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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A law student who died after four remote GP consultations might have lived had he been given a face-to-face appointment, a coroner ruled. David Nash, 26, died in November 2020 from a bone infection behind his ear that caused an abscess on the brain. Over a 19-day period leading up to his death, he had four phone consultations with his GP. The coroner, Abigail Combes, said the failure to see him meant he underwent surgery ten hours later than it could have been. Andrew and Anne Nash fought for more than two years to find out whether their son would have lived if he had been seen in person by clinical staff at Burley Park Medical Centre in Leeds. Yesterday they said they were “both saddened and vindicated by the findings that the simple and obvious, necessary step of seeing him in person would have saved his life” and wanted to make sure “others don’t die as David did”. Read full story (paywalled) Source: The Times, 21 January 2023
  2. News Article
    Offering women annual breast cancer checks could save 1,000 lives a year, the Government’s women’s health tsar has said. Dame Lesley Regan said that the current system of screening women aged 50 to 70 once every three years was “not based on scientific evidence”. The UK’s breast screening programme has the longest gap between screens in the world. In the US, it is every one or two years, and in Europe, it is every two years. Dame Lesley, who is also a professor of obstetrics and gynaecology at Imperial College London, claimed that the decision to give women mammograms once every three years had been based on the budgets available in the Eighties, when checks were introduced. However, she said that more recent studies showed annual mammograms could save significant numbers of lives. On Tuesday, she told the launch of the Hologic Global Women’s Health Index in London: “If [someone] has a mammogram which is reported as normal today and she developed, for example, a precancerous lesion next month, she will then be waiting [until her next check], when it may well have become invasive, in the belief that she’s fine. “If you have yearly mammography – and I appreciate that’s an expensive resource – there are very good studies demonstrating how many lives you save.” Read full story (paywalled) Source: The Telegraph, 25 January 2023
  3. News Article
    A third of Black and ethnic minority health staff have suffered racism or bullying as the NHS fails to address “systemic” levels of discrimination, The Independent can reveal. Levels of bullying and harassment of minority workers have not improved in the past five years with almost 30% saying they have been targeted in the past year, compared to 20%of white staff. Despite being one-quarter of the workforce, minority ethnic staff make up just 10% of the most senior positions, the NHS’s flagship report is set to reveal. One nurse told The Independent she was forced to leave her job following a campaign of bullying, while another, who has left for the private sector, said her mental health was hugely impacted by the discrimination she experienced. Another nurse said she was left “traumatised” by bullying and harassment and she was “gaslighted” by her employer. “This incident is going to affect me for the rest of my life … when I first joined [the NHS trust] I thought I was going to retire there but ... my career [has been cut] short and it’s not fair,” she said. Equality for Black Nurses, a membership organisation founded by Neomi Bennett in 2020, has launched 200 cases of alleged racism against a number of NHS trusts since it was set up. “Racism is driving nurses out of the NHS,” Ms Bennett, told The Independent, warning that this issue had reached “pandemic levels”. Read full story Source: The Independent, 24 January 2023
  4. News Article
    Simultaneous big waves of Covid and flu - the 'twindemic' experts warned of as people returned to 'normal' pre-pandemic mixing - cost the NHS this winter, say NHS bosses. NHS England chief strategy officer Chris Hopson said hospital pressures in England peaked on 29 December. The workload involved gave hospitals a "significant problem" at the turn of the year, he said. It was at this point that record-long waits at A&E were seen. Since then the pressures have begun to ease a little. Speaking to MPs on the House of Commons' health committee, Mr Hopson said: "The issue was always going to be this winter was the degree to which we saw prevalence of both Covid and flu and the degree to which they combined. "Now we're obviously not through winter yet but the really important point - that I don't think has come out enough - is both Covid and flu peaked so far on 29 December." At the turn of the year one in eight beds were occupied by patients with either Covid or flu. And Mr Hopson added this combined with the 12,000 beds occupied by patients medically fit to leave but unable to be discharged because of the lack of support in the community meant more than a quarter of beds were lost. "It gives a significant problem in terms of patient flow, which then means you get the back up right the way through the system." Read full story Source: BBC News, 24 January 2023
  5. News Article
    Manchester city council is setting up two special children’s homes to house the increasing number of vulnerable young people who end up stuck in hospital because no residential providers will take them. The homes, believed to be the first of their kind, aim to undercut private operators which sometimes demand tens of thousands of pounds each week to look after children with the most complex needs. Five Manchester children with complex emotional needs spent many weeks in hospital in 2022 because no children’s homes would take them because of their challenging behaviour, according to the city council’s director of children’s services. Manchester council has developed what it calls the Take a Breath model. Two houses are being renovated to house up to four children in total, with the first hopefully moving in by March. The idea is that when children first turn up at hospital – often at accident and emergency after a suicide attempt or self-harming incidents – once their injuries have been treated they can be discharged straight into the new homes rather than occupying a paediatric bed they do not need. Jointly commissioned by the council and the NHS, the two homes will cost £1.4m a year. Of that, MCC expects to spend £5,500 a week for each child. It represents a huge cost saving compared with some external placements. Last year the council was charged £16,550 a week by one private provider to look after a young profoundly autistic person with learning difficulties deemed a danger to themselves and to others. Read full story Source: The Guardian, 22 January 2023
  6. News Article
    A study of 10,650 females in the UK found those with a combined household income of up to £25,000 per annum are less health literate and are less likely to attend health screenings or vaccination invitations. In fact, 1 in 10 have never had health issues such as blood pressure or cervical cancer checked, compared to just 5% of those in a household earning more than £40,000 per annum. 15% of lower earners said they didn’t take up offers of preventative healthcare because they felt it was not needed. They are also the least able to talk to and understand healthcare professionals (72% compared to 81% of high-income households) and least likely to know where to access health information (79% compared to 89% of high-income households). Although 75% feel informed about what is needed to be healthy, this rises to 88% of those in high-income households. It also emerged 30% of low earners who experience daily pain, such as joint pain, backaches or headaches, have stopped work completely as a result, compared to just 10% of high-income households. Read full story Source: The Independent, 24 January 2023
  7. Content Article
    Hologic launched the Hologic Global Women’s Health Index — a multiyear, comprehensive global survey about women’s health — to help fill a critical gap in what the world knows about the health and wellbeing of the world’s women and girls. Conducted annually, the survey provides the most timely, globally comprehensive data from womens' perspectives on their health and wellbeing.  The results from the 2021 Hologic Global Women’s Health Index, conducted with nearly 127,000 women and men in 122 countries and territories, show that leaders need this framework more than ever. Health situations for women and girls worldwide did not get better in 2021. The divide between women in high-income and low-income economies grew even larger than the year before. The findings in this year’s report provide a crucial update on the state of women’s health worldwide in the second year of the COVID-19 pandemic, as women around the world lived through an uneven economic recovery and a “hurricane of humanitarian crises.” This year’s report answers key questions about women’s knowledge, attitudes and behaviours regarding healthcare and, most importantly, whether women are getting preventive care and using health services.
  8. Content Article
    This download A4 Easy Read booklet from Jo's Cervical Cancer Trust uses simple language and pictures to talk about smear tests. It explains what a smear test is and has tips to make it better for you. It also has a list of words you might hear. Please note this edition of the Easy Read booklet has not been updated with HPV primary screening, but the information and tips about cervical screening are correct. 
  9. News Article
    "I got my cervical screening letter in November and I've been putting it off because I don't want to do it - I don't think any girl really wants it done to them." Elena Coley Perez is 26 and due to have her first cervical screening - or smear test - that examines the opening to your womb from your vagina. NHS records show 4.6 million women - or 30% of those who are eligible - have never been screened for cervical cancer or are not up to date with their tests. Women are sometimes too embarrassed to come forward or put it off because they are anxious, surveys have found. Struggling to book their tests due to GP backlogs will not help the situation, say charities. Elena has told the BBC she was already worried about having a smear test, and the difficulty she experienced in booking one put her off even more. "I got another letter in December so I went to book online because with my local GP you have to go through this long-winded form," she said. "I typed in cervical screening and nothing was coming up, so I ended up waiting 35 minutes on the phone to be told they had no appointments for the rest of the year and to phone back in the new year." Elena then tried again in January and was told there was no availability. "At this point I was like, 'what's the point?' - you're trying to do something that can hopefully prevent you from getting cancer and you get to the doctor's surgery and you just get a 'no' - it's really off-putting," she says. Read full story Source: BBC News, 25 January 2023 Further resources on the hub: For patients: Having a smear test. What is it about? (Jo's Cervical Cancer Trust) Cervical cancer symptoms (Jo's Cervical Cancer Trust) For staff: RCN guidance: Human papillomavirus (HPV), cervical screening and cervical cancer
  10. News Article
    The new national target to see 76% of A&E patients within four hours by March 2024 has been described as ‘extremely unambitious’ by senior emergency clinicians. Adrian Boyle, president of the Royal College of Emergency Medicine, also told the Commons Health and Social Care Committee that the objective – included in NHS England planning guidance for 2023-24 and agreed with government – could also drive “perverse incentives” for some emergency department managers. The new target to admit, transfer or discharge 76% of patients by the end of 2023-24 is the first time a specific bar has been set against the four-hour standard for several years. In December, just three acute trusts were hitting the new 76% objective. But Dr Boyle told MPs: “The aspiration from NHS England is that we return to a four-hour target performance of 76%. We think that is too unambitious, and we think that is going to create all sorts of perverse incentives, because it’s going to encourage managers and senior clinicians just to focus on people who can be discharged from hospital, without dealing with our problem, which is exit block [people who cannot be admitted as wards are full]. “We think the 76 per cent is an extremely unambitious target. It was 95% – I know that’s going to be a long way to go back to and we haven’t achieved it since 2015, but we would say we need to have a trajectory to a higher target.” Read full story (paywalled) Source: HSJ, 24 January 2023
  11. News Article
    Ambulance crews say they are treating a growing number of patients who are falling ill because they are unable to afford to heat their homes. The soaring cost of gas and electricity has forced many people to switch off their heating in the winter months. Scottish Ambulance Service crews say they are seeing people who are unwell because their homes are so cold or they cannot afford to eat properly. Charities have warned many people are dealing with a "toxic cocktail" of increasing energy bills, growing inflation and higher interest rates this winter. Glasgow ambulance workers Tanya Hoffman and Will Green say that most weeks they see patients who are facing the stark choice between eating and heating. They have been in homes which feel ice cold, where the patients are clearly struggling to cope. "It is sad to see people are living like that," said Tanya. "There's been quite a few patients I have been out to who can't afford to buy food. They have to choose one or other, heating or food. "So they'll sit quietly at home and it's usually a relative or a friend who will phone for them as they don't want to bother anybody. "They're sitting there [and] you can't get a temperature off them because they're so cold. "So you take them into hospital because they are not managing. You know if you leave that person at home they are probably going to die through the fact they are so cold." Read full story Source: BBC News, 24 January 2023
  12. News Article
    Being placed on immunotherapy to treat Stage 4 cancer was a life-saver for Imogen Llewellyn. Three years on, the 34-year-old is currently cancer-free, but said if it was not for specialist doctors, the side effects could have killed her. The Royal College of Physicians (RCP) claims Wales needs more oncology experts in A&E to recognise and treat emergencies. The Welsh government said all acute hospitals were expected to have an acute oncology service. The RCP report wants investment in emergency cancer care because of the sheer volume of patients who need urgent care during their treatment. With about a fifth of acute hospital beds occupied by people who have a cancer-related problems, they add that about a third of admissions could be avoided if same-day care were more widely available in Wales - which in turn would relieve pressure on hospitals. Dr Hilary Williams, consultant oncologist and Wales Cancer Network lead for acute oncology, said: "Wherever a patient lives in Wales, they should be able to access excellent acute oncology services. "When people think about cancer treatment, they might think about undergoing surgery or receiving chemotherapy, radiotherapy or immunotherapy in an organised way, perhaps during weekday hours in a specialist centre. But what happens when an emergency arises?" Read full story Source: BBC News, 24 January 2023
  13. Content Article
    Many people see their GP with symptoms that could either get better without treatment, or be a sign of serious illness; their diagnosis is uncertain. Research has explored how GPs and patients can work together to develop follow-up plans (a process known as safety-netting). New recommendations could help GPs manage uncertain diagnoses. To avoid unnecessary referrals, GPs may adopt a ‘watch and wait’ strategy when someone has an uncertain diagnosis. This strategy should come with a clear follow-up plan so that people understand the possible causes of their symptoms, how to look after themselves and what to do if symptoms persist. This is good safety-netting. Without good safety-netting, watch and wait carries risks. For example, late cancer diagnoses have been linked to poor safety-netting. However, professional guidance on safety-netting is lacking. This is a knowledge and practice gap. A study from Friedemann Smith explored the best ways to deliver safety-netting advice. It suggests that people are more likely to follow advice if they are involved in developing the follow-up plan. They need to understand: why they are receiving this advice what actions are required, and by whom. The lack of time within primary care consultations is well known. This may need to be addressed for clinicians to have long enough to develop a safety-netting plan. Professionals may also need training to develop the appropriate communication skills.
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  15. Event
    Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. There will be an extended focus on the role of human factors in patient safety investigation in line with the new National Patient Safety Incident Response Framework (PSIRF). This conference will enable you to: Network with colleagues who are working to embed a human factors approach. Learn from outstanding practice in using human factors and ergonomics to improve patient safety and quality. Reflect on national developments and learning including the patient safety syllabus and the role of human factors within the new patient safety incident response framework. Understand the tools and methodology. Develop your skills in training and educating frontline staff in human factors. Understand how you can improve patient safety incident investigation by using a human factors approach. Learn from case studies demonstrating the practical application of human factors to improve patient care and safety. Understand the role of human factors in improving culture and delivering psychological safety. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register
  16. Content Article
    The original National Safety Standards for Invasive Procedures (NatSSIPs) were published in 2015. Understanding of how to deliver safe care in a complex and pressurised system is evolving. These revised standards (NatSSIPs2) are intended to share the learning and best practice to support multidisciplinary teams and organisations to deliver safer care.
  17. News Article
    A hospital has stopped using gas and air in its maternity unit to "protect our midwifery and medical team". The Princess Alexandra Hospital in Harlow, Essex, said the decision followed tests on nitrous oxide levels. It said it would temporarily suspend the use of Entonox while additional safety equipment was installed. Giuseppe Labriola, director of midwifery, said: "There is no risk to mothers, birthing people, their partners and babies." Other hospitals have previously temporarily suspended the use of gas and air in recent months including Basildon and Ipswich. Read full story Source: BBC News, 22 January 2023
  18. News Article
    A mental health trust has spent millions this year on places in “bed and breakfast” accommodation in order to discharge inpatients, HSJ has learned. South London and Maudsley Foundation Trust, which serves four London boroughs, confirmed to HSJ it had spent £3.1m since April for a range of basic bed and breakfast places, and spaces with a specialist housing association, to ease its bed shortage pressures. The trust told HSJ clinicians were often reluctant to discharge patients to street homelessness, and that people with mental health problems can be more challenging to find accommodation for. The trust’s chief executive officer David Bradley told HSJ system leaders had been asked to think “innovatively” about how to mitigate discharge problems. B&Bs are generally a cheaper and more appropriate alternative to a £500 a night mental health hospital bed for people who don’t need acute treatment and have no housing, he said. Read full story Source: HSJ, 24 January 2023
  19. News Article
    The World Health Organization (WHO) has called for “immediate and concerted action” to protect children from contaminated medicines after a spate of child deaths linked to cough syrups last year. In 2022, more than 300 children - mainly aged under 5 - in the Gambia, Indonesia and Uzbekistan died of acute kidney injury, in deaths that were associated with contaminated medicines, the WHO said in a statement on Monday. The medicines, over-the-counter cough syrups, had high levels of diethylene glycol and ethylene glycol. “These contaminants are toxic chemicals used as industrial solvents and antifreeze agents that can be fatal even taken in small amounts, and should never be found in medicines,” the WHO said. As well as the countries above, the WHO told Reuters on Monday that the Philippines, Timor Leste, Senegal and Cambodia may be affected because they may have the medicines on sale. It called for action across its 194 member states to prevent more deaths. “Since these are not isolated incidents, WHO calls on various key stakeholders engaged in the medical supply chain to take immediate and coordinated action,” WHO said. Read full story Source: The Guardian, 24 January 2023
  20. News Article
    The health trust behind the worst maternity scandal in NHS history has accepted responsibility for a boy's brain injury. Adam Cheshire, 11, contracted a Group B Strep (GBS) infection following his birth at the Royal Shrewsbury Hospital in 2011. A High Court judge approved a pay out from Shrewsbury and Telford Hospitals NHS Trust (SaTH) to provide special care for the rest of his life. His case was examined as part of senior midwife Donna Ockendon's investigation into SaTH which found catastrophic failures might have led to the deaths and life-changing injuries of hundreds of babies, as well as the deaths of nine mothers. Adam, from Newport, Shropshire, was born nearly 35 hours after his mother's waters broke in the afternoon of 24 March 2011. In the hours that followed, he began to show signs of early onset GBS including struggling to feed, crying and grunting. After weeks in intensive care, he was finally diagnosed with the infection and meningitis. Adam is living with multiple conditions including hearing and visual impairments, autism, severe learning difficulties and behavioural problems so he relies on others to care for him. His mum, the Reverend Charlotte Cheshire, said she had expressed concerns about bright green discharge at one of her last antenatal appointments but no action was taken. "From that point I just had a mother's instinct something wasn't right but I was reassured by the midwives so many times that everything was OK," the 45-year-old said. Mrs Cheshire added: "While Adam is adorable and I am so thankful to have him in my life, it's difficult not to think how things could have turned out differently for him if he'd received the care he should have. "Adam will never live an independent life and will need lifelong care. While I'm devoted to him, I'm now raising a severely disabled son, which is extremely challenging and has changed the path of both our lives forever". Read full story Source: BBC News, 23 January 2023
  21. News Article
    A trust that sacked a whistleblower who had warned them about potential patient harm from a new procedure has been told to pay her more than £200,000. Jasna Macanovic won her case against Portsmouth Hospitals University Trust last year after the employment tribunal found board members had broken employment rules, including by telling her she would get a good reference if she agreed to quietly resign. Earlier this month, an employment tribunal judgment to establish the compensation she was owed said the trust had subjected Dr Macanovic to “a campaign of harassment” and rejected Portsmouth’s claim she had contributed to her own dismissal. The consultant nephrologist, who had been at the trust for 17 years, raised concerns about a technique called “buttonholing” – carried out to make kidney dialysis more convenient and less painful – that she claimed had caused harm to patients. After the procedures continued, the dispute escalated, culminating with Dr Macanovic being dismissed in March 2018. The employment tribunal panel said Dr Macanovic had raised her concerns about buttonholing properly, adding: “She was not alone in her concerns. The consultant body were fairly evenly divided. “She, however, went further than others, and where she believed that risks were being downplayed she did not hesitate to describe this as a cover-up or an act of dishonesty. Most people would not use that language, and it did cause very serious offence, but it had a specific meaning. It was not a general slur.” Read full story (paywalled) Source: HSJ, 23 January 2023
  22. News Article
    Older women are at higher risk than older men of experiencing adverse reactions to drugs prescribed by their family doctor, and older patients taking more than 10 medicines are at higher risk than those taking fewer, according to a study. Overall, one in four older people experience adverse drug reactions (ADRs) to pills prescribed by their GP, the research published in the British Journal of General Practice suggests. It has prompted calls for GPs to consider deprescribing ineffective medications and prioritise patients taking lots of drugs for a regular review of their prescriptions. The medicines most commonly associated with ADRs included those used to treat high blood pressure and other cardiac conditions, strong painkillers such as tramadol, and antibiotics such as amoxicillin, according to the study. The study monitored 592 patients aged 70 and older across 15 general practices in the Republic of Ireland over a six-year period. One in four experienced at least one ADR. Patients prescribed 10 or more medicines had a threefold increased risk of experiencing a reaction, researchers said. Women were at least 50% more likely to have ADRs than men, the study found. “ADRs can be difficult to identify in medically complex older adults as they often present as non-specific symptoms,” the researchers wrote in the British Journal of General Practice. “GPs are well placed to detect the occurrence of ADRs from drugs prescribed in primary care as well as in other care settings. Deprescribing of ineffective medications and those no longer clinically indicated is one approach to reducing the risk of ADRs in older patients.” Read full story Source: The Guardian, 24 January 2023
  23. Content Article
    To date, research on adverse drug reactions (ADRs) has focused on secondary care, and there is limited studies that have prospectively examined ADRs affecting older adults in general practice. This study from Doherty et al. examined the cumulative incidence and severity of ADRs and associated patient characteristics in a sample of community-dwelling older adults. They found that over one-quarter of older adults experienced an ADR over a 6-year period. Polypharmacy is independently associated with ADR risk in general practice and older adults on ≥10 drug classes should be prioritised for regular medication review.
  24. News Article
    The waiting list for endoscopies has broken the record set during the height of the covid pandemic, as referrals for suspected colorectal cancer surged, HSJ analysis shows. In November 2022, 110,00 people were waiting for a colonoscopy (or flexible sigmoidoscopy) and the median wait was 4.2 weeks, double the median wait in November 2019. The pandemic peak waiting list for these tests was 107,000 in September 2020. Nearly a quarter of those waiting as of November 2022, the most recent figures, were on the list for more than 13 weeks. In November 2019 only 2.9 per cent of the list waited this long. Health policy manager Matt Sample said: “As with all diagnostic services, endoscopies were hit hard by the pandemic, but the service was under considerable strain even before this as staff numbers and equipment simply weren’t rising to match demand. “The latest data shows that more than two in 10 people who started treatment for bowel cancer in England waited more than 104 days since their urgent referral – this is unacceptable. “Without continued efforts to expand diagnostic capacity, and in particular investment in addressing chronic workforce shortages, people affected by cancer will not receive the care they deserve.” Read full story (paywalled) Source: HSJ, 24 January 2023
  25. News Article
    Ministers have ordered an inquiry into the quality of care in mental health inpatient units in England after a series of scandals in which vulnerable patients were abused or neglected. Maria Caulfield, the mental health minister, announced the establishment of a “rapid review” in a written ministerial statement in the House of Commons on Monday. The inquiry “is an essential first step in improving safety in mental health inpatient settings”, she said. In recent years, coroners and the Care Quality Commission, the NHS care watchdog, have repeatedly raised concerns about dangerously inadequate care that inpatients have received. It will examine the evidence of “patient safety risks and failures in care” in units that hold and treat patients who have serious conditions including psychosis and personality disorder. It will look in particular at evidence of failings brought forward by patients and their families and how better use of data can help show that care has fallen below acceptable levels. The inquiry will be headed by Dr Geraldine Strathdee, a psychiatrist who used to be NHS England’s national clinical director for mental health. She is likely to look at problems including patients being subjected to controversial restraint techniques, left at risk of being able to take their own lives and segregated from fellow inpatients, and the impact of their experiences on their recovery. Read full story Source: The Guardian, 23 January 2023
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