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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    ECRI’s Top 10 Patient Safety Concerns 2023 list identifies potential sources of danger for patients and staff. ECRI believe these risks require the greatest focus for the coming year and offer actionable recommendations for reducing these risks. ECRI conducts independent medical device evaluations, annually compiles scientific literature and patient safety events, concerns reported to or investigated by the organization, and other data sources to create its top 10 list.
  2. News Article
    A scandal-hit hospital group has been sanctioned by inspectors after The Independent revealed “systemic abuse” at a string of children’s mental health units. England’s safety watchdog issued an official warning to Ivetsey Bank Hospital in Staffordshire, run by The Huntercombe Group, after an extensive investigation by this newspaper found the private hospital had put the safety of young mental health patients at risk. The Care Quality Commission also downgraded the hospital’s rating to “inadequate”. If improvements are not made in line with the warning notice, the hospital could be forced to close. An inspection was carried out two weeks after The Independent revealed widespread allegations of abuse and excessive restraint across The Huntercombe Group’s hospitals. The investigation revealed the provider, which also runs Taplow Manor children’s hospital in Maidenhead, was facing allegations from more than 50 former patients as well as claims of poor care from staff whistleblowers and dozens of negligence claims. Read full Source: The Independent, 15 March 2023
  3. News Article
    Certain cough medicines sold behind the counter at pharmacies are being withdrawn over safety concerns. Health experts say there is a very rare chance that some people could experience an allergic reaction linked to an ingredient called pholcodine. People should check the packaging of any cough tablets or syrups they have at home to see if pholcodine is listed among the ingredients. If it is, talk to your pharmacist about taking a different medicine. Products containing pholcodine do not need a prescription, but cannot be bought without consultation with the pharmacist as they are kept behind the counter. The Medicines and Healthcare Products Regulatory Agency (MHRA) described removing the products from sale as a precautionary measure. Read full story Source: BBC News. 15 March 2023
  4. News Article
    Acute trusts are reporting high demand at emergency departments (EDs) despite junior doctor strikes, which in some cases threaten to lead to overflowing wards and long ambulance handover delays. Chief executives and directors from trusts around England told HSJ their EDs had been as busy or busier than usual. Many had hoped prominent media coverage and NHS announcements about the strikes would lead to reduced demand, helping them cope with fewer doctors on duty. Several claimed it showed national communications about the strikes were lacking. NHS England has said some hospitals saw their busiest Monday of the year so far yesterday, which it said “presents a major challenge as our staff continue to do all they can to mitigate the impact of the industrial action for patients.” Read full story (paywalled) Source: HSJ, 14 March 2023
  5. Content Article
    The World Health Organization's 5th Global Ministerial Summit took place on the 23 and 24 February and was an opportunity for experts from across the world to send clear messages to ministers globally, and for ministers to respond with their pledges about what they were going to do to improve patient safety. Watch the opening and read the outcomes and documents from the Summit,
  6. News Article
    The patient safety commissioner has complained to MPs that she does not have enough staff to cope with her ‘significant workload’, it has emerged. Henrietta Hughes’ concerns are revealed in a letter from Commons health and social care committee chair Steve Brine to health and social care secretary Steve Barclay. Mr Brine asks for assurances over the commissioner’s resources and says he was “concerned” Dr Hughes had told him her current funding was “too little to make the necessary improvements” to safety oversight. Mr Brine wrote on 6 March: “I am in regular contact with Dr Hughes and the matter of resources for her office is something that she has raised with me. She tells me that her office is under extreme pressure, with a significant workload, including correspondence from patients.” Mr Brine told Mr Barclay he shared Dr Hughes’ concerns that without “sufficient resourcing” there was a risk that the safety commissioner role would – according to Dr Hughes – “let down the hopes of patients that were raised by the publication of Baroness Cumberlege’s report”. Read full story (paywalled) Source: HSJ, 14 March 2023
  7. News Article
    A new US study highlights a striking racial disparity in infant deaths: Black babies experienced the highest rate of sudden unexpected deaths (SIDS) in 2020, dying at almost three times the rate of White infants. The findings were part of research by the Centers for Disease Control and Prevention, which also found a 15% increase in sudden infant deaths among babies of all races from 2019 to 2020, making SIDS the third leading cause of infant death in the United States after congenital abnormalities and the complications of premature birth. “In minority communities, the rates are going in the wrong direction,” said Scott Krugman, vice chair of the department of pediatrics and an expert on SIDS at Sinai Hospital in Baltimore. The study found that rising SIDS rates in 2020 was likely attributable to diagnostic shifting — or reclassifying the cause of death. The causes of the rise in sleep-related deaths of Black infants remain unclear but it coincided with the arrival of the coronavirus pandemic, which disproportionately affected the health and wealth of Black communities. Read full story (paywalled) Source: The Washington Post, 13 March 2023
  8. News Article
    Data revealed for the first time shows nearly three-quarters of adult patients needing community mental health care are waiting more than four weeks for treatment to start, which is the timeframe that NHS England wants to introduce as a national standard. Figures shared with HSJ also show two-thirds of children needing community care are waiting more than four weeks from referral to treatment. In 2021, NHS England proposed a series of new waiting time standards in mental health, including a four-week standard for non-urgent community care. A lack of new funding, as well as data recording problems, mean the new standards have not so far been introduced, and no timeline set for implementation. Read full story (paywalled) Source: HSJ, 14 March 2023
  9. News Article
    A couple whose baby died after he was starved of oxygen during a home birth are campaigning for risky breech deliveries to be spotted earlier. Arthur Trott was an undiagnosed breech baby, born after a planned home birth in Burgess Hill on 24 May 2021. A breech delivery is when a baby's bottom or feet will emerge first. An inquest into his death found a delay in transfer to hospital "materially contributed" to his brain injury. The South East Coast Ambulance Service Trust said it welcomed "any changes to national breech birth guidance". Arthur's parents believe a breakdown in communication between the paramedics who attended and their control room meant Mrs Trott was kept at home too long. Arthur's father, Matt Trott, said: "You could hear the panic and confusion in everyone's voices. One minute they were told to go to hospital, the next minute to stay." As a result of Arthur's death, all planned home births in Sussex are being offered a presentation scan at 38 weeks. Read full story Source: BBC News, 14 March 2023
  10. News Article
    NHS England was aware of concerns about upper gastrointestinal surgery at a hospital nearly three years before the Care Quality Commission intervened to stop it being carried out, HSJ can reveal. NHSE in the South East commissioned a report into upper GI cancer services in parts of the region in January 2020. In particular, HSJ understands the review was prompted by concerns the small number of surgeries carried out at the Royal Sussex County Hospital in Brighton meant it may be unable to comply with parts of the service specification and face difficulties maintaining an adequate surgical workforce rota. Despite these concerns, Brighton continued to carry out upper GI surgery until the CQC suspended planned oesophagic-gastric resections last August. Read full story (paywalled) Source: HSJ, 14 March 2023
  11. News Article
    An NHS England investigation into claims of a toxic culture at a hospital trust has been described as lacking transparency and undermining trust. The Parliamentary Health Service Ombudsman also said there were "very serious" patient safety issues at University Hospitals Birmingham (UHB). Criticism is contained in letters seen by the BBC between the ombudsman, the trust and NHS England. The inquiries, commissioned by the Birmingham and Solihull Integrated Care Board and the local NHS, were begun in response to an investigation by BBC Newsnight and BBC West Midlands which heard from current and former clinicians from the trust, who accused it of being "mafia-like". One of England's biggest hospital trusts, UHB has been in the spotlight for months after three probes were started following allegations doctors there were threatened for raising safety concerns. The trust denies this and says its "first priority is patient safety". The ombudsman, however, said he was sceptical about the reviews' transparency and independence. His finding of "very serious" patient safety issues at UHB is based on the trust's response to the ombudsman's recommendations and findings, including a case of an avoidable patient death. Read full story Source; BBC News, 14 March 2023
  12. Content Article
    This is Patient Safety Learning’s submission to the consultation by the Royal College of Obstetricians and Gynaecologists seeking views on a draft Green-top Guideline on outpatient hysteroscopy. The aim of this guideline is to provide clinicians with up to date, evidence-based information regarding outpatient hysteroscopy, with particular reference to minimising pain and optimising the patient experience. The consultation is now closed.
  13. News Article
    The patient lay slumped next to a pile of pills and a personally signed note reading: 'do not resuscitate me'. His breathing was agonal, his skin mottled, his pupils fixed, no pulse discernible. The attending doctor, in agreement with both paramedics and family member, decided to respect his wishes. Yet, this GP was placed under investigation for gross negligence manslaughter by the Crown Prosecution Service (CPS) for not resuscitating the patient, setting in motion a sequence of investigations, including by the coroner and the General Medical Council (GMC), that were triggered by the statement of one policeman at the scene. All investigations and allegations were eventually dismissed but not until the GP had been through years of significant physical and mental stress. Still today, questions remain unanswered – in particular, concerning the actions of the police and the CPS. Speaking under the condition of anonymity, the GP spoke to Medscape News UK, and said that now, over 7 years after that fateful home visit, she remained resolute that she made the correct clinical decisions at the time. "It has all been very stressful for me. What was behind this case? What was driving this potential prosecution? And throughout, the patient, the family and their concerns were completely forgotten in the pursuit of so-called justice," she pointed out. Read full story Source: Medscape News, 9 March 2023
  14. News Article
    Hospitals are being asked to offer a wider range of gown sizes to better protect patients' dignity. It follows the experience of a patient from Wiltshire who said she was offered a gown that was "far too small" during a hospital stay in Bristol. Barbara Gale said it gaped at the back and made her feel "embarrassed". The experience sparked calls for more sizing options.. An independent study conducted by the University of Strathclyde in Glasgow in 2019 asked patients across the UK for their thoughts on the issue of hospital gowns. Consultant clinical psychologist for the NHS, Nicola Cogan, led the research and said the findings showed Ms Gale's experience was not an isolated case. She said: "We spoke to a 1,000 patients and found over two thirds reported they struggled to get a gown on themselves and 70% reported the gown did not fit". "It's not cost effective for the NHS, but also it shows that the gown is currently not fit for purpose." Read full story Source: BBC News, 13 March 2023
  15. Event
    Part of Whistleblowers Awareness Week (WBUK). Aims and Objectives: 1. To engage MPs, organisations and policy makers in understanding the consequences of the victimisation of healthcare whistleblowers for patients and the public. 2. To help remove the stigma around the subject of whistleblowing. 3. To inform attendees of the benefits of change and how this links to the Protection for Whistleblowing Bill [HL] and an Office for the Whistleblower. 4. To provide information that will enable attendees to take practical, measurable steps to move the agenda forward and join in with the work of the APPG and WBUK. Speakers: Dr Jenny Vaughan OBE - Doctors’ Association U.K. Cathryn Watters RGN – Whistleblowers and regulation Steve Turner RMN – Patient experience Professor Emmanouil Nikolousis (online) – Cultures of fear Panel members: Mr Chris Day - CQC Director of Engagement Dr Chris Day Dr Chaand Nagpaul CBE Tom Grimes - NHS England Head of Advocacy and Learning (FTSU) Dr Jayne Chidgey-Clark - National Guardian for the NHS More information
  16. Event
    until
    This is a free live webinar event on ''Transforming the ‘waiting list’ into a ‘preparation list’ for Cheshire and Merseyside ICS'' with speaker Dr Mark Ratnarajah. The session will focus on how smart triage and digital health coaching is improving patient outcomes and reducing elective surgery waiting times across the Cheshire and Merseyside ICS. This event is open to everyone to attend and share thoughts and experiences on different topics. Join us to discuss, discover and learn about the latest ongoings in health tech. Register
  17. Event
    until
    Whistleblowing is barely out of the news. We cannot turn on the TV without a headline or plot that relies on whistleblowers and how badly they are treated. Think about our police, NHS, armed forces, media, banks, corporations - the list goes on... Whistleblowing is good for society and good for business. Whistleblowers are the most effective first line of defence against crime, corruption and cover up. Whistleblowing Awareness Week (WBAW) is an opportunity for MPs to understand how proposed legislation is key to driving a culture where speaking up is valued, and where people who try to silence whistleblowers or suppress evidence of wrongdoing face the full force of the law. WBAW will dispel the stigma and suspicion that overshadow whistleblowers. It will also set out how the Whistleblowing Bill developed by WhistleblowersUK for the APPG for Whistleblowing will transform the way that whistleblowers and whistleblowing are treated. See the events going on for WBAW
  18. News Article
    More than 100,000 patients, including children, have been treated in so-called virtual wards over the last year, NHS officials have said. Leading medics said that the use of the system to monitor patients at home has been a “real game changer”. Officials say virtual wards can help patients avoid unnecessary hospital trips altogether, or enable them to be sent home from hospital sooner. Using various equipment and technology, clinicians can monitor vital signs such as a patients’ heart rate, oxygen levels and temperature remotely. NHS England’s national medical director, Professor Sir Stephen Powis, said: “The advantages of virtual wards for both staff and patients have been a real game-changer for the way hospital care is delivered and so it is a huge achievement that more than 100,000 patients have been able to benefit in the last year alone, with the number of beds up by nearly two thirds in less than a year. “With up to a fifth of emergency hospital admissions estimated to be avoided through better supporting vulnerable patients at home and in the community, these world-leading programmes are making a real difference not just to the people they directly benefit but also in reducing pressure on wider services.” Read full story Source: The Independent. 11 March 2023
  19. News Article
    MPs from across the political spectrum have called for a ban on electroconvulsive therapy (ECT) as a treatment for mental illness in England, and want the practice to be subject to an urgent inquiry. MPs told The Independent they have serious concerns that women are disproportionally given electroconvulsive therapy, and argued that patients are not properly notified of the treatment’s potential side effects. Some patients have also reported that they weren’t asked to provide consent before it was administered. Dr Pallavi Devulapalli, a GP, called for the government to undertake an “urgent and comprehensive review” of the treatment as she warned that patients’ wellbeing was “at stake”. The calls come after The Independent previously reported that thousands of women were being given ECT despite concerns that it can cause irreversible brain damage. It comes after Dr Sue Cunliffe, who began receiving ECT in 2004, previously told The Independent that the treatment had “completely destroyed” her life despite a psychiatrist having told her there would be no long-term side effects. Dr Cunliffe, a former children’s doctor, said: “By the end of it, I couldn’t recognise relatives or friends. I couldn’t count money out. I couldn’t do my two times table. I couldn’t navigate anywhere. I couldn’t remember what I’d done from one minute to another.” Read full story Source: The Independent, 12 March 2023
  20. News Article
    Bereaved families are having to report maternity blunders because watchdogs and hospitals are unable to spot failings, an expert has warned. Bill Kirkup said avoidable deaths were "a badge of shame" but would continue without urgent change. Eight years on from his report into the Morecambe Bay maternity scandal, he said the failure of officials to act had needlessly cost more lives. "I am very disappointed – and surprised – that we're still where we are", he said. "That's a terrible badge of shame for the health service that it takes families to come and tell us what's wrong. "Yet just about every tragedy that I've ever been involved with investigating has come to light when there's a group of families who say 'You've got a problem here'. "People are lying, they're not being open and they're concealing what's happening. "If we can't bring this change, I'm not confident that there won't be another East Kent, Morecambe Bay or Nottingham, somewhere else." Read full story Source: Mail Online, 10 March 2023
  21. News Article
    A cross-border trial has improved care for patients prescribed multiple medicines. The iSIMPATHY project, funded by the European Union's INTERREG VA Programme, worked with professionals in Scotland, the Republic of Ireland and Northern Ireland to comprehensively review patient medication. Taking multiple medicines can be problematic if the increased risk of harm from interactions between drugs, or between drugs and diseases, outweighs the intended benefits. Interim findings showed these interventions potentially prevented major organ failure, adverse drug reactions, avoided hospital admissions and saw patients moved to more appropriate medication. Scotland’s Public Health Minister Maree Todd said: “This project looked at some of our most vulnerable patients taking more than five medications. The reviews have avoided adverse combinations of drugs and hospitalisations while also reducing prescriptions and drugs costs. “We will know more when the full evaluation is published in June, we will work with partners to see how we can these improvements can be applied more widely, potentially saving lives and money.” Read full story Source: Scottish Government, 10 March 2023
  22. News Article
    The drug giant behind weight loss injections newly approved for NHS use spent millions in just three years on an “orchestrated PR campaign” to boost its UK influence. As part of its strategy, Novo Nordisk paid £21.7m to health organisations and professionals who in some cases went on to praise the treatment without always making clear their links to the firm, an Observer investigation has found. Among the vocal champions of the Wegovy jabs was a clinical expert who gave evidence to the National Institute for Health and Care Excellence (NICE) and others who publicly praised the so-called “skinny jabs” as a “gamechanger”. The revelations come as the Danish drug giant is investigated by the UK’s pharmaceutical watchdog after it was found to have breached the industry code seven times in relation to a “disguised promotional campaign” of another of its weight loss drugs via online webinars for healthcare professionals. Prof Allyson Pollock, professor of public health at Newcastle University, said Novo’s campaign was “not unusual” in the drugs industry and called for measures to improve trust. “The public really aren’t being made aware enough about the potential for bias and over-claiming,” she said. Read full story Source: The Guardian, 12 March 2023
  23. News Article
    A review into the culture at Birmingham's biggest hospitals trust amid allegations of bullying and undue pressure on staff has found 'substantial issues' of concern, a brief report has revealed. A short briefing for councillors by NHS Birmingham and Solihull chief executive David Melborne offers the first insight into the findings of Professor Mike Bewick and his review team who were tasked with investigating damning allegations made by current and former staff at University Hospitals Birmingham. More than 50 medics, including some with decades of experience, came forward to criticise a 'toxic' working culture at the trust, many sharing their experiences with MP Preet Kaur Gill (Birmingham Edgbaston). Among the most serious claims that emerged were that whistleblowers concerned about patient safety were silenced with threats of disciplinary action. In a written report to Birmingham and Solihull councils' joint health overview and scrutiny committee, meeting Monday, Mr Melborne says the rapid review into the Newsnight allegations and subsequent complaints has found 'no fundamental safety issues at the Trust'. However, he goes on: "That said, there are substantial issues around culture, behaviour, leadership and governance that will need to be addressed". Read full story Source: Birmingham Live, 10 March 2023
  24. News Article
    The U.S. Food and Drug Administration (FDA) is providing an update on reports of squamous cell carcinoma (SCC) in the scar tissue (capsule) that forms around breast implants. Previously, on 8 September 2022, the FDA released a safety communication informing the public of reports of cancers, including SCC and various lymphomas, in the capsule that forms around breast implants. The various lymphomas are not the same as the lymphomas described previously by the FDA as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This update includes information from the FDA’s review of literature and medical device reports (MDRs). The FDA is aware of 19 cases of SCC in the capsule around the breast implant from published literature. There have been reports in the literature of deaths from progression of the disease. While the FDA continues to believe that occurrences of SCC in the capsule around the breast implant may be rare, the cause, incidence and risk factors remain unknown. Read full story Source: US FDA, 8 March 2023
  25. News Article
    GPs are facing “insurmountable pressures”, experts have said as they warned that the NHS “will not survive” without general practice. A new report into GP pressures suggests one in four staff fear their practice is in danger of closing because of unmanageable workloads and rising demand. The document, from the Royal College of GPs (RCGP), says general practice is “in crisis”, and makes a series of calls to help ease pressures and stop the growing number of GPs from quitting. The report says GPs are bracing for “winter-style pressures” well into spring and summer. “The workload pressures in general practice over this winter have been immense, and high levels of patient demand are set to continue for some time,” the report authors wrote. “General practice is in crisis. We cannot rely on short-term emergency funding pots over winter to try and paper over the cracks." Read full story Source: The Independent, 10 March 2023
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