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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Patients are not safe from harm in three out of seven emergency departments, a damning new Hiqa inspection report has revealed. The report was released on the same day as an Oireachtas committee was warned of a growing crisis in primary care, with patients in some parts of the country unable to access basic GP services. Emergency Departments in Cork University Hospital (CUH) and University Hospital Limerick (UHL) were among seven EDs assessed by the health watchdog. In three EDs, including Cork and Limerick, inspectors found failures to ensure “service providers protect service users from the risk of harm.” Inspectors also found patients’ “dignity, privacy and autonomy” was not respected in UHL, while CUH was only partially compliant in this area. The report also highlighted lengthy waiting times, including one patient who spent 116 hours on a trolley at UHL. Read full story Source: The Irish Examiner, 15 December 2022
  2. Content Article
    This report provides an overview of the findings of Ireland's Health Information and Quality Authority (HIQA)’s monitoring programme against the national standards in emergency departments in 2022.  Throughout 2022, HIQA commenced a new monitoring programme of inspections in healthcare services against the National Standards for Safer Better Healthcare. As part of the initial phase, HIQA’s core assessment in emergency departments focused on key standards relating to governance, leadership and management, workforce, person-centred care and safe and effective care. The report highlights, HIQA has identified key areas for both immediate and longer-term attention to address safety issues in our emergency departments. 
  3. News Article
    As many as 250,000 people die every year because they are misdiagnosed in the emergency room, with doctors failing to identify serious medical conditions like stroke, sepsis and pneumonia, according to a new analysis from the US federal government. The study by the Agency for Healthcare Research and Quality estimates roughly 7.4 million people are inaccurately diagnosed of the 130 million annual visits to hospital emergency departments in the United States. Some 370,000 patients may suffer serious harm as a result. Researchers from Johns Hopkins University analysed data from two decades’ worth of studies to quantify the rate of diagnostic errors in the emergency room and identify serious conditions where doctors are most likely to make a mistake. While these errors remain relatively rare, they are most likely to occur when someone presents with symptoms that are not typical. “This is the elephant in the room no one is paying attention to,” said Dr. David E. Newman-Toker, a neurologist at Johns Hopkins University and director of its Armstrong Institute Center for Diagnostic Excellence, and one of the study’s authors. The findings underscore the need to look harder at where errors are being made and the medical training, technology and support that could help doctors avoid them, Dr. Newman-Toker said. “It’s not about laying the blame on the feet of emergency room physicians,” he said. Read full story Source: New York Times, 15 December 2022
  4. Content Article
    Diagnostic errors are a known patient safety concern across all clinical settings, including the emergency department (ED). The authors from the John Hopkins University conducted a systematic review to determine the most frequent diseases and clinical presentations associated with diagnostic errors (and resulting harms) in the ED, measured error and harm frequency, as well as assessing causal factors.
  5. Content Article
    For decades, western Europe’s national healthcare systems have been widely touted as among the best in the world. But an ageing population, more long-term illnesses, a continuing recruitment and retainment crisis plus post-Covid exhaustion have combined, this winter, to create a perfect healthcare storm that is likely to get worse before it gets better, writes Jon Henley (Berlin), Kate Connolly (Berlin), Sam Jones (Madrid) and Angela Giuffrida (Rome) in this Guardian article.
  6. Content Article
    The aim of this study was to investigate the potential role of transvaginal mesh bacterial colonisation in the development of mesh-related complication (MRCs).  An observational and exploratory study from Diedrich et al. was performed including 49 patients indicated for mesh removal and 20 women of whom vaginal tissue was retrieved during prolapse surgery as a reference cohort. The authors observed distinct differences in bacterial numbers and species between patients suffering from MRCs compared to a reference cohort. Bacteria were observed at the mesh-tissue interface in a biofilm. These results strongly support the potential role of bacterial mesh colonization in the development of MRCs.
  7. Content Article
    Operating rooms are major contributors to a hospital’s carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study from Sullivan et al., published in the Journal of the American College of Surgeons, was to identify quality improvement initiatives that aimed to reduce environmental impact of the operating room while decreasing costs.
  8. Content Article
    NHS England has recorded two podcasts sharing insight and advice from organisations that have completed the transition from the National Reporting and Learning System (NRLS) to the new Learn from Patient Safety Events (LFPSE).
  9. Content Article
    Incident reporting is a crucial tool for improving patient safety, alongside an open culture that supports this. In the NHS the new Learn from Patient Safety Events (LFPSE) service is now being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS). This article details correspondence between Patient Safety Learning and NHS England in relation to concerns raised by staff about the development and implementation of the LFPSE service
  10. News Article
    One in eight adults in the UK have paid for private medical care in the last year because of long delays in getting NHS treatment, renewing fears that the NHS is becoming “a two-tier system”. “Around one in eight (13%) adults reported they had paid for private medical care, with 5% using private insurance and 7% paying for the treatment themselves,” according to a new report by the Office for National Statistics (ONS). Patients also say that waiting for tests or treatment is badly affecting them, including making their illness worse. The ONS survey of 2,510 adults across the UK found that one in five were waiting for an appointment, test or treatment at an NHS hospital. Of those in that situation: Three-quarters said their delay had had either a strongly (34%) or slightly (42%) negative impact on their life 36% said waiting had made their condition worse 59% said it had damaged their wellbeing A third said long waits had affected either their mobility (33%) or ability to exercise (34%) Read full story Source: The Guardian, 16 December 2022
  11. News Article
    Flu hospitalisations in England have jumped by more than 40 per cent in a week as the NHS braces for one of the worst outbreaks of the virus in recent years. Analysis of NHS data by The Telegraph shows that rates are more than eight times higher than expected at this time of year. On the current trajectory, admissions next week could pass the peak of the 2017-18 outbreak – one of the worst of the last 20 years – which led to nearly 30,000 deaths. Flu hospitalisations are so high that they have overtaken Covid admissions for the first time since the start of the pandemic. The rise could not come at a worse time for the NHS. It is already suffering the biggest treatment backlog in its history, which is set to be exacerbated by strikes by nurses and ambulance paramedics. Read full story Source: The Telegraph, 15 December 2022
  12. News Article
    Three more children have died from strep A, it has emerged, and pharmacists in the UK have been told they can supply alternative antibiotics to those originally prescribed, in a bid to ease shortages of certain forms of penicillin. The UK Health Security Agency (UKHSA) data shows at least 19 children have now died across the UK, while there are 7,750 cases of scarlet fever so far this season. This is more than treble the 2,538 at the same point in the year during the last comparably high season in 2017 to 2018. The Department of Health and Social Care (DHSC) has issued serious shortage protocols (SSPs) for three penicillin medicines amid increased demand for the antibiotics. Pharmacists and GPs in the UK have faced serious difficulties in securing supplies of penicillin and amoxycillin, antibiotics used to treat infections including strep A. As a result, parents have reported having to visit a string of pharmacies to obtain medicines prescribed for their sick children, while the price of some antibiotics has risen sharply – a situation pharmacists say has left them facing losses. The health minister Will Quince said: “The increased demand for the antibiotics prescribed to treat strep A has meant some pharmacists have been unable to supply the medicine shown on the prescription. “These serious shortage protocols will allow pharmacists to supply an alternative form of penicillin, which will make things easier for them, patients, and GPs. “We are taking decisive action to address these temporary issues and improve access to these medicines by continuing to work with manufacturers and wholesalers to speed up deliveries, bring forward stock they have to help ensure it gets to where it’s needed, and boost supply to meet demand as quickly as possible.” Read full story Source: The Guardian, 15 December 2022
  13. News Article
    There is a "moral case" for compensation to be paid to people affected by the contaminated blood scandal, the government has said. But Paymaster General Jeremy Quin told MPs he could not commit to a timetable. In August, the government announced that 4,000 UK victims would receive interim payments of £100,000. Tens of thousands of people contracted HIV or hepatitis C in the 1970s and 80s after being given infected blood. In September, modelling by a group of academics commissioned by the public inquiry estimated that 26,800 people were infected after being given contaminated transfusions between 1970 and 1991. The study calculated that 1,820 of those died as a result, but that the number could be as high as 3,320. The inquiry, chaired by retired High Court judge Sir Brian Langstaff, began taking evidence in 2018. The interim compensation announcement in August came after Sir Brian argued there was a compelling case to make payments quickly - saying victims were on borrowed time because of their failing health. Payments have been made to those whose health is failing after developing hepatitis C and HIV, and partners of people who have died. But families have complained that many people affected, such as bereaved parents, missed out. Read full story Source: BBC News, 15 December 2022
  14. News Article
    Elderly people who fall may only be sent an ambulance after they have spent four hours on the floor, and some category 2 calls may not be responded to under one of the first agreements with ambulance unions about next week’s strikes. But the deal between South East Coast Ambulance Service and the GMB union will see many union staff continue to work on ambulances and in control rooms – and others may be asked to come off the picket line if operational pressures escalate. HSJ has seen the details of the deal – thought to be one of the first agreed before next Wednesday’s strike. Some other trusts are hoping to conclude negotiations shortly, but for several — such as in the North West and London — it is thought no strike “derogations” (exceptions) have so far been agreed, and managers are concerned that unions are resistant. Trusts have been pushing for more cover on strike days – especially around category 2 calls. Read full story (paywalled) Source: HSJ, 15 December 2022
  15. Content Article
    Recording of the Health and Social Care Committee meeting held on Tuesday 13 December 2022. Meeting started at 10.03am, ended 11.45am.
  16. News Article
    The ambulance staff strike next week represents a far higher risk to patient safety and services than the nurses’ strike, but a blanket elective ban will only be used as “an absolute last resort”, a senior NHS England director said today. However, NHSE elective recovery chief Sir Jim Mackey’s comments come despite several local leaders telling HSJ significant amounts of elective activity are likely to need to be postponed due to the ambulance staff walkout on 21 and 28 December, to free up capacity to deal with emergency care pressure. Speaking at a King’s Fund conference this morning, Sir Jim said: “The ambulance strike is a completely different order of magnitude of risk [than the nurses’ strike]. I think that’s the main thing people are worried about because of the complexity and fragility of urgent care.” However, he added: “If we were to give [national guidance on what elective activity to cancel] today, the only guidance we could give would be to cancel absolutely everything, and that’s really not going to help anybody… “I think we’ll just have to take it day-by-day and keep learning from each other and sharing intelligence… and then, if at some point, there is a case for blanket order, we’ll consider that… But, we really want to do that as an absolute last resort.” Read full story (paywalled) Source: HSJ, 15 December 2022
  17. News Article
    In Kisii town, south-west Kenya, a rundown roadside building houses a pharmacy. Like many others in the area, the pharmacy doubles as a clinic. Lilian Kemunto (not her real name), a former surgical nurse, set it up after she retired in 2018. She mainly does health check-ups but has also offered female genital mutilation (FGM) services on request. Kemunto has performed cuts since the 90s, after receiving training in basic surgical techniques from male colleagues in the local hospital where she worked. She would do the cuts in the hospital at night, but it was risky, she says, because management didn’t approve. “They would tell us: ‘Just do it, but if you’re caught, you’re on your own.’” She preferred cutting girls in a private home, in the middle of the night, saying it was much easier: “By 6am, the girls are back in their own homes, like nothing happened.” In Kisii county, medicalisation is standard. Two out of three cases of cutting are performed by health practitioners, in contrast to much of the country, where 70% of FGM cases are performed by traditional practitioners. Kemunto says she tries to avoid mishaps, and at a minimum requires some anaesthesia, a surgical blade, sterile towels, and cleaning solution to proceed. She also claims to use a non-invasive procedure: a small incision of the clitoris that practitioners call a “signature”. Kisii’s FGM practice is considered less severe than other areas, and anti-FGM campaigners are concerned that there’s a growing acceptance of the practice as more safe, hygienic and cosmetic. FGM rates in Kenya have gone down significantly over the past decade. The country passed strong laws in 2011, imposed hefty fines on practitioners, and stepped up surveillance and enforcement. But medicalisation is posing a new challenge for the east African nation, which has a 15% medicalisation rate: one of the highest in Africa. Earlier this month, Kenyan president William Ruto backed the country’s chief justice who said that FGM “should not be a conversation we are having in Kenya in the 21st century”, and reiterated his administration’s commitment to eradicating the practice. Read full story Source: The Guardian, 15 December 2022
  18. Content Article
    The World Health Organization (WHO) has been tracking the progression of the COVID-19 pandemic since the beginning of 2020. This report is a comprehensive and consistent measurement of the impact of the COVID-19 pandemic by estimating excess deaths, by month, for 2020 and 2021. It estimates 14.83 million excess deaths globally, 2.74 times more deaths than the 5.42 million reported as due to COVID-19 for the period. There are wide variations in the excess death estimates across the six World Health Organization regions.
  19. News Article
    A coroner says an investigation into the death of a newborn baby at a hospital was compromised by the way the placenta was dealt with. Quinn Lias Parker was born at Nottingham's City Hospital in July 2021 but died two days later from multiple organ failure. It later emerged the placenta was dissected by pathology staff when it should have been preserved. Hospital bosses said procedures had since been revised. An inquest into Quinn's death, held in April, returned a narrative verdict. After Quinn's birth, Ms Studencki's placenta was sent from the hospital's maternity unit to pathology, where it was dissected - meaning it was cut up for examination. But Dr Elizabeth Didcock, assistant coroner for Nottinghamshire, said the dissection meant the post-mortem examination was compromised. In a prevention of future deaths report, she detailed how Quinn was born in a "poor condition" and there was a "high probability that he would not survive" and therefore "thought needed to be given to the preservation of the placenta" to ensure it could be used in an examination. "It is not clear to me exactly how the placenta was cut into after Quinn's death without discussion with the coroner," she said. "What is clear is that the outcome has been highly detrimental to the independent investigation by the coroner and other agencies investigating the circumstances of this case. "This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost."
  20. Content Article
    On the 19 July 2021, an investigation commenced into the death of Quinn Lias Parker, born on the 14 July 2021, who died on 16 July 2021. The investigation continues and the case will come to Inquest in 2022. Quinn was born in a very poor condition, and it was sadly clear within 1- 2 hours of his birth, that he remained extremely unwell, and there was a high probability that he would not survive. There were concerns raised by his parents at this early point, regarding the care provided by The Trust, in relation to the management of Emmie, his mother, in late pregnancy, and regarding the timing of Quinn’s delivery. In the event of Quinn’s death, it would therefore require referral to the coroner, and thought needed to be given to the preservation of the placenta, to ensure that it was available for examination as part of the Paediatric post mortem. In this case, the placenta was cut into/dissected after Quinn’s death without discussion with the Coroner. This has affected the ability of the Paediatric Pathologist instructed by the Coroner, to determine the likely cause of Emmie’s antepartum haemorrhage. Whilst the medical cause of Quinn’s death will be explored in full at the Inquest, it is likely that the antepartum haemorrhage, and the underlying pathology causing it, is directly related to Quinn’s death. It is not clear how the placenta was cut into after Quinn’s death without discussion with the Coroner - this will be fully explored at the Inquest, but what is clear is that the outcome is highly detrimental to the independent investigation by the Coroner and other agencies investigating the circumstances of this case. This death follows a number of similar early neonatal deaths in Nottingham, where the placenta has not been retained, and therefore key information regarding placental pathology has been lost
  21. News Article
    Pharmacists say supplies of key antibiotics to treat strep A have "gone from bad to worse" in the past week. The Association of Independent Multiple Pharmacies (AIMP) said the situation was "unacceptable" and it was time for the government to get a plan in place. Four antibiotics, which treat different conditions, have been added to a list of products that the UK cannot export. The UK government says it is working urgently with manufacturers and wholesalers to speed up deliveries. However, Leyla Hannbeck, chief executive of the AIMP, which represents 4,000 pharmacies in the UK, said the supply of antibiotics to treat bacterial infections including strep A and scarlet fever was "very poor". She said the problem had been highlighted a week ago, but it was now getting worse, making it very difficult to get hold of any antibiotics. "People are having to go from one pharmacy to another - it's chaos," she said. "Supplies are not coming through to us and it feels like no-one cares." Read full story Source: BBC News, 14 December 2022
  22. News Article
    Nurses in England, Wales and Northern Ireland have started a nationwide strike in the largest action of its kind in NHS history. Staff will continue to provide "life-preserving" and some urgent care but routine surgery and other planned treatment is likely to be disrupted. The Royal College of Nursing said staff had been given no choice after ministers refused to reopen pay talks. RCN general secretary Pat Cullen has called on the government to "do the decent thing" and resolve the dispute before the year ends. Ms Cullen told BBC Breakfast the strike marked "a tragic day in nursing". "We need to stand up for our health service, we need to find a way of addressing those over seven million people that are sitting on waiting lists, and how are we going to do that? By making sure we have got the nurses to look after our patients, not with 50,000 vacant posts, and with it increasing day by day," she said. Health Minister Maria Caulfield, a former nurse, accepted "it is difficult" living on a nurse's wage, but said that a 19% pay rise "is an unrealistic ask". Under trade union laws, the RCN has to ensure life-preserving care continues during the 12-hour strike. Chemotherapy and kidney dialysis should run as normal, along with intensive and critical care, children's accident and emergency and hospital neonatal units, which look after newborn babies. Read full story Source: BBC News, 15 December 2022
  23. News Article
    Orthopaedic patients in NHS Highland face a wait of up to seven years for surgery, new research has found. A University of Aberdeen study said the worst case estimate would apply if surgical rates did not increase for those listed in July this year. Researchers also discovered the average wait across Scotland's 14 health boards could be as long as two years and three months. The Scottish government said it was working to maximise NHS capacity. Luke Farrow, clinical research fellow, warned that the significance of the delays could not be underestimated. He said: "Prolonged waits for certain orthopaedic procedures can have a major negative impact on patient health. "This occurs both in terms of deterioration in quality of life whilst awaiting surgery, as well as potential negative connotations for post-operative recovery and longer-term health in addition to reduced independence and increased social care needs." Read full story Source: BBC News, 14 December 2022
  24. News Article
    Rare genetic disorders will be diagnosed and treated in babies thanks to a project to sequence the complete DNA of 100,000 newborns. It should spare hundreds of families in England months, or years, of anguish waiting to find out why their children are ill. The project is the first time that whole genome sequencing (WGS) has been offered to healthy babies in the NHS. It will screen for around 200 disorders, all of them treatable. The Newborn Genomes Programme, to begin next year, is thought to be the biggest study of its kind in the world. If successful, it could be rolled out across the country. Owen, 9, has an extremely rare genetic condition which affects his growth and development. Called THRA-related congenital hypothyroidism, it is one of the disorders which will be included in the new genetic test. Father, Rob Everitt, told the BBC: "I think of all the hours we spent in hospital waiting rooms, getting referred around different departments, all the tests - some of which were quite invasive - that drew a blank every time. I lost count of how many doctors and consultants we went to see and how many tests they did on him." Mother, Sarah Everitt, says getting the diagnosis was life-changing: "It was like winning the lottery….because we knew there was a treatment pathway; we knew we could get him support and he could attend a mainstream school." Read full story Source: BBC News, 13 December 2022
  25. News Article
    NHS leaders fear patients will come to harm as cancer services are “hit hard” by upcoming nurses’ strikes. The NHS’s four chief nurses wrote to the Royal College of Nursing (RCN) general secretary Pat Cullen warning patients’ lives are at risk due to life-saving services not being protected when nurses walk out on Thursday. And a separate letter from Dame Cally Palmer, the national cancer director for NHS England, urged Ms Cullen to protect urgent cancer operations from strike action “to ensure a consistent and compassionate approach for patients across the country”. The RCN has since agreed that staff will cover emergency cancer and mental health crisis services on strike days but has maintained only night-level staffing for inpatient services. But trust executives told The Independent that they were concerned they won’t be able to fill any gaps with agency staff due to RCN rules, which will worsen existing shortages. One senior NHS source claimed cancer services weren’t being prioritised by unions despite national agreements to protect chemotherapy treatments. They said: “I fear that someone is going to get hurt as the system is so pressured and fragile right now, whether strike-related or not, public sympathy will shift considerably if this were to happen.” Read full story Source: The Independent, 14 December 2022
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