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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The deaths of two nurses from Covid-19 in the early days of the pandemic have been ruled as industrial disease. Gareth Roberts, 65, of Aberdare, and Domingo David, 63, of Penarth, were found to have been most likely to have contracted the virus from colleagues or patients while working for hospitals under the Cardiff and Vale University Health Board. The senior coroner Graeme Hughes concluded on Friday that although they were given appropriate personal protective equipment (PPE), Roberts and David were “exposed to Covid-19 infection at work, became infected and that infection caused” their deaths. He made a finding of industrial disease. Roberts’ family had argued for a conclusion of industrial disease, while the health board had made the case for ruling that both deaths were from natural causes. Unions are campaigning for Covid-19 to be considered an industrial disease by the UK government so workers affected by it would receive greater financial support. Read full story Source: The Guardian, 13 January 2023
  2. News Article
    Hospital staff have to complete 50 separate steps on average to discharge a patient, it has emerged, as the NHS grapples with a bed-blocking crisis. On average, around 14,000 patients deemed fit to leave hospital are stuck in beds every day, according to the latest official figures. The congestion is helping to fuel the backlog in accident and emergency (A&E) departments, where more than 55,000 patients waited 12 hours or longer last month. Steve Barclay, Health Secretary, announced an additional £250 million in funding last week to buy up care beds to help discharge thousands of patients. But doctors, social care experts and families have warned discharges are being delayed by NHS “bureaucracy” and excessive form filling. Dr Matt Kneale, co-chair of the Doctors’ Association UK and a junior doctor in Manchester, said patients are held up by “numerous bottlenecks” before being sent home. “While social care shortages are the predominant issue, smaller factors stack up to create a big problem,” he told The Telegraph. Many hospitals have limits on the times their pharmacies are open, he explained, meaning patients can often be stuck on the ward all day, or an extra night, waiting for their medication. Read full story (paywalled) Source: The Telegraph, 15 January 2023
  3. News Article
    There are 10 patients in the corridor and the nurses are about to go out to assess two more waiting in an ambulance outside. The senior sister, Susan Beswick, who has worked in the hectic and often stressful world of NHS accident and emergency for 30 years, says she has never seen anything like it. "The last six to 12 months have been more challenging than I have ever known," she says. "We have been exceptionally busy for quite a number of weeks now. We're running two to three times above our capacity continually and often more than that." Susan's whole nursing career has been at Royal Bolton Hospital, which, like many in the country, is facing overwhelming demand from a growing as well as ageing population and has out-of-date buildings that are not fit for purpose. A policy of cohorting, adopted by many hospitals, has been agreed between emergency-department staff and paramedics. One member of an ambulance team will be left to look after two or three patients in a corridor, allowing others to get back on the road more quickly. The problem is space. There are simply too many patients coming in to be accommodated, even with all the streaming initiatives. Read full story Source: BBC News, 13 January 2023
  4. Content Article
    This report considers the number of safety incidents in surgery occurring in the NHS since 2015 and calls for action to improve surgical safety. It also highlights the perceptions of patients from a survey of people who have had surgery in the last five years. It is authored by surgical care platform Proximie, with support from experts in the surgical space.
  5. Event
    This one-day virtual course is suitable those engaged or interested in patient safety, quality improvement & service delivery. On this interactive virtual course we will explore how human factors and ergonomics impact everyday working practices & patient safety. This material aligns with key focuses of the National Patient Safety Strategy, PSIRF & several domains of the National Patient Safety Syllabus 2.0. This course is equivalent to 6 hours of education. It will show you how to take a systems approach to respond to patient safety investigations using the SEIPS Model. Participants have the opportunity to practically apply SEIPS to a patient safety incident & explore contributory factors. We introduce methods such as observation & interview and consider how to generate areas for improvement and safety actions. Includes: A one-day healthcare focused course. Facilitated by experienced, doctors, nurses & educators. Small group work. Selected course materials. Membership of the Being Human in Healthcare Network. Register
  6. News Article
    Victims and family members affected by the contaminated blood scandal are calling for criminal charges to be considered as the public inquiry into the tragedy draws to a close. While the inquiry, which will begin to hear closing submissions on Tuesday, cannot determine civil or criminal liability, people affected by the scandal are keen for the mass of documents and evidence accumulated over more than four years to be handed over to prosecutors to see whether charges can be brought. About 3,000 people are believed to have died and thousands more were infected in what has been described as the biggest treatment disaster in the history of the NHS. The inquiry has heard evidence that civil servants, the government and senior doctors knew of the problem long before action was taken to address it and that the scandal was avoidable. But no one has ever faced prosecution. Eileen Burkert, whose father, Edward, died aged 54 in 1992 after – like thousands of others – contracting HIV and hepatitis C through factor VIII blood products used to treat his haemophilia, said the inquiry had shown there was a “massive cover-up”. She said: “In my eyes it’s corporate manslaughter. You can’t go giving people something that you know is dangerous, and they just carried on doing it. As far as my family’s concerned, they killed our dad and they killed thousands of other people and there’s been no recognition for him since he died, there’s been nothing. Read full story Source: The Guardian, 16 January 2023 See UK Infected Blood Inquiry website for further details on the inquiry.
  7. News Article
    The health secretary said "voluntary arrangements" for emergency cover during recent ambulance strikes could not "ensure patient and public safety". In a letter to the GMB, Steve Barclay acknowledged unions that walked out had agreed to answer the most serious category one 999 calls. But he said the lack of cover for category two calls, including strokes, in some areas put lives at risk. The GMB has accused the government of "demonising" its striking workers. In response, Mr Barclay wrote on Sunday that he recognised the right to strike and accepted "that a certain amount of disruption is inherent to any strike". He said he "greatly" valued the "vital work ambulance workers do" but criticised the "volatile" assurances given to him about cover by trade unions during December's industrial action. The government's anti-strike bill is due to be considered by MPs again on Monday. The legislation would set minimum service levels for fire, ambulance and rail services during industrial action and could leave unions at risk of legal action if they fail to comply. Read full story Source: BBC News, 15 January 2023
  8. News Article
    Staff at a maternity unit were exposed to almost 30 times the legal workplace exposure limit for nitrous oxide, documents have shown. Testing at Basildon Hospital revealed the levels more than 16 months before colleagues were informed. The Royal College of Midwives said its members there were considering legal action. Routine testing of the maternity suite in June 2021 revealed nine staff members had been exposed to excess nitrous oxide levels during the course of their shifts. Three had readings of more than 1,000 parts per million (ppm) of the gas, while a fourth recorded almost 3,000. The Workplace Exposure Limit is set at 100ppm. Trust management apologised after failing to notify staff at the unit until October 2022. A briefing seen by the BBC stated the issue was logged on the risk register, but "there has not been proper oversight of the problem and staff have not been informed". One person familiar with the situation, who did not want to be identified, said: "We had an email sent out that said 'emergency maternity staff briefing' and there was a Teams meeting. "The Teams meeting was very, very difficult to listen to. It was very emotive. People were angry understandably, but I feel like the executive who were on the call didn't handle it very well." Read full story Source: BBC News, 16 January 2023
  9. News Article
    Fewer women who gave birth in NHS maternity services last year had a positive experience of care compared to 5 years ago, according to a major new survey. The Care Quality Commission’s (CQC) latest national maternity survey report reveals what almost 21,000 women who gave birth in February 2022 felt about the care they received while pregnant, during labour and delivery, and once at home in the weeks following the arrival of their baby. The findings show that while experiences of maternity care at a national level were positive overall for the majority of women, they have deteriorated in the last 5 years. In particular, there was a notable decline in the number of women able to get help from staff when they needed it. Many of the key findings from the survey include a drop in positive interactions with staff and lack of choices about the birth. Just over two-thirds of those surveyed (69%) reported 'definitely' having confidence and trust in the staff delivering their antenatal care. Results were higher for staff involved in labour and birth (78%). In addition, while the majority of women (86%) surveyed in 2022 said they were 'always' spoken to in a way they could understand during labour and birth, this was a decline from 90% who said this in 2019. The proportion of respondents who felt that they were 'always' treated with kindness and understanding while in hospital after the birth of their baby remained relatively high at 71%, however had fallen from 74% in 2017. Just under a fifth of women who responded to the survey (19%) said they were not offered any choices about where to have their baby. Also, less than half (41%) of those surveyed said their partner or someone else close to them was able to stay with them as much as they wanted during their stay in hospital. Read full story Source: Medscape, 13 January 2023
  10. Content Article
    This survey from the Care Quality Commission (CQC) looked at the experiences of women and other pregnant people who had a live birth in early 2022.
  11. News Article
    The intense pressure on the NHS in recent weeks has left hospitals unable to cope, patients at risk and staff in despair, writes an A&E doctor in this Guardian article. "I’ve worked in the NHS for over 10 years and I’ve never known it as bad as it is now. A&Es are swamped and primary care is swamped too. It’s a very sorry of state for all concerned. The last few weeks have been beyond dreadful and it was all predicted by those on the ground months ago". We’re now in a position in our A&E where we are looking after a ward and a half of admitted patients, who take up the bedded spaces, while simultaneously running an emergency department out of the corridor and waiting room. Having to manage the very sick in inappropriate areas is now becoming the norm. An emergency department (ED) is not a safe place. It’s filled with some of the sickest people in a hospital, in a chaotic environment. There are lots of comings and goings, with patients being moved frequently and staff looking after multiple patients. It’s a recipe for things getting missed. If you add in the fact that ED personnel work a shift rota, so new staff come on duty every few hours and they don’t necessarily know the patients, there is more scope for potentially vital information being lost. "As ED doctors, we have always tried to give the dying a place of privacy, where loved ones can be with them in some relative peace. I would hope that same degree of compassion was present in all A&Es, but it’s becoming more challenging to provide." Read full story Source: The Guardian, 12 January 2023
  12. News Article
    Patients with emergencies such as heart attacks and strokes in England had to wait more than 90 minutes on average for an ambulance at the end of 2022. It came after a sharp deterioration in 999 response times in December - they were nearly twice as bad as November. Record worst waits were also recorded for life-threatening cardiac arrests, while A&E waits of over four-hours reached their highest level ever. Patient groups warned the delays would be leading to real harm. Combined, the data - released by NHS England - represents the worst-ever set of emergency care figures since modern records began in 2004. The figures show: Average waits of more than 90 minutes to reach emergency calls such as heart attacks - five times longer than the target time - with waits of over 150 minutes in some regions. Response times for the highest priority calls, such as cardiac arrests, taking close to 11 minutes - 4 minutes longer than they should. More than a third of patients in A&E waiting longer than 4 hours. One in seven patients waiting more than 12 hours for a bed on a ward when they need to be admitted. But there has been some progress with the waiting list for routine treatment falling slightly, to 7.19 million by the end of November. Read full story Source: BBC News, 12 January 2023
  13. Content Article
    In this article, HSJ's Annabelle Collins reflects on the increasing number of NHS staff quitting their jobs and the risk to patient safety of 'corridor care'.
  14. News Article
    Health secretary Steve Barclay has privately conceded that he will have to offer a higher pay rise to NHS staff. Mr Barclay has admitted that more than one million NHS staff members deserve more money despite previously insisting that existing pay increases were all the government could afford. But, he also made clear that any new pay rises would come from the current health budget meaning potential cuts to key services, according to The Guardian. His U-turn comes in advance of nurses in England staging two more strikes next week, which is likely to force hospitals to again work at a reduced capacity following previous industrial action. Read full story Source: The Independent, 13 January 2023
  15. News Article
    ADHD awareness hassoared among women in the UK in the past year, but waiting times and the dearth of clinical awareness are leaving people awaiting diagnosis in a perilous position, leading experts have warned. Dr Max Davie, a consultant paediatrician and co-founder of ADHD UK, said that people talking openly about their diagnoses – including a number of high-profile celebreties – had led to more people seeking referrals for the condition. However, while awareness is increasing many trusts and private providers have shut waiting lists because of demand. “I think it’s probably as big a year as we’ve ever had. We are seeing a lot more people from all walks of life seeking a diagnosis later in life, particularly women,” Dr Davie said. “At the same time waiting lists have gone through the roof. NHS services have been swamped for a while and private providers are also closing their lists – there are wildly inadequate services for ADHD diagnosis, particularly for adults.” Dr Tony Lloyd, the chief executive of the ADHD foundation, said its own figures suggested a 400% increase in the number of adults seeking a diagnosis since 2020, adding that prescription volumes did not take account of those who do not use medication. “ADHD remains significantly under-diagnosed and under-treated in the UK – at great cost to public services and to the individual and the workforce,” he said. "Stigma around the condition, which the charity says affects one in 20 people in the UK, resulted in negative outcomes for individuals and high costs to the economy. Dismissing ADHD as a cultural construct and undeserving drain on finite NHS resources only adds to the enduring stigma and stereotyping of those with ADHD,” Read full story Source: The Guardian, 13 January 2023
  16. News Article
    Death rates from cancer in the US have fallen by 32% over the three decades from 1991 to 2019, according to the American Cancer Society. The decline is thanks to prevention, screening, early diagnosis and treatment of common cancers, including lung and breast cancer. The drop has meant 3.5m fewer deaths. However, cancers are still the second leading cause of death in the US, after heart disease. In 1991, the cancer death rate was 215 per 100,000 people and in 2019 it dropped to 146 per 100,000 people. Lung cancer, of which there are 230,000more cases each year, kills the most patients, 350 per day. But people are being diagnosed sooner, and technological advancements have increased the survival rate by three years. The report also examined racial and economic disparities in cancer outcomes. The Covid-19 pandemic added to already existing difficulties for marginalised groups to get cancer screenings and treatment. For nearly every type of cancer, white people have a higher survival rate than black people. Black women with breast cancer face a 41% higher death rate than white women. Read full story Source: BBC News, 12 January 2023
  17. News Article
    The chair of an inquiry into hundreds of deaths at a mental health trust has revealed she may not be able to deliver it in its current form following a ‘hugely disappointing’ lack of staff coming forward to give evidence. Former national clinical director for mental health, Geraldine Strathdee, chair of the non-statutory inquiry into deaths at Essex Partnership University Trust, has penned an open letter warning just 11 of 14,000 staff contacted said they will attend evidence sessions. It was meant to report in spring 2023. However, after raising concerns with ministers, Dr Strathdee said she believes the inquiry will not be able to meet its terms of reference with a non-statutory status. The inquiry was announced in 2021 and last year chiefs revealed they were probing 1,500 deaths of people in contact with Essex mental health services between 1 January 2000 and 31 December 2020. However, without statutory powers, staff are not compelled to give evidence under oath. Many bereaved families, of which just one in four has engaged with the current probe, are campaigning for a statutory inquiry into deaths. Read full story (paywalled) Source: HSJ, 13 January 2023
  18. News Article
    Eight trusts have been awarded roles trialling a new accreditation scheme for surgical hubs as part of an NHS England pilot that will run until March. The creation of up to 140 surgical hubs, sites which are ring-fenced for surgical work only, is a key plank of the NHS England and government elective recovery plan for addressing the backlog. The full benefits are still being finalised but accredited trusts will likely get better access to additional recovery funding and central support from the Getting It Right First Time team. The hubs will focus mainly on providing high volume, low complexity surgery, as previously recommended by the Royal College of Surgeons of England, with particular emphasis on ophthalmology, general surgery, trauma and orthopaedics (including spinal surgery), gynaecology, ear nose and throat, and urology. Read full story (paywalled) Source: HSJ, 12 January 2023
  19. Content Article
    Dr Henrietta Hughes, England's Patient Safety Commissioner, discusses how the experiences of people from Black and minority ethnic groups has worsened since the pandemic and how this has impacted on patient safety, in a blog for the NHS Race & Health Observatory.
  20. Event
    until
    This virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
  21. Event
    until
    This virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
  22. Event
    until
    This virtual workshop from the Institute for Safe Medication Practices Canada will provide healthcare professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
  23. News Article
    About 15 million more people in England could be prescribed daily cholesterol-lowering statin pills to cut their risk of heart attacks and stroke, new advice for the NHS says. Given the very cheap price of the tablets and the possible health gains, they should be considered more often, the draft guidance says. There can be side effects though and there is debate about how widely this long-term treatment should be given and what associated risks are acceptable. The National Institute for Health and Care Excellence (NICE), which advises the NHS, says people should be thoroughly assessed before statins are prescribed, warning the pills are not a quick fix or substitute for a healthy diet and exercise. The previous advice was for anyone with a one in 10 chance of having a cardiovascular event, such as a heart attack or stroke, within the next 10 years - based on factors such as age, blood pressure and cholesterol levels - to be offered a statin. But NICE now says including adults with a one in 20 chance could save 2% of them from having a heart attack or stroke during that period. Spokesman Paul Chrisp said patients should discuss the benefits and risks with their doctor, adding: "The evidence is clear, in our view, that for people with a risk of 10% or less over 10 years, statins are an appropriate choice." Read full story Source: BBC News, 12 January 2023
  24. News Article
    John Watkinson was one of the country's top ear, nose and throat surgeons. But Mr Watkinson's life and career were turned upside down when he was accused of shortening the lives of three patients, suspended and investigated. General Medical Council investigators would eventually close his case, taking no further action, and Mr Watkinson would receive an apology for what he had experienced from his employer University Hospitals Birmingham (UHB) NHS Trust. But that was six years after he was first suspended - six years that would see him pushed to the brink. "As doctors, we're trained in communication skills, we have appraisals, mandatory training," he says. "But the one thing we're not trained to cope with is when somebody declares war on you." The hospital trust stands by its decision to suspend Mr Watkinson and says its referral to the General Medical Council was "appropriately made following a clinical colleague raising significant concerns" about patient care. UHB has been in the spotlight in recent weeks, with reviews launched into its culture, leadership, and allegations of poor patient care aired in a Newsnight investigation late last year. It says a review into patient care is now well under way. Mr Watkinson says he was at the sharp end of this culture when he was suspended and suddenly went "from hero to zero". He accepts mistakes were made, but not just by him and not ones that would have affected the patients' outcomes. Read full story Source: BBC News, 13 January 2023
  25. News Article
    Other countries are looking on appalled as the UK’s failure to reform social care has left its health service struggling to survive. There are blockages on the way in to the hospital, blockages inside them, and perhaps most frustrating for healthcare staff and patients, blockages getting those who have been treated and have recovered out of the front door and home, or into the community. It is this last problem that is proving hardest to crack. Despite promises from successive UK prime ministers to mend the broken social care system, it remains completely dysfunctional. This country is by no means unique in its health and social care struggles. Even in nations often held up as having model healthcare systems – such as France and Germany – the combined pressures caused by ageing populations, financial constraints, recruitment problems, Covid-19 and flu have taken their toll. On the issue of social care, French doctors and experts admit to shortcomings, though not on the scale of those in the UK. “It’s not that we don’t have problems, but things are organised differently,” said Blanche Le Bihan, a professor at the French School of Public Health and researcher at the Arènes scientific research centre in Rennes specialising in social care. “The system is far too fragmented, that’s the main issue with social care in France – communication, coordination are always complicated,” Le Bihan says. “But while it’s far from perfect, it’s not a major factor in hospitals’ current problems.” Read full story Source: The Guardian, 8 January 2023
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