care was exposed by Susan Beswick’s family, who called it “totally inadequate”. They say they had been told visits to 78-year-old Beswick, who has Alzheimer’s disease, were supposed to last 30 or 45 minutes.
    Across nine visits this month, care workers formally logged close to six hours of care. But security cameras suggest they were in the house for under one hour 20 minutes – less than nine minutes a visit on average.
    On one evening visit, footage showed two carers entering, asking if Beswick had eaten and checking her incontinence pad, before leaving three minutes and 15 seconds later. But they appeared to log on a care tracking app that they had been with her for one hour and 16 minutes.
    Beswick, who for years was a care worker herself, “deserves so much better”, said her daughter-in-law Karen Beswick.
    “It’s upsetting us the way mum is being cared for here,” she said. “They come in and check her [incontinence] pad and go. They are supposed to be encouraging her to drink. They don’t really talk to mum a lot. It’s not good at all. I will start crying. We are all trying to get the best for mum.”
    Read full story
    Source: The Guardian, 30 January 2023
  5. Patient Safety Learning
    Six wards in a busy London Hospital, added at a cost of £24 billion during the pandemic, are lying empty because the builders did not install sprinklers. 
    With the NHS in crisis, the Royal London Hospital in east London, has had to mothball the space, which is large enough to take 155 intensive care beds, while officials work out what to do with it. They have no patients in it since last May.
    Source: The Sunday Times, 29 January 2023
    Shared by Shaun Lintern on Twitter
  6. Patient Safety Learning
    Parkinson’s patients are suffering from “devastating effects” as GPs have started to switch to cheaper drugs which have different release rates into the body.
    Parkinson’s UK put out a warning when a 65-year-old man who had been successfully managing the condition for 17 years suddenly needed help eating and getting dressed.
    This happened after his branded medication Sinemet was changed to a cheaper form of the drug.
    Barrie Smith - who comes from Birmingham - was left in pain, developed slow speech and experienced an uncontrolled tremor when his normal Sinemet medication was switched to a more generic form of medication last year without consultation. He called the effects “devastating”.
    Dr Rowan Wathes, Associate Director of the Parkinson’s Excellence Network at Parkinson’s UK, said: “Changes to brands or manufacturers can trigger a significant deterioration of symptoms. It is vitally important for prescribers to specify the Parkinson’s medication brand or generic manufacturer on prescriptions for people with Parkinson’s. ”
    Read full story
    Source: The Independent, 30 January 2023
    You may also be interested in the following blogs written by Parkinson's UK for the hub:
    Medication delays: A huge risk for inpatients with Parkinson’s Keeping patients with Parkinson’s safe in hospital: 4 key actions for staff Preparing to go into hospital – tips for people with Parkinson's and their carers
  7. Patient Safety Learning
    Trusts are getting better at coping with industrial action and are still on track to hit the national target of eliminating the backlog of 78-week waiters, an NHS England director has told staff.
    Paul Doyle, NHS England’s programme director for elective recovery, said: “We continue to make really good progress [on elective recovery]… we are very much in the end game now of meeting the 78-week ambition for the end of March.”
    There have been concerns about the impact of recent strike action on eliminating the 78-week backlog, but Mr Doyle praised managers’ handling of the strikes and said administrative staff were doing an “incredible job”.
    He added: “Most organisations affected have got better and better as time has gone on about making sure that there are as few cancellations as possible and that cancellations are rebooked quickly or that clinical time is put to good use such as doing virtual outpatient appointments or doing validation of waiting list.”
    Read full story (paywalled)
    Source: HSJ, 30 January 2023
  8. Patient Safety Learning
    More than half a million patients a year will be treated in “hospitals at home” in an attempt to relieve pressure on A&E departments.
    Under the plans, elderly and frail patients who fall will be treated by video link, with ministers saying that a fifth of emergency admissions could be avoided with the right care.
    Health officials said the “virtual wards” would be backed up by £14 billion in extra spending on health and care services over the next two years, as the NHS tackles record backlogs, with seven million people on waiting lists.
    Rishi Sunak said the Urgent & Emergency Care Recovery Plan showed that the NHS was one of his “top priorities”.
    Read full story (paywalled)
    Source: The Telegraph, 29 January 2023
  9. Patient Safety Learning
    The National Crime Agency and Interpol has been drafted in by detectives investigating a junior doctor accused of multiple sexual assaults on children and adults in A&E departments. 
    Last year, Staffordshire police began an investigation into a 35-year-old medic's work at two hospitals, the Royal Stoke University Hospital in Staffordshire and the Russells Hall Hospital in Dudley, West Midlands.

    Source: Sunday Times
    Shared by Shaun Lintern Tweet, 29 January 2023
  10. Patient Safety Learning
    Artificial hip and knee joints that have to be removed after failing early are to be examined routinely to save the NHS £200million a year – and reduce unnecessary pain for patients in future.
    Less than 1 in 100 removed implants are examined to see why they failed, so surgeons don’t learn what went wrong or pick up on potential scandals.
    Consultant orthopaedic surgeon Raghavendra Sidaginamale, of North Tees and Hartlepool NHS Trust, said: "Most removed implants are put in the bin. A wealth of information goes down the drain."
    Now the NHS is setting up an Implants Analysis Service, enabling hospitals to send them off to be analysed for signs of unusual wear or chemical degradation.
    Each year, 15,000 hip and knee replacements are replaced. If this happens within ten years, they are deemed to have failed early. Jason Wilson, of the IAS, said they are ‘like a black box flight recorder in a plane’, adding: "They hold a wealth of information we can learn from."
    Read full story
    Source: Daily Mail, 29 January 2023
  11. Patient Safety Learning
    Erik, a 26-year-old Seattle grocery clerk, who also has attention-deficit hyperactivity disorder (ADHD), has been unable to get his medications filled for months now – and he’s worried he’ll lose the first full-time job he’s ever had.
    For people like Erik, ADHD medication is a prerequisite for basic functioning – and over the last year it’s become dramatically harder for patients like them to access care. Last October, the Food and Drug Administration (FDA) announced a shortage of Adderall, one of the most common stimulant medications for ADHD.
    In recent months, patients have reported problems filling nearly every type of ADHD medication. What’s stranger is that no one seems to know why. Is it some kind of supply chain issue? A pandemic-era surge in demand? A government crackdown?
    Official explanations have offered little clarity. The FDA’s announcement mentioned “intermittent manufacturing delays” at Teva, the producer of the branded version of Adderall, but few other details. The American Society of Health Pharmacists reports shortages of multiple ADHD drugs but says manufacturers have given no explanation.
    The situation has left patients in turmoil.
    Read full story
    Source: The Guardian, 30 January 2023
  12. Patient Safety Learning
    The government’s target for England to become smoke-free by 2030 – which integrated care systems are expected to pursue – is being undermined by the unavailability of two smoking cessation medicines.
    The objective, set by government in 2019, is being taken forward by many ICSs, as they seek to prevent premature illness and death, and narrow health inequalities, with smoking rates normally higher in more deprived populations.
    However HSJ analysis of drug shortages revealed that the two cessation medicines are both currently unavailable for an extended period.
    Champix (varenicline) has been unavailable since October 2021, a situation exacerbated by the absence of Zyban (bupropion), since December 2022.
    Both drugs were withdrawn because of concerns about the presence of nitrosamines, which may increase risk of cancer if people are exposed to them above acceptable levels, and will be subject to further tests and regulatory checks if they are to return.
    Matthew Evison, a lung cancer and tobacco dependency specialist at Manchester University Foundation Trust, said Champix was clinicians’ “most powerful weapon” against smoking. He said the treatment gap would make the target harder because “smoking prevalence declines will be slower without varenicline”.
    Read full story
    Source: HSJ, 30 January 2023
  13. Patient Safety Learning
    The NHS faces an alarming mass exodus of doctors and dental professionals, health chiefs have said, as a report reveals 4 in 10 are likely to quit over “intolerable” pressures.
    Intense workloads, rapidly soaring demand for urgent and emergency healthcare and the record high backlog of operations are causing burnout and exhaustion and straining relationships between medics and patients, according to the report by the Medical Defence Union (MDU), which provides legal support to about 200,000 doctors, dental professionals and other healthcare workers in the UK.
    In an MDU survey of more than 800 doctors and dental professionals across the UK, conducted within the last month and seen by the Guardian, 40% agreed or strongly agreed they were likely to resign or retire within the next five years as a direct result of “workplace pressures”.
    Medical leaders called the report “deeply concerning”. There are already 133,000 NHS vacancies in England alone.
    NHS chiefs said it laid bare the impact of the crisis in the health service on staff, and MPs said it should serve as a “wake-up call” to ministers on the urgent need to take action to persuade thousands of NHS staff heading for the exit door to stay.
    Read full story
    Source: The Guardian, 29 January 2023
  14. Patient Safety Learning
    Thousands of NHS staff across the UK are facing pay cuts because of a change in Covid sickness policy.
    Analysis by BBC Panorama suggests that between 5,000 and 10,000 NHS workers could be off sick with Long Covid.
    Unions are accusing the government of failing to support health staff who worked during the coronavirus pandemic.
    The government says the Covid-19 public inquiry will examine these issues when it begins taking evidence in May.
    Changes to special sick pay rules introduced during the pandemic mean that some NHS staff unable to work due to Long Covid may soon no longer receive full pay.
    Enhanced provision ended last year. Many had a six-month transition, so expect their wages to go down soon.
    Some face losing their jobs.
    Professor David Strain is the chair of the Board of Science at the British Medical Association (BMA) and says this makes him "genuinely angry".
    He explains: "We've got a group of people that have put themselves forward to look after the population, they've been left with an illness and they're not being supported.
    "They're just in a no man's land."
    He believes that health workers with long Covid should be allowed to focus on their recovery without money worries.
    Read full story
    Source: BBC News, 30 January 2023
  15. Patient Safety Learning
    A highly toxic chemical compound sold illegally in diet pills is to be reclassified as a poison, a government minister has said.
    Pills containing DNP, or 2,4-dinitrophenol, were responsible for the deaths of 32 young vulnerable adults, said campaigner Doug Shipsey.
    His daughter Bethany, from Worcester, died in 2017 after taking tablets containing the chemical.
    The deaths were down to a "collective failure of the UK government", he said.
    DNP is highly toxic and not intended for human consumption. An industrial chemical, it is sold illegally in diet pills as a fat-burning substance.
    Experts say buying drugs online is risky as medicines may be fake, out of date or extremely harmful.
    Mr Shipsey said he had targeted the minister following the death of another young man who had taken the drug sold as a slimming aid.
    Prior to this, following the inquests of dozens of young people who had suddenly and unexpectedly died from DNP toxicity, the government had "ignored numerous coroners reports" to prevent future deaths, he said.
    "So, at last after 32 deaths and almost six years of campaigning, the Home Office (HO) finally accept responsibility to control DNP under the Poisons ACT 1972," he added.
    Read full story
    Source: BBC News, 28 January 2023
  16. Patient Safety Learning
    Thousands of extra hospital beds and hundreds of ambulances will be rolled out in England this year in a bid to tackle the long emergency care delays.
    The 5,000 new beds will boost capacity by 5%, while the ambulance fleet will increase by 10% with 800 new vehicles.
    Details of the £1bn investment will be set out later in a joint government and NHS England two-year blueprint.
    Questions have also been raised about how the extra resources will be staffed - 1 in 10 posts in the NHS is vacant.
    The government believes the measures, which will be introduced from April, will help the NHS to start getting closer to its waiting time targets.
    It has set goals that by March 2024:
    76% of A&E patients will be dealt with in four hours. Currently fewer than 70% are. The official target is 95% An average response time of 30 minutes for emergency calls such as heart attacks and strokes. In December patients waited over 90. The official target is 18. Prime Minister Rishi Sunak said cutting NHS waiting times was one of his five main priorities.
    Read full story
    Source: BBC News, 30 January 2023
  17. Patient Safety Learning
    NHS England has revealed a new intervention regime, as it seeks to deliver on its new urgent and emergency care recovery plan.
    Systems will be placed in three “tiers of intervention”, with those systems deemed “off-target on delivery” being given “tier three intensive support” from NHSE, which will include on-the-ground planning, analytical and delivery capacity, “buddying” with leading systems and “targeted executive leadership”.
    The approach follows that which has been taken over the past year for elective and cancer care recovery. 
    The urgent care plan, published by NHSE and the Department of Health and Social Care today, says: “NHS England will identify and share good practice so that all can learn from the best. For those systems that are struggling, we will offer support to ensure that they have the best opportunities to drive improvement locally.”
    Read full story (paywalled)
    Source: HSJ, 30 January 2023
  18. Patient Safety Learning
    The UK health department was forced to write down £14.9bn worth of personal protective equipment and other medical items, according to a report by the independent public spending watchdog, which also issued a scathing criticism of the UK Health Security Agency.
    The National Audit Office said that the Department for Health and Social Care did not complete an “effective programme of year-end stock counts” to assess the quality and quantity of coronavirus-related items, such as lateral flow tests.
    During the last two financial years, the DHSC reported nearly £15bn of write down costs associated with PPE and other health items. The department estimated that the continuing cost of storage and disposal of excess and unusable equipment stands at £319mn.
    The watchdog found a “lack of adequate governance, oversight and control” at the UKHSA. It noted that due to a “lack of sufficient, appropriate audit evidence and significant shortcomings in financial control” the NAO was unable to provide an audit opinion on the 2021-22 accounts of the agency.
    Read full story (paywalled)
    Source: Financial Times, 27 January 2023
  19. Patient Safety Learning
    Children came to “significant” harm due to chronically low staffing levels at scandal-hit mental health hospitals, whistleblowers have said.
    In a third exposé into allegations of poor care at private hospitals run by The Huntercombe Group, former employees have claimed that staffing levels were so low “every day” that patients were neglected, resulting in:
    Patients as young as 13 being force-fed while restrained. Left alone to self-harm instead of being supervised. Left to “wet themselves” because staff couldn’t supervise toilet visits. One staff member, Rebecca Smith, said she was left in tears after having to restrain and force-feed a patient.
    Following a series of investigations by The Independent and Sky News, 50 patients came forward with allegations of “systemic abuse” and poor care, spanning two decades at children’s mental health hospitals run by the organisation.
    The government has since launched a “rapid review” into inpatient mental health units across the country following the newspaper’s reporting.
    Read full story
    Source: The Independent, 28 January 2023
  20. Patient Safety Learning
    The NHS in England is set to have a major conditions strategy to help determine policy for the care of increasing numbers of people in England with complex and often multiple long-term conditions.
    Conditions covered by the strategy will include cardiovascular disease, chronic respiratory disease, dementia, mental health conditions, and musculoskeletal disorders. Cancer will also be included and will no longer have its own dedicated 10 year strategy.
    England’s health and social care secretary, Steve Barclay, told the House of Commons on 24 January that the strategy would build on measures in the NHS long term plan.
    Read full story (paywalled)
    Source: BMJ, 25 January 2023
  21. Patient Safety Learning
    The impetus to tackle health security has started to “melt away”, despite the devastation wrought by the Covid pandemic, Tony Blair has warned.
    In the foreword to a new book, ‘Disease X’, the former British prime minister said that while there are “concurrent crises jostling for the attention of governments”, leaders should not miss the opportunity to implement the “hard-won lessons” of the past three years.
    “Covid-19 was an unprecedented global crisis and should mark a turning point in global health policy and preparedness,” Mr Blair wrote. 
    “Our governments need to demonstrate the same level of political will, ambition and international cooperation that leaders demonstrated in the wake of World War II, when they coalesced around the objective of a sustainable peace. 
    “This must be applied to the post pandemic order because, at its heart, health security is national security,” he added. “It is clear this will not be the last pandemic threat of our lifetimes … there is no excuse to be unprepared, again.” 
    Read full story (paywalled)
    Source: The Telegraph, 25 January 2023
  22. Patient Safety Learning
    High levels of microplastics have been found in operating theatres by researchers who highlighted the “astoundingly high” amounts of single-use plastic used in modern surgical procedures.
    A team from the University of Hull found the amount of microplastics in a cardiothoracic operating theatre was almost three times that found in homes, and said this identifies another route through which the tiny particles can enter the human body, with unknown consequences.
    The study, published in the journal Environment International, is the first to examine the prevalence of microplastics in surgical environments.
    The team analysed levels in the operating theatre and the anaesthetic room in cardiothoracic surgeries and discovered an average of 5,000 microplastics per metre squared when the theatre was in use.
    Jeanette Rotchell, professor of environmental toxicology at the university, said the types of microplastic particles identified relate to common plastic wrapping materials and could also come from blister packs, surgical gowns, hairnets and drapes for patients.
    Prof Rotchell said: “Although we know microplastics are in the air in a variety of settings, we can’t yet say what the consequences are or whether microplastics are harmful to health. Researchers have yet to establish this.
    Read full story
    Source: The Independent, 27 January 2023
  23. Patient Safety Learning
    A major London trust has been criticised for ‘underplaying’ the problems caused by a ‘catastrophic’ IT outage, a new report has revealed.
    The Guy’s and St Thomas’ Foundation Trust report also noted one patient suffered “moderate harm” and several others “low” level harm after last July’s incident, which was caused by a combination of a heatwave and ageing infrastructure. 
    However, the trust said there was no evidence the “underplaying” of issues was deliberate.
    The report identified one incident of “moderate” patient harm, in which a patient was unable to receive a pancreas transplant due to staff being unable to safely monitor critical observations. The patient has since had a successful operation, the trust’s report stated.
    Another 20 “low” harm incidents were reported, which included delays in patients receiving their test results and/or medicines, while the report added the trust could not rule out that “further harm events may be identified” amidst an ongoing harm review.
    Read full story (paywalled)
    Source: HSJ, 27 January 2023
  24. Patient Safety Learning
    Medicine supply issues have soared in the past year, with the number of unavailable medicines nearly doubling from 52 in January 2022 to 97 this month, figures seen by HSJ reveal.
    Analysis of NHS supply alerts shared with HSJ shows a persistent monthly rise over the past year in the number of unavailable drugs. It also reveals that 12 “serious shortage protocols” – a more serious level of alert which allow pharmacists to dispense alternatives more easily – have been issued this month, compared to three in January last year.
    This is based on an analysis by the British Generics Manufacturers Association of NHS Specialist Pharmacy Service (SPS) medicines supply tool data. SPS data, seen by HSJ, shows several “high impact” shortages, which means they have the potential to change clinical practice or have safety implications.
    Read full story (paywalled)
    Source: HSJ, 26 January 2023
  25. Patient Safety Learning
    Concerns raised about dangerous discrepancies at a Covid testing lab which has since been blamed for causing an estimated 23 deaths were ignored by health officials for months.
    Documents show Public Health Wales flagged "significant concerns" about results from Immensa, in Wolverhampton, in letters to colleagues in England.
    They were told nothing was wrong and testing continued for six months.
    Letters were released after a Freedom of Information request by the Times.
    The UK Health Security Agency (UKHSA) has said as many as 39,000 positive results were wrongly reported as negative in September and October 2021, mostly originating from south-west England.
    Read full story
    Source: BBC News, 26 January 2023