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Patient Safety Learning

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  1. Patient Safety Learning
    With a focus on pharmaceutical supply chain regulation, Bonafi is one of the latest companies to launch within the regtech startup sector.
    “Companies operating in the global pharma industry must verify that those they are buying from and selling to are authorised to handle medicinal products for human use in their own countries,” explains its founder, Katarina Antill. “At present, this verification process is manual. Companies are using screenshots as proof and relying on spreadsheets to track verification activities, which increases the risk of errors.”
    “Manual processes are very labour intensive not least because companies must deal with multiple registries across multiple countries,” she says. “Most pharma manufacturers and wholesalers don’t have the resources to reverify their trading partners more than once a year, which is the current minimum legal requirement, and this too creates a potential vulnerability that can ultimately have an impact on patient safety and increase corporate risk.
     “I could see that this huge volume of manual work was a threat to patient-safety and extremely inefficient,” she adds. “Our solution gives companies much greater control over their compliance activities because they no longer have to rely on manual processes. It can also retrieve and aggregate data from multiple registers across multiple countries and has a constant monitoring and alert system, quality management dashboards, electronic signatures and workflows and will strengthen the attributes of traceability, transparency and security. It is all designed to help companies to be pro-active in their compliance activities, enabling them to go beyond compliance alone to reduce corporate risk and patient risk.”
    Read full story
    Source: The Irish Times, 13 February 2020
  2. Patient Safety Learning
    NHSX has launched a ‘simpler and faster’ technology assessment process to help healthcare providers pick digital tools that meet NHS standards.
    The new digital technology assessment criteria provides NHS and social care teams with guidance to decide which tools to use or to recommend to patients. NHS organisations, national bodies and social care will be encouraged to apply the DTAC when considering any form of digital health technology procurement.
    NHSX described DTAC as “a new simpler and faster assessment process to help give staff, patients and the public confidence that the digital health tools they use meet NHS standards”, adding it “is a rapid process that can be completed in days”.
    It has previously taken as long as two months for tools to go through assessment processes. 
    The guidance brings together legislation and best practice across five areas. Tools will receive a pass or fail score in the first four categories — clinical safety, data protection, technical security and interoperability — and an additional percentage score for usability and accessibility. 
    Read full story (paywalled)
    Source: HSJ, 23 February 2021
  4. Patient Safety Learning
    The government has announced that the “restoration of other NHS services” will start today on a “hospital-by-hospital” basis.
    Health and social care secretary Matt Hancock in his daily ministerial coronavirus briefing announced the resumption of healthcare which has been suspended due to coronavirus will begin today. He said the initial focus would be on the most urgent services, citing cancer and mental health as examples.
    They will be reintroduced on a locally decided basis, depending on the level the virus is currently impacting different areas and trusts, which varies widely, and how easily they can reintroduce the work, he said.
    Mr Hancock, asked about the plan by HSJ during the briefing, indicated that a large-scale return would be enabled because the government is setting out to avoid a so-called second peak of the virus spreading, so the NHS will not need to keep tens of thousands of extra beds free in readiness. Experts and governments around the globe are concerned about the prospect of further peaks of the virus spread as they move to release distancing measures. 
    Further NHS England guidance on the plan is expected later this week. 
    Read full story
    Source: HSJ, 27 April 2020
  5. Patient Safety Learning
    NHS 111 sends too many people to accident and emergency departments because its computer algorithm is “too risk averse”, the country’s top emergency doctor has warned.
    Dr Adrian Boyle, president of the Royal College of Emergency Medicine (RCEM), said that December was the “worst ever” in A&E with 9 in 10 emergency care leaders reporting to the RCEM that patients were waiting more than 24 hours in their departments.
    Asked what measures could help improve pressures in emergency care, Dr Boyle said more clinical input was needed in NHS 111 calls.
    “In terms of how we manage people who could be looked after elsewhere, the key thing to do is to improve NHS 111,” Dr Boyle told MPs.
    “There is a lack of clinical validation and a lack of clinical access within NHS 111 - 50 per cent of calls have some form of clinical input, there’s an awful lot which are just people following an algorithm.”
    Dr Boyle added where clinical input is lacking “it necessarily becomes risk averse and sends too many people to their GP, ambulance or emergency department”.
    Read full story (paywalled)
    Source: The Telegraph, 24 January 2023
  6. Patient Safety Learning
    A coroner has urged the health secretary to take action to prevent needless deaths after a woman died of heart failure following a four-hour wait in the back of an ambulance.
    Lyn Brind, 61, was taken to the Queen Elizabeth Hospital (QEH) in King’s Lynn, Norfolk, with chest pains and low blood oxygen levels but could not be admitted because the hospital had “no space”. Instead she remained in a queue of ambulances outside A&E without a timely diagnosis or treatment and where warning signs about her condition were missed.
    It was only after four hours and 25 minutes of waiting that she was transferred to a ward, by which time she was “agitated and short of breath”. She was placed on life support but died 22 minutes later.
    Brind’s family believe the grandmother of four, a former dinner lady from the town, “might still be alive today” had she been admitted more swiftly. “She wasn’t given a chance,” her partner of 38 years, Richard Bunton, said.
    After an inquest earlier this month into Brind’s death in May 2022, the senior coroner for Norfolk, Jacqueline Lake, took the unusual step of writing to England’s health secretary, Steve Barclay, to raise concerns about the NHS and social care.
    She warned that others could die in similar circumstances unless action was taken. “I believe you have the power to take such action,” Lake wrote in a prevention of future deaths report.
    Read full story
    Source: The Guardian, 29 January 2023
  7. Patient Safety Learning
    A robot paramedic is to be used for the first time to carry out chest compressions on ambulance patients to free up the emergency team who can perform other vital treatments.
    The device is known as LUCAS 3 and is able to deliver consistent, high-quality CPR chest compressions whilst the patient is on their journey to hospital. CPR is essential to maintaining oxygen levels in the body and flow of blood when someone is no longer breathing.
    South Central Ambulance Service (SCAS) is the first ambulance service in the country to use the robots, which cost about £12,000.
    An SCAS spokesman said: “Once paramedics arrive and begin CPR or take over from bystanders who may have initiated it, the transition from manual compressions to LUCAS can be completed within seven seconds, ensuring continuity of compressions.”
    Data of the event can also be collected which can be reviewed at a later date.
    Dr John Black, medical director at SCAS, said: “We know that delivering high quality and uninterrupted chest compressions in cardiac arrest is one of the major determinants of survival to hospital discharge but it can be very challenging for a number of reasons.
    “People can become fatigued when performing CPR manually which then affects the rate and quality of compressions, and patients may need to be moved from difficult locations, such as down a narrow flight of stairs, or remote places which impedes the process.”
    Dr Black went on to explain that these devices don’t “fatigue or change” their delivery as a human might. This means “high quality CPR can be delivered for as long as is required.”
    Read full story
    Source: The Independent, 22 May 2020
  8. Patient Safety Learning
    ‘Rubbish’ communications on Group A Strep from government agencies made A&Es more ‘risky’ over the weekend, after services were flooded with the ‘worried well’, several senior provider sources have told HSJ.
    On Friday the UK Health Security Agency, successor to Public Health England, issued a warning on a higher than usual number of cases after the deaths of five children under 10 in a week.
    Several senior sources in hospital, 111/ambulance, urgent care and primary care providers, told HSJ they were not warned UKHSA were making an announcement that would also see services flooded by the worried well.
    NHS England’s clinical lead for integrated urgent care issued a letter, seen by HSJ, saying a “considerable increase” in 111 demand over the weekend was “in part due to Group A Strep concerns”. Sources in the sector said the increase in demand was “heavily” Strep-related.
    One senior accident and emergency leader told HSJ that when parents could not get through on 111 they brought their children to emergency departments. “The media messaging has been handled terribly”, they added.
    They added: “Huge numbers of ‘worried well’ makes the A&E a much more dangerous place. We are just not equipped to deal with the volume of patients. [There is a] much greater chance we would miss one seriously unwell child when we are wading through a six-hour queue of viral, but otherwise well, kids.”
    Read full story (paywalled)
    Source: HSJ, 6 December 2022
  9. Patient Safety Learning
    An MP who has just become a ministerial assistant in the Department of Health and Social Care has called for ‘underperforming’ NHS managers to be ‘sacked’, claiming some executives in the health service earn up to £500,000 per year.
    James Sunderland, who was made a Department of Health and Social Care parliamentary private secretary just days ago, told a Conservative party conference fringe event that money spent on executives should be reinvested into the coal face.
    Mr Sunderland, MP for Bracknell since 2019, also said the NHS is “better funded now than at any time in its history”.
    He said: “The solution is not more money, it’s better managers. We need to get to grips with the senior management of the NHS. People not performing need to be sacked.
    “We need to reinvest money spent on executives and management into the coalface. It’s about efficiency in how we do business.”
    Read full story
    Source: HSJ, 3 October 2022
  10. Patient Safety Learning
    Following the unprecedented impact and strain that the COVID-19 pandemic has placed on the NHS and social care, both the public and the healthcare sector believe politicians must prioritise the improvement of both patient and healthcare worker safety.
    The Safety for All white paper, Patient and Healthcare Worker Safety – Two sides of the same coin, is published today by the Safety for All campaign, set up by the Safer Healthcare and Biosafety Network (SHBN), an independent forum focused on improving healthcare worker and patient safety, including Patient Safety Learning and the Association of British HealthTech Industries.
    The white paper sets out the symbiotic relationship between healthcare worker safety and patient safety and that you cannot have one without the other. The pandemic has shone a light on the interconnection of these two issues, from the importance of effective infection control to ensuring healthcare professionals feel safe to speak up about incidents of unsafe care. This white paper makes the case for a new focus and priority for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all.
    Dean Russell MP, a member of the Health and Social Care Select Committee, said:
    “The NHS estimates that there are 11,000 avoidable deaths in the UK each year due to patient safety incidents. We must look at the issue of patient safety holistically. If we can change our approach then then we can reduce the number of serious safety incidents. Also, if we ensure, in the transition back to normality following the pandemic, that the safety of healthcare workers is a priority this will also impact positively on patient safety.”
    Jonathan Hazan, chair of Patient Safety Learning, said:
    “I welcome the publication of the Safety for All white paper with its focus on the relationship between patient safety and staff safety. At Patient Safety learning, we have always understood that improvements in one area reinforce safety in the other. We recognise that avoidable harm has complex causes and to address them, we must transform the system so that patient safety is core to the purpose of health and social care, not just one of many competing priorities. We are engaging with politicians, healthcare organisations, professionals and patients to push for the system-wide change which will result in the reduction of harm. Dean Russell and his colleagues in Parliament have a key role in improving safety and we look forward to working with them.”
    Mike Fairbourn, Board Member of the Association of British HealthTech Industries, said:
    “Today the Safety for All campaign is launching its white paper called “Patient and Healthcare Worker Safety – Two sides of the same coin”.  This makes the case for a new focus and priority for improvements in, and between, patient and healthcare worker safety to prevent safety incidents and deliver better outcomes for all. There needs to be a better understanding and advocacy of the mutual benefits to be accrued for patient safety by improving healthcare worker safety, and vice versa. Safety needs to be a core purpose for both the NHS and social care and for patient and workplace safety, with greater support for staff and for them to speak up following patient safety incidents.”
    Read the full story
    Source: Safer Healthcare and Biosafety Network (20 October 2021)
  11. Patient Safety Learning
    The Labour Party will call on the government to commit to a target of ending the Black maternal mortality gap during a landmark debate about the topic later on Monday.
    This comes as shocking figures show Black women are over four times more likely than white women to die during or after pregnancy or childbirth in the UK.    
    MPs will debate a petition relating to Black maternal healthcare and mortality.
    Scheduled to take place at 6.15pm this evening, the session will be led by Petitions Committee Chair Catherine McKinnell MP.
    Read full story
    Source: The Independent, 19 April 2021
  12. Patient Safety Learning
    Serious systemic failings contributed to the death of a newborn baby in a cell at Europe’s largest women’s prison, a coroner has concluded.
    Rianna Cleary, who was 18 at the time, gave birth to her daughter Aisha alone in her prison cell at HMP Bronzefield, in Surrey, on the night of 26 September 2019. The care-leaver was on remand awaiting sentence after pleading guilty to a robbery charge.
    The inquest into the baby’s death heard that Cleary’s calls for help when she was in labour were ignored, she was left alone in her cell for 12 hours and bit through the umbilical cord to cut it.
    In a devastating witness statement read to the court, Cleary described going into labour alone as “the worst and most terrifying and degrading experience of my life”.
    She said: “I didn’t know when I was due to give birth. I was in really serious pain. I went to the buzzer and asked for a nurse or an ambulance twice.” Cleary passed out and when she woke up she had given birth.
    The senior coroner for Surrey, Richard Travers, said Aisha “arrived into the world in the most harrowing of circumstances”. He concluded it was “unascertained” whether she was born alive and died shortly after or was stillborn.
    Read full story
    Source: The Guardian, 28 July 2023
  13. Patient Safety Learning
    Serious failings by healthcare staff at Broadmoor Hospital were likely to have contributed to the death of a patient from self-asphyxiation, a jury has found.
    Following a two-week inquest at Reading Coroner’s Court, a jury found staff failed to recognise and reduce the risks that acutely unwell patient Aaron Clamp presented to himself in the minutes leading to his death.
    Mr Clamp died on 4 January 2021 after choking in his room at the NHS-run high secure mental health hospital Broadmoor.
    In the weeks prior to his death, Mr Clamp’s mental health had deteriorated. He was transferred into a “psychiatric intensive care” ward at Broadmoor Hospital and placed in long-term segregation.
    A summary of the jury’s findings shared with The Independent has found there was “a serious failure in the timely manner to recognise and reduce the level of risk, and a serious failure to recognise and execute the steps to remove the item of fabric” that Mr Clamp choked on.
    “This omission probably contributed to the death,” the jury said.
    It was also found there was “insufficient” recording by the trust of previous incidents of self-asphyxiation by Mr Clamp when he died.
    Jurors said the plan for staff to carry out constant eyesight observations was appropriate, but not all aspects of the plan were adequately followed by staff members.

    Read full story
    Source: The Independent, 7 March 2022
  14. Patient Safety Learning
    Five years after launching a plan to improve treatment of black and minority ethnic staff, NHS England data shows their experiences have got worse.
    Almost a third of black and minority ethnic staff in the health service have been bullied, harassed or abused by their own colleagues in the past year, according to “shameful” new data.
    Minority ethnic staff in the NHS have reported a worsening experience as employees across four key areas, in a blow to bosses at NHS England, five years after they launched a drive to improve race equality.
    Critics warned the experiences reported by BME staff raised questions over whether the health service was “institutionally racist” as experts criticised the NHS “tick box” approach and “showy but pointless interventions”.
    Read full story
    Source: The Independent, 18 February 2020
  15. Patient Safety Learning
    Seaman Danyelle Luckey “didn’t die in combat or any military operation. She died from gross negligence of the medical providers on the ship she served, the USS Ronald Reagan,” said her father, Derrick Luckey.
    Danyelle Luckey died from sepsis on 10 October 2016. The 23-year-old had been on the ship for two weeks, and had been going back and forth to medical from 3 to 9 October with worsening symptoms. “Her death was very preventable. She died in excruciating pain, instead of being properly treated,” Derrick Luckey told lawmakers during a hearing about patient safety and the quality of care in the military medical system.
    “If the medical providers had given her a simple treatment of antibiotics instead of turning her away, she would be alive today,” he said.
    Luckey and Army veteran Dez Del Barba, who said he lost part of his left leg and suffered 70% muscle and tissue damage after his strep infection went untreated, urged lawmakers to make changes so others in the military community don’t have to suffer.Both contend this could have been avoided if proper medical care, such as antibiotics, had been provided. And both said they haven’t been able to get any information on investigations, or any actions to hold anyone accountable.Read full story
    Source: Yahoo News, 31 March 2022
  16. Patient Safety Learning
    An investigation into whistleblowing claims which described patients “hanging off trolleys” and “vomiting down corridors” in a crowded emergency department has upheld most of the concerns.
    It comes after a staff member at Northern Lincolnshire and Goole Foundation Trust wrote to the chief executive and trust’s commissioners after working a weekend shift within the emergency department at Diana, Princess of Wales Hospital in Grimsby.
    In their original email, sent in January 2020, the anonymous whistleblower said they were writing out of “sheer desperation for the safety of patients”.
    They added: “I have never in my whole career seen patients hanging off trolleys, vomiting down corridors, having [electrocardiograms] down corridors, patients desperate for the toilet, desperate for a drink. Basic human care is not being given safely or adequately…"
    “Your hospital is full, your A&E department is over-flowing, you are expecting staff to manage treble the amount of patients in majors and resus than they would do normally, without breaks, this is not safe. They cannot provide that care – which is evident.”
    Read full story (paywalled)
    Source: HSJ, 7 November 2021
  17. Patient Safety Learning
    A former national director has expressed her shock at visiting an accident and emergency department struggling with record numbers of mental health patients accompanied by police officers, and warned the issue needs an “absolute solution” from the area’s mental health trusts.
    Kathy McLean, a non-executive director at Barking, Havering, and Redbridge University Hospitals Trust, and previously NHS Improvement’s medical director, told a board meeting last week there were “police officers everywhere you looked” at the accident and emergency at King George Hospital in Ilford, which had just experienced its third consecutive record month for mental health referrals.
    While she recognised nearby mental health trusts North East London Foundation Trust and East London FT were “working hard”, she added: “This is not our problem, it is their problem that we’ve now got, and it’s not right for [patients], nor is it right for other people attending the emergency departments.
    “I’ve been to more emergency departments than most people in the country and I was shocked, everywhere you looked there was a police officer… This now needs an absolute solution. If this was ambulances sitting outside our ED, people would be saying, you’ve got to sort it.”
    Read full story (paywalled)
    Source: HSJ, 14 July 2023
  18. Patient Safety Learning
    MPs will be asked this week to end the “shocking” practice of making cystic fibrosis patients in England pay prescription charges for the drugs that they need to stay alive. The condition is the nation’s most common inherited, life-threatening disease and affects more than 7,000 people.
    Prescription charges, first introduced in 1952, were abolished in 1965; then, when they were reintroduced in 1968, exemptions were made for those suffering from long-lasting ailments such as cancers, diabetes and epilepsy. But children with cystic fibrosis were not expected to live to adulthood and so the condition was not exempted.
    As a result of new medicines and the creation of special physiotherapy regimes, cystic fibrosis patients now live well into their 40s.
    “Medicine and society have moved on, so should the exemption list to reflect modern-day experience,” said Paul Maynard, the Conservative MP for Blackpool North and Cleveleys, who will call for an end to prescription charges for the disease at a special Commons debate on the illness this week. “As someone who has a long-term medical condition – epilepsy – it has always amazed me that adults with cystic fibrosis have to pay for their prescriptions whilst I do not.”
    Read full story
    Source: The Guardian, 30 January 2022
  19. Patient Safety Learning
    The government must allow health systems to plan their finances over a longer period to help deliver ‘real’ savings by rationalising services, says a leading chief executive.
    Kevin McGee, who recently stepped down from Lancashire Teaching Hospitals, said the “short-termism” baked into the annual NHS budget cycle is a major source of frustration for local leaders.
    Many trusts and systems have struggled to deliver their financial plans this year due to the savings required, and Mr McGee warned that continuing to “salami slice” the budgets will exacerbate patient safety risks.
    He said Lancashire and many other systems urgently need to rationalise and consolidate acute services on fewer sites, which would bring significant cost savings. However, changes such as these can often take years to plan and implement.
    Read full story (paywalled)
    Source: HSJ, 1 November 2023
  20. Patient Safety Learning
    Ambulance chiefs have warned of a ‘significant escalation’ in the strike action being planned by unions next week – saying the flexibilities that helped deal with previous walk-outs will no longer be available.
    In a letter to local NHS leaders, seen by HSJ, North West Ambulance Service said unions are “becoming more stringent in their approach”, and the trust’s ability to respond to incidents will be severely weakened.
    For the last day of strike action in February, the GMB union told NWAS it was abandoning exemptions (derogations) for category 2 calls, which include heart attacks and strokes.
    The NWAS letter, sent yesterday, said the Unite union also now intends to take this approach on 6 March.
    Last month the head of the London Ambulance Service said the reduced level of service in the capital “causes harm to our patients”
    Read full story (paywalled)
    Source: HSJ, 2 March 2023
  21. Patient Safety Learning
    The number of suspected scarlet fever cases since September has risen to nearly 30,000 after the UK Health Security Agency added almost 10,000 potential new infections in the last week.
    More than 27,000 people could have had infections since 12 September, according to the UKHSA, who revealed on Tuesday that there were more cases than first thought because of the “significant rise” in infections.
    The figures come from medical practitioners referring suspected cases to the local authority or health protection team.
    A total of 16 children aged under 18 have died from invasive group A streptococcus (iGAS), otherwise known as strep A.
    Parents are advised to contact 111 or a GP surgery if a child has symptoms. They can also include nausea and vomiting.
    New serious shortage protocols were issued to pharmacists last week in an attempt to help those experiencing supply issues with penicillin.
    Chemists had widely reported problems getting hold of liquid penicillin and amoxycillin due to the increase in demand. The antibiotics are often prescribed for children who have scarlet fever or strep A. People in the industry have also reported rising prices.
    Pharmacists are now able to prescribe an alternative antibiotic or formulation of penicillin, such as tablets.
    Read full story
    Source: The Guardian, 20 December 2022
  22. Patient Safety Learning
    A trust’s gastroenterology service was ‘in a very poor state with significant risks to patient safety’ and had poor teamworking which “blighted” the service, an external review found.
    The problems in the service at Salisbury Foundation Trust, Wiltshire, were so severe that the Royal College of Physicians suggested it should consider transferring key services such as management of GI bleeds and the care of hepatology patients to other hospitals.
    The service was struggling with poor staffing which had led to increased reliance on a partnership with University Hospital Southampton Foundation Trust, outsourcing and the daily use of locum consultants, according to the report. The trust board had identified “inability to provide a full gastroenterology service due to lack of medical staff capacity” as an extreme risk.
    The report said: “This review was complex and necessary as the gastroenterology service is in a very poor state with significant risks to patient safety and the reputation of the trust. We found a wide range of problems which now need timely action to ensure patients are safe.”
    Read full story (paywalled)
    Source: HSJ, 7 June 2021
  23. Patient Safety Learning
    Pioneering new technology could help patients with non-healing wounds avoid infections and the need for antibiotics, scientists say.
    Wirelessly powered, environmentally friendly “smart bandages” have been developed by a team of scientists from the UK and France, with the University of Glasgow and the University of Southampton leading the research.
    The bandage could help improve the quality of life for people with chronic non-healing wounds as a result of conditions such as cancer, diabetes or damaged blood vessels, they said.
    Currently, wounds require painful cleaning and treatment.
    Researchers believe the technology could help to slow the rise of dangerous new strains of antibiotic resistant bacteria known as superbugs.
    Read full story
    Source: The Independent, 30 May 2023
  24. Patient Safety Learning
    “Smart socks” that track sweat levels, heart rate and motion are being given to dementia patients to alert carers if they are becoming distressed.
    The unintrusive technology was developed by Dr Zeke Steer, of Bristol Universit. Dr Steer wanted to find a way to spot the early warning signs of distress, so carers or relatives could intervene with calming techniques to de-escalate the situation. 
    The hi-tech hosiery - which look and feel like normal socks - use e-textiles to transmit data in real time to an app, which alerts carers when stress levels are rising.
    The socks are now being trialled among mid to late stage dementia patients. Researchers think they will also help people with autism and other conditions that affect communication. 
    Fran Ashby, manager from Garden House Care Home, in Bristol, said: “We were really impressed at the potential of assisted technology to predict impending agitation and help alert staff to intervene before it can escalate into distressed behaviours. 
    “Using modern assistive technology examples, like smart socks, can help enable people living with dementia to retain their dignity and have better quality outcomes for their day to day life.”
    Read full story (paywalled)
    Source: The Telegraph, 9 May 2022
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