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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Community health workers are stepping in to provide critical services and information in rural areas in Texas, USA, with few hospitals or doctors. When Claudia Salazar and her family migrated to San Elizario, Texas, a small city in El Paso county, they settled into a colonia – informal, low-income housing often found in rural parts along the US-Mexico border. But the remoteness of their new home soon presented problems – Salazar suddenly found herself in a medical desert. The nearest hospital is a 35-minute drive away. Even that is challenging to get to – the community’s mostly farm worker population works 10- to 12-hour days, and often lacks adequate time to travel for medical attention between workdays. The lack of consistent medical access is just one of the many public health issues that colonias face, and a group of women familiar with the dynamics in this region thought of a relatively simple solution: bringing medical care to the people who need it most in these borderland communities. “Familias Triunfadoras has been really helpful since they provide a mobile unit clinic,” Salazar said. “That’s when we get a chance to visit a doctor or get a doctor’s appointment.” Familias Triunfadoras is a San Elizario-based non-profit that is composed of women who step in as community organizers to connect residents like Salazar to resources they may not know exist. Their efforts to make healthcare more accessible in medical deserts like San Elizario has proven invaluable to residents. Read full story Source: The Guardian, 2 February 2023
  2. Content Article
    In this podcast to support providers with the transition to the Learn from Patient Safety Events (LFPSE) service, the NHS's new national system for the recording and analysis of patient safety events, NHS England talks to Zahra and Mandy, NHS England reporting leads, about the practical steps providers can take to get connected to LFPSE. It covers how to get started, what to do with your old data, the kinds of support available, what transition means for ICBs, and what the Reporting Leads have learned from the process so far.
  3. News Article
    A major hospital in the UK has declared a critical incident, warning it is facing “immense pressures” on its services. Wigan’s Royal Albert Edward Infirmary urged people to avoid its A&E unless suffering a “life or limb-threatening emergency”. Wrightington, Wigan and Leigh (WWL) Teaching Hospitals NHS Foundation Trust warned that “unprecedented attendances” meant the emergency department was “full”. It said it is working with partners to discharge patients who are ready to leave hospital. The trust, which previously declared a critical incident in December, said the safety of its patients is the “top priority”. By declaring a critical incident, hospitals are able to take action so that safe services are maintained despite increasing pressures. Read full story Source: The Independent, 1 February 2023
  4. News Article
    Some ambulance trusts are not sending paramedics to up to around a quarter of their most serious calls, according to figures obtained by HSJ. HSJ submitted data requests to all 10 English ambulance trusts after the Care Quality Commission raised concerns about the proportion of category one calls not being attended by a paramedic at South Central Ambulance Service Foundation Trust. The regulator said in a report published in August last year that between November 2021 and April 2022 around 9% of the trust’s category one calls were not attended by a paramedic. Inspectors said this meant some patients “did not receive care or treatment that met their needs because there were not appropriately qualified staff making the decisions and providing treatment.” But data obtained via freedom of information requests reveals other ambulance trusts had far lower proportions of category one calls attended by paramedics than the South Central service last year. Read full story Source: HSJ, 2 February 2023
  5. News Article
    Researchers have warned there is a lack of evidence around prescribing antidepressants for chronic pain. Guidance from the National Institute for Health and Care Excellence (Nice) in 2021 recommends that an antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) can be considered for people aged 18 and over with pain lasting longer than three months which cannot be accounted for by another diagnosis. The guidance said the drugs may help with quality of life, pain, sleep and psychological distress, even if the patient is not suffering depression. A separate guideline on neuropathic (nerve) pain recommends offering a choice of treatments, including amitriptyline and duloxetine, alongside a discussion on possible benefits and side-effects. However, researchers writing in the BMJ have warned that recommending antidepressants for pain is not always backed by evidence. Professor Martin Underwood from the University of Warwick, said: “There is a role for antidepressants in helping people living with chronic pain, however, this is more limited than previously thought. “Antidepressants may have unpleasant side effects that patients may wish to avoid. “We need to work harder to help people manage their pain and live better, without relying on the prescription pad.” Read full story Source: The Independent, 1 February 2023
  6. Content Article
    Chronic pain is common and debilitating, affecting about one in five people globally. However, chronic pain can be difficult to treat, and management is often suboptimal. The 2021 National Institute for Health and Care Excellence guideline for chronic primary pain explicitly recommends against the use of pain medicines, with the exception of antidepressants. To provide patients and clinicians with an updated and comprehensive resource on the efficacy, safety, and tolerability of antidepressants to treat pain, Ferreira et al. conducted an overview of relevant systematic reviews.  The study found no review could provide high certainty evidence on the effectiveness of antidepressants for pain for any condition. Nine reviews did provide evidence that some antidepressants were effective, such as moderate evidence suggesting serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine, were effective for back pain, post-operative pain, fibromyalgia and nerve pain. However, the study only found low certainty evidence that selective serotonin reuptake inhibitors (SSRIs) were effective for people with depression and pain related to other conditions, and that tricyclic antidepressants (TCAs) were effective for irritable bowel syndrome, nerve pain and chronic tension-type headaches. The findings suggest that a more nuanced approach is needed when prescribing antidepressants for pain conditions.
  7. News Article
    Donna Ockenden, who is leading an independent review examining how dozens of babies died or were injured at the Nottingham University Hospitals (NUH) trust, is due to meet with chief executive of NUH, Anthony May, and other members of the NUH executive team. Speaking ahead of the meeting, she said: "The commitment I want to give to the women and families of Nottingham is that real learning, real improvement in maternity safety will happen throughout the life of this review. "It won't be a case of waiting until the end and then presenting the trust with a huge amount of learning that they then have to start putting in place. "Today's meeting with the trust is at executive level. Along with colleagues from NHS England, I'll be meeting with the chief executive and some of his colleagues to talk about how we will ensure that learning reaches the trust on a regular basis and in a timely way so families can be assured that the maternity improvement plan is including learning from our review." Read full story Source: BBC News, 2 February 2023
  8. News Article
    NHS England has effectively admitted the backlog of cancer long-waiters will still be higher in March 2024 than before covid hit, in a document seen by HSJ. The consultation document, detailing trajectories for reducing numbers waiting 62 days or more from referral, shows the expected national total in March 2024 is 18,755. NHS England previously committed to reducing this to pre-pandemic levels (14,226) by March 2022, then delayed the target until March this year. There are now significant backlogs in diagnostics, with particular challenges in endoscopy and breast screening. NHS Providers director of policy and strategy Miriam Deakin said: “Cancer is a key priority for trusts. They understand the risk to patients who have to wait. “The pandemic left people waiting longer than NHS trusts wanted for diagnosis or to start treatment, with some people not coming forward, but now urgent referrals for suspected cancer are far higher than pre-pandemic. Read full story (paywalled) Source: HSJ, 1 February 2023
  9. Content Article
    This paper aims to highlight how to reduce medication errors through the implementation of human factors science to the design features of medication containers. Despite efforts to employ automation for increased safety and decreased workload, medication administration in hospital wards is still heavily dependent on human operators (pharmacists, nurses, physicians, etc.). Improving this multi-step process requires its being studied and designed as an interface in a complex socio-technical system. Human factors engineering, also known as ergonomics, involves designing socio-technical systems to improve overall system performance, and reduces the risk of system, and in particular, operator, failures. The incorporation of human factors principles into the design of the work environment and tools that are in use during medication administration could improve this process. During periods of high workload, the cognitive effort necessary to work through a very demanding process may overwhelm even expert operators. In such conditions, the entire system should facilitate the human operator’s high level of performance. Regarding medications, clinicians should be provided with as many perceptual cues as possible to facilitate medication identification. Neglecting the shape of the container as one of the features that differentiates between classes of medications is a lost opportunity to use a helpful characteristic, and medication administration failures that happen in the absence of such intentional design arise from “designer error” rather than “user error”. Guidelines that define a container’s shape for each class of medication would compel pharmaceutical manufacturers to be compatible and would eliminate the confusion that arises when a hospital changes the supplier of a given medication.
  10. News Article
    Ambulance crews in the North East frequently responded to emergencies without access to life-saving drugs, a damning inspection report has found. The study of North East Ambulance Service NHS Trust (NEAS) concluded patients were potentially put at risk by the poor management of medicines. The Care Quality Commission (CQC) found a deterioration of services and rated NEAS's urgent care as "inadequate". In response, NEAS said it had faced a year of "unprecedented pressures". The damaging assessment follows the launch of a full independent NHS review into numerous "tragic failings" involving patients. Announcing the review, the then health secretary Sajid Javid said he was "deeply concerned" about claims NEAS had covered up mistakes. Whistleblowers have told Newsnight multiple deaths were not investigated properly because information was not always provided to coroners and families. Read full story Source: BBC News, 1 February 2023
  11. News Article
    NHS staff are failing to follow guidelines for providing care to sickle cell patients - and some of the advice has been branded as “unfit for purpose”. The NHS Race and Health Observatory commissioned research, undertaken by Public Digital, to explore the lived experience of people undergoing emergency hospital admissions for sickle cell and managing crisis episodes at home. The Sickle cell digital discovery report: Designing better acute painful sickle cell care, found that the existence of service-wide information tailored by the National Institute for Health and Care Excellence has “arguably not been designed for an ambulance, A&E and emergency setting”, and states it has been proven that this guideline is “not being used and adhered to consistently”. Moreover, healthcare professionals have warned that the National Haemoglobinopathy Register (NHR) - a database of patients with red cell disorders - is not being readily accessed, while patients reported being treated in a way that breached prescribed instructions. “We believe that sickle cell crisis guidelines could be improved in terms of their usability in a high-pressure emergency setting, and in terms of promoting access to them,” the report authors concluded, adding that current guidance should be adapted. Read full story Source: The Independent, 31 January 2023
  12. News Article
    A mental health trust has received a warning from the Care Quality Commission over staff sleeping on duty and other serious concerns. Essex Partnership University Foundation Trust was sent a “letter of intent”, which warns the CQC is considering taking urgent enforcement action, following an unannounced visit in November, according to a board report last week. The trust is already subject to a high-profile inquiry into hundreds of patient deaths. Natalie Hammond, executive nurse, said this would be “a fine tuning of our health roster which will be an early warning system that will determine and flag all staff members that may be at risk of working too much or their hours of working might perform a pattern that means they are at risk more of falling asleep on duty.” She added: “We’ve done learning lessons and videos that link the importance of being fit and alert for work and how when you’re not, what mitigation and what steps you should undertake and what risk there is to patient safety.” Read full story (paywalled) Source: HSJ, 1 February 2023
  13. News Article
    A prolific surgeon accused of poor care — some with a ‘catastrophic outcome’ — and altering patient notes has been found guilty of misconduct following a tribunal hearing. Jeremy Parker, who performed hundreds of operations at Colchester Hospital and the private Oaks Hospital until his suspension in 2019, faced a misconduct hearing in December and January. The medical practitioners tribunal investigated allegations that between August 2015 and November 2018, Mr Parker failed to provide good clinical care to six patients. It was also alleged he performed surgery in breach of restrictions on his clinical practice between October 2018 and January 2019 and that his actions were dishonest. Richard Holland, opening the tribunal case for the General Medical Council, said Mr Parker’s care of six patients – referred to as patients A-F – was “deficient” in a number of ways, with that provided to patient A leading to a “catastrophic outcome” where their leg was amputated below the right knee following “catastrophic blood loss” caused by severing of an artery during surgery. Read full story (paywalled) Source: HSJ, 1 February 2022
  14. News Article
    The amount of time people over 80 spend in A&E in England has almost doubled in a year, leaving them at increased risk of coming to harm and dying, emergency care doctors are warning. An analysis by the Royal College of Emergency Medicine (RCEM) found that people of that age are spending 16 hours in A&E waiting for care or a bed, a huge rise on the nine hours seen in 2021. The college, which represents the UK’s A&E doctors, warned that long waits, allied to overcrowding in hospitals and older people’s often fragile health, is putting them in danger. Doctors specialising in emergency and elderly care warned that older people forced to spend a long time in A&E are more likely to suffer a fall, develop sepsis, get bed ulcers or become confused. Dr Adrian Boyle, the RCEM’s president, said that it is also likely that some older people are dying as a result of the delays they are facing, combined with their often poor underlying health. The risks older people face while waiting in sometimes chaotic A&E units are so great that they are likely to be disproportionately represented among the 500 people a week who the RCEM estimates are dying as a direct result of delays in accessing urgent medical help. Read full story Source: The Guardian, 31 January 2023
  15. Content Article
    Last year, the independent NHS Race and Health Observatory commissioned consultancy, Public Digital, to undertake a ‘digital discovery’ project to explore the lived experience of people undergoing acute emergency hospital admissions for sickle cell and managing crisis episodes at home. The NHS Race and Health Observatory’s January 2023 publication – ‘Sickle cell digital discovery report – Designing better acute painful sickle cell care’ – sets out to understand the broad availability of digital products and services that currently exist. The report explores the range of technology that is in place for Accident and Emergency clinicians, red-cell specialists, and ambulance care, to aid timely support to sufferers on their emergency hospital arrival. A number of focus groups and interviews were carried out with those that have lived experience of the disease, including patients who have suffered acute, painful sickle cell episodes during NHS A&E admissions. Research found a lack of individual care plans in place and, more broadly, no clear definition of what constitutes an actual care plan. A number of recommendations are set out in the report for the NHS and the wider healthcare system.
  16. News Article
    A woman who died shortly after giving birth to her daughter did not receive the correct medication, a coroner has ruled. Jess Hodgkinson, 26, from Chesterfield, died from a pulmonary embolism in 2021. Assistant coroner Matthew Kewley said there was a "failure" to ensure Ms Hodgkinson received blood thinners right up until the birth. Chesterfield Coroner's Court heard Ms Hodgkinson had a high risk pregnancy due to severe hypertension. On 21 April 2021, a consultant in Chesterfield prescribed a prophylactic dose of tinzaparin due to an increased risk of clotting, the inquest heard. During the inquest, the consultant said the intention was for Ms Hodgkinson to continue to receive a daily dose of anticoagulant medication up until birth. Ms Hodgkinson was transferred to a hospital in Sheffield the next day, but there was a "failure to communicate" the medication plan, Mr Kewley said. After being discharged, clinicians in Chesterfield "failed to identify" Ms Hodgkinson was no longer receiving the medication, the coroner said in his ruling. On 13 May, Ms Hodgkinson attended Chesterfield Royal Hospital and a decision was made to carry out an emergency Caesarean section. The procedure was successful and Ms Hodgkinson's baby was born. But after delivery, Ms Hodgkinson went into cardiac arrest and later died. In his concluding remarks, Mr Kewley said: "There was a failure to ensure that Jess received anticoagulant medication that a clinician had intended should be taken until birth. This failure made a more than minimal, negligible or trivial contribution to Jess' death". Read full story Source: BBC News, 31 January 2023
  17. News Article
    A further 1,500 patients of convicted breast surgeon Ian Paterson are to be recalled and their treatment investigated. Spire Healthcare, which runs private hospitals, said patients were being contacted after a trawl of IT systems. Paterson was jailed for 20 years in 2017 for 17 counts of wounding people with intent. The healthcare provider said it remained committed to tracking down all "outstanding patients". The former surgeon subjected hundreds of patients to needless and damaging surgery over 14 years. A 2020 independent inquiry ruled "a culture of avoidance and denial" left him free to perform botched operations in NHS and private hospitals in Birmingham and Solihull. The inquiry recommended all 11,000 patients Paterson treated should be recalled for review. Read full story Source: BBC News, 1 February 2023
  18. News Article
    “I was worried it would grow and spread,” Charlotte Park, a breast cancer patient tells The Independent. “What happens if I hadn’t been that really pushy person? Sometimes I still go into a dark place and I think: I am so lucky to be here.” The 50-year-old, from Richmond in Yorkshire, found a lump in her breast in June 2020 and went straight to see her GP who informed her she would have to wait two weeks to see a specialist. After a fortnight of waiting, she started to panic and rang the clinic who said they were still working through referrals from four to six weeks prior to her referral. “I was getting frustrated and impatient by this point,” Ms Park recalls. “There was no leeway and they didn’t see if they could squeeze me in. I just felt frustrated. There was nothing I could do. It was all out of my hands. I was feeling teary.” Ms Park is one of thousands of women with breast cancer in England facing delays of weeks or months to see a specialist or receive treatment. Data, shared exclusively with The Independent, shows delays were substantially worse for those with breast cancer than other forms of cancer. In the end, Ms Park was forced to wait 25 days to see a specialist. The wait was “agony”, she said. It was difficult to definitively determine if the delays caused her cancer to grow, she noted. Her comments come in the context of thousands of women with breast cancer being forced to wait longer than the NHS-recommended time of two months to get treatment, in a situation branded “perilous” by healthcare professionals. Exclusive data shows only seven in ten women in England received treatment for breast cancer two months after getting an urgent doctor’s referral between January and November 2022. This amounts to just more than 16,500 women and is way below the NHS target for 85% of breast cancer patients diagnosed via an urgent GP referral to start their cancer treatment within two months of their GP visit. Read full story Source: The Independent. 31 January 2023
  19. News Article
    Thousands of ambulance staff across five services in England - London, Yorkshire, the South West, North East and North West - will walk out on Friday 10 February, Unison says. It means strikes over pay will now be happening across the NHS every day next week, apart from Wednesday. Life-threatening 999 calls will be attended to but others may not be. Downing Street says the continuing industrial action will concern the public. The NHS's biggest day of industrial action is set to happen on 6 February, when many nurses and ambulance crews across England and Wales will be on strike. Unison says the government must stop "pretending the strikes will simply go away" and act decisively to end the dispute by improving pay. The union warned that unless the government had a "major rethink" over NHS pay, and got involved in "actual talks" with unions, it would announce strike dates running into March. The government says the above-inflation pay rises requested are unaffordable. Read full story Source: BBC News, 31 January 2023
  20. News Article
    A health minister has called for more staff to take part in an inquiry into deaths at a mental health trust. An independent review into 1,500 deaths at the Essex Partnership University Trust (EPUT) over a 21-year period was launched in 2020. It emerged earlier this month that 11 out of 14,000 staff members had come forward to give evidence to an independent inquiry. The trust said it was encouraging staff to take part in the inquiry. During a parliamentary debate, Health Minister Neil O'Brien said the trust was being given a "last chance" before the government intervened and instigated a statutory inquiry. A statutory inquiry would allow staff to be compelled to give evidence. In December, a further 500 deaths were made known to the review chair, Dr Geraldine Strathdee. She said the inquiry could not continue without full legal powers. Chelmsford MP Vicky Ford said she had been told by the chief executive of EPUT that staff were "very scared" to give evidence. Read full story Source: BBC News, 31 January 2023
  21. News Article
    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
  22. News Article
    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
  23. News Article
    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
  24. News Article
    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
  25. News Article
    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
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