Patient Safety Learning

The Prescription Charges Coalition, which brings together around 50 organisations and professional bodies to campaign to scrap prescription charges in England for people with long-term conditions, conducted the survey between February and March. It found: Nearly 1 in 10 people have skipped medication in the past year due to the cost of prescriptions. Of this group: Almost a third (30%) of those who have missed medication now have other physical health problems in addition to their original health condition. 37% now have other mental health problems in addition to their original health condition. And over half (53%) have had to take time off work as a result of worsening health. 12% of people who pay for their NHS prescription have cut medication in half to make it last longer. Over a third (35%) of survey respondents reported they had the duration of their prescription changed, meaning they’re paying more frequently for their medicines. Almost 2 in 5 (38%) people with long-term health conditions only learned about the prepayment certificate more than a year after their diagnosis. The survey shows that people with long-term health conditions that cannot afford their medication are seeing an increase in GP visits, trips to accident and emergency (A&E), and hospital stays. Some survey respondents reported they had to stay in hospital for up to 6 weeks. Not being able to afford medicine has also led to mental health is sues and increased time off work.

Due to the scale of the pandemic, despite being in a healthcare setting, patients in hospital and other in-patient settings faced an increased risk of hospital acquired COVID-19. In its first year, the programme has supported NHS Wales organisations to assess and investigate over 5,000 cases of nosocomial COVID-19, where they meet the definition of a patient safety incident and is on track to have successfully investigated all cases of hospital-acquired COVID-19 by March 2024. Findings in the report include; The value of bereavement support and care-after-death services have for people experiencing grief and signposting to support at the earliest opportunity. The benefits of a single point of contact and support for people navigating the concerns process. The impact of visiting restrictions and visiting considerations should continue to be carefully balanced with risk. Inequities in the concerns process for people who receive healthcare via independent providers. Inconsistent approaches to the management and reporting of health care acquired infections across Wales.The need for improved application and improvement of DNACPR (Do Not Attempt Cardio-Pulmonary Resuscitation. The need for improvement in how Infection prevention and control (IP&C) guidance, is reviewed and communicated to staff. Better communication with families and carers around ward movements.

Findings The investigation found there are currently no long-term haemodialysis catheters on the UK market, or being developed, that have integrated ‘safety-valves’. Manual clamps on haemodialysis catheters rely on people ensuring that the clamp is on before accessing the haemodialysis catheter ports and do not mitigate against design-induced error. A review of patient safety risks associated with other haemodialysis devices (for example, fistulas) showed several mitigations which are not consistently used for haemodialysis catheters. These include a coloured patient wristband, line labelling, alert cards being carried by the patient and educating patients/family members. The training and education of all grades of medical staff has not been consistent in relation to the risks of catheter-related air embolism. There is currently no recognised national training or national training guidelines regarding the safe access of haemodialysis catheters. Incidents appear to be under-reported to the Medicines and Healthcare products Regulatory Agency, due to misconceptions about ‘human error’ being the cause, rather than the design of the equipment. The Medicines and Healthcare products Regulatory Agency, in partnership with NHS England, have explored integrated incident reporting system possibilities. While a recent funding bid to support full development for an in-service solution was unsuccessful, the organisations are committed to drive this project forward. There is a general lack of literature on, and knowledge of, catheter-related air embolism in relation to access when the catheter is in situ (in position), rather than during insertion or removal of the catheter. Safety recommendations HSIB recommends that the General Medical Council engages with relevant stakeholders to amend the procedure for taking blood cultures in its ‘Practical skills and procedures’ guidance, making clear that the procedure relates to taking blood from a peripheral site, so mitigating the risks to patient safety associated with central lines. HSIB recommends that the General Medical Council, supported by the Medical Schools Council, revises ‘Achieving good medical practice’ to include guidance for medical students on how to handle uncertainty in clinical settings, including challenging a culture, or an expectation, that a learner undertake unfamiliar tasks to gain competencies without appropriate supervision or support. HSIB recommends that the Medicines and Healthcare products Regulatory Agency amends its 2022 ‘Dialysis guidance’ to include the safety risk of air emboli associated with unclamped haemodialysis catheters. Safety observations It may be beneficial for manufacturers of haemodialysis catheters to develop an engineering solution to maintain a sealed system upon disconnection, thereby reducing the risk of an air embolism. It may be beneficial to consider how junior doctors can be supported to work safely within their level of competence and feel empowered to decline tasks they are not competent to undertake, with specific reference to the safety risks associated with accessing haemodialysis catheters if not trained and competent. It may be beneficial to explore the design of a visual alert which prompts healthcare professionals to the increased safety risks associated with in situ haemodialysis catheters and the access to this medical device by staff specifically trained in their use. It may be beneficial if the approach outlined in the White Paper published by the National Infusion and Vascular Access Society in 2022 was adopted for wider bore lines such as haemodialysis catheters. This is in relation to a standardised structure and approach for the NHS to deliver vascular access services in every hospital.

These documents make up the report from phase 1 of our review into how well CQC listen and respond when people share concerns with them. Phase 1 was an independent review which Zoë Leventhal KC was appointed to lead. This looks into the handling of protected disclosures shared by Mr Kumar, alongside a sample of other information of concern shared with us by health and care staff. See also Listening, learning, responding to concerns (phase 2).

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