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Patient Safety Learning

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  1. Content Article
    Celia Marsh died on 27 December 2017 at Royal United Hospital, Bath. She had a known allergy to milk. On that day whilst in Bath City Centre she ate a super veg rainbow flatbread which she believed was safe to eat; she suffered an anaphylaxis reaction caused by milk protein which was in an ingredient within the wrap; this caused her to collapse and despite the efforts of the medical teams The medical cause of death was 1a) Anaphylaxis triggered by the consumption of milk protein.
  2. News Article
    The families of two Pret a Manger customers who died after experiencing severe allergic reactions have welcomed a report from a senior coroner suggesting hospitals should be obliged to report fatal and near-fatal anaphylaxis. Maria Voisin, the senior coroner for Avon, said a robust system of capturing and recording serious cases of anaphylaxis could provide an early warning of the risk posed to allergic individual byproducts with an undeclared allergen content. She said the system could involve mandatory reporting by hospitals to local health protection officials of anaphylaxis similar to the current system for notifiable diseases. Voisin sent her recommendations in a prevention of future deaths report to bodies including the UK health department and the Food Standards Agency (FSA) after the case of Celia Marsh, a Wiltshire dental nurse with a severe dairy allergy who died after eating a “vegan” Pret a Manger wrap contaminated with milk protein. Marsh’s family said: “We welcome the prevention of future deaths report as the next step in our fight to make the world a safe place for allergy sufferers like our beloved mum and wife. “Above all, we hope that the FSA, UK Health Security Agency and the Department of Health and Social Care will now start working together to put in place a system for mandatory reporting of fatal and near-fatal anaphylactic reactions to allow the public to be alerted of unsafe allergen products and provide an accurate record of such incidents. This will ensure important lessons can be learned with the appropriate enforcement action being taken.” Tanya Ednan-Laperouse, whose 15-year-old daughter, Natasha, died in 2016 after eating a Pret baguette containing sesame seeds, said: “The coroner’s clear and concise recommendations should herald a transformation of the way anaphylaxis cases are dealt with in this country and mean that Celia’s death was not in vain. Read full story Source: The Guardian 5 December 2022 Other hub posts you may be interested in: Why allergies are the Cinderella service of the NHS – a blog by Tim McLachlan AllergyWise: Free course for parents and carers of children with severe allergies
  3. Content Article
    Paul Batalden is the host of "The Power of Coproduction". Prepared as a pediatric physician, he has been an international architect, teacher, and advocate for the improvement of healthcare services for five decades. His current focus is the coproduction of healthcare services.
  4. Content Article
    The Between the Flags (BTF) system is a 'deteriorating patient safety net system' for patients who are cared for in New South Wales (NSW) public health facilities in Australia. It is designed to assist clinicians to recognise when patients are deteriorating and to respond appropriately when they do.
  5. Content Article
    Sarah Kay and Jaydee Swarbrick are involved in the Patient Safety in Primary Care Project in Dorset. In this blog, they summarise a recent event they held to share learning from medicines incidents.
  6. News Article
    Five million people were unable to book a GP appointment in October, analysis of NHS data suggests. The Labour party, which studied figures from the GP Patient Survey, warned the struggle to see a doctor will mean many patients will not have serious medical conditions diagnosed until it is “too late”. According to the survey, some 13.8% of patients, or around one in seven, did not get an appointment the last time they tried to book one. With almost 32 million GP appointments reported in England in October, the party said it means that more than 5 million people could have been unable to book a GP appointment when they tried to make one that month. October saw GP surgeries carry out the highest number of appointments since records began in 2017, despite a depleted work force. Labour’s shadow health secretary Wes Streeting told Labour List: “Patients are finding it impossible to get a GP appointment when they need one. I’m really worried that among those millions of patients unable to get an appointment, there could be serious conditions going undiagnosed until it’s too late". Professor Kamila Hawthorne, chair of the Royal College of General Practitioners, said in a statement: “GPs and their teams are working flat out to deliver the care and services our patients need. GPs want our patients to receive timely and appropriate care, and we share their frustrations when this isn’t happening. But difficulties accessing our services isn’t the fault of GP teams, it’s a consequence of an under-resourced, underfunded, and understaffed service working under unsustainable pressures.” Read full story Source: The Independent, 6 December 2022
  7. News Article
    The parents of a 25-year-old man left to die in a cell by a negligent prison nurse given responsibility for 800 inmates have told how the conditions in which their son died will haunt them for ever. The case – the 27th death in just five years at HMP Nottingham – was said to illustrate the desperate state of Britain’s understaffed and increasingly dangerous prison system. Alex Braund was being held on remand awaiting trial when he fell ill in his cell with the first signs of pneumonia on 6 March 2020. Four days later, on the morning of 10 March, after a series of ill-fated attempts by Braund’s cellmate to get prison staff to take the situation seriously, the young man collapsed. Prison staff responded to an emergency bell rung by Braund’s cellmate at 6.55am, but they initially only looked through the cell hatch, taking five minutes to enter the cell in order to give CPR. Braund was subsequently taken to Queen’s medical centre in Nottingham, where he was pronounced dead at 11.44am of cardiac arrest caused by pneumonia. The jury at an inquest at Nottinghamshire coroner’s court found there had been a “continuous failure to provide adequate healthcare”, with a prison officer told by a nurse a few hours before Braund’s death that there was “nothing to be done at this time of night”. Questioning during the hearing revealed that the nurse, who has since lost her job and been reported to the nursing and midwifery council, had amended her records on the morning of Braund’s death. Read full story Source: The Guardian, 6 December 2022
  8. News Article
    Vulnerable parents may be forced to resort to unsafe practices to feed their babies because of sharp increase in the cost of infant formula, charities have warned. The price of the cheapest brand of baby formula has leapt by 22%, according to analysis by the British Pregnancy Advisory Service (BPAS). BPAS said the cost of infant formula needed to safely feed a baby in the first six months of their life was no longer covered by Healthy Start vouchers, which are worth £8.50 a week and provided to women in England, Wales and Northern Ireland who are pregnant or have young children. The charity Feed said families that were unable to afford enough infant formula had resorted to watering down the product or feeding their babies unsuitable food such as porridge. BPAS’s chief executive, Clare Murphy, said: “We know that families experiencing food poverty resort to unsafe feeding methods, such as stretching out time between feeds and watering down formula. The government cannot stand by as babies are placed at risk of malnutrition and serious illness due to the cost of living crisis and the soaring price of infant formula. “The government must increase the value of Healthy Start vouchers to protect the health of the youngest and most vulnerable members of our society.” Read full story Source: The Guardian, 6 December 2022
  9. News Article
    More than 10,000 patients have been given a faulty knee replacement which doubles the risk of joint failure, The Telegraph has disclosed. The implant, which has been in use since 2003, was withdrawn from the market by its manufacturer in October. The Telegraph has learnt that UK health regulator the Medicines and Healthcare products Regulatory Agency (MHRA) is now preparing to issue a field safety notice, prohibiting its use. Available across multiple NHS trusts, the implant, manufactured by Zimmer Biomet, a US firm, has been shown to fail in up to 7% of patients after ten years - twice the accepted failure rate of 3.5% set by the National Joint Registry. One study found the failure rate to be much higher at 17.6% - more than five times as high as the accepted level. This can have catastrophic consequences for patients, many of whom are elderly, as undergoing a second knee replacement operation poses a much greater risk. The knee replacement, called the Nexgen, is part of a family of Zimmer Biomet implant devices with 88 possible variants. In total, these have been given to over 183,000 people in England, Wales and Northern Ireland, and more than five million worldwide. Of these variants, three combinations have been proven to place patients at a dangerously high risk of joint failure. Read full story (paywalled) Source: The Telegraph, 5 December 2022
  10. News Article
    ‘Rubbish’ communications on Group A Strep from government agencies made A&Es more ‘risky’ over the weekend, after services were flooded with the ‘worried well’, several senior provider sources have told HSJ. On Friday the UK Health Security Agency, successor to Public Health England, issued a warning on a higher than usual number of cases after the deaths of five children under 10 in a week. Several senior sources in hospital, 111/ambulance, urgent care and primary care providers, told HSJ they were not warned UKHSA were making an announcement that would also see services flooded by the worried well. NHS England’s clinical lead for integrated urgent care issued a letter, seen by HSJ, saying a “considerable increase” in 111 demand over the weekend was “in part due to Group A Strep concerns”. Sources in the sector said the increase in demand was “heavily” Strep-related. One senior accident and emergency leader told HSJ that when parents could not get through on 111 they brought their children to emergency departments. “The media messaging has been handled terribly”, they added. They added: “Huge numbers of ‘worried well’ makes the A&E a much more dangerous place. We are just not equipped to deal with the volume of patients. [There is a] much greater chance we would miss one seriously unwell child when we are wading through a six-hour queue of viral, but otherwise well, kids.” Read full story (paywalled) Source: HSJ, 6 December 2022
  11. News Article
    There have been five recorded deaths within seven days of an invasive Strep A diagnosis in children under 10 in England this season, the UK Health Security Agency has said. A child under the age of 10 has also died in Wales after contracting the infection. Group A strep bacteria can cause many infections, ranging from minor illnesses to deadly diseases, but serious complications and deaths are rare. According to UKHSA data, there were 2.3 cases of invasive disease per 100,000 children aged one to four this year in England, compared with an average of 0.5 in the pre-pandemic seasons (2017 to 2019). There have also been 1.1 cases per 100,000 children aged five to nine, compared with the pre-pandemic average of 0.3 (2017 to 2019). The UKHSA said investigations are under way following reports of an increase in lower respiratory tract Group A Strep infections in children over the past few weeks, which have caused severe illness. It added that there is no evidence to suggest a new strain of Strep A is circulating, and the increase is most likely related to high amounts of circulating bacteria and social mixing. Read full story Source: Sky News, 3 December 2022
  12. Content Article
    Medication is the main part of the therapeutic process for hospital patients and with stocks of up to 200 medications held by hospital settings, it is estimated to be the second-highest spending chapter of health budgets. Management of medication stocks, their prescription and administration to patients (better known as the “medication management pathway”) is an onerous activity for hospitals and healthcare professionals. Tasks in this pathway are largely manual and non-digitalised. Visibility of medicine stocks is low; medication data is unfindable and low digitalisation of the pathway makes it highly prone for the occurrence of medication errors. Current rates of digitalisation combined with the high rates of manual activities undermines patients and healthcare professionals’ wellbeing and hospital systems resilience. For medication errors alone, the impact from the current low levels of digitalisation in hospitals costs the OECD group $54 billion and 3 million avoidable hospital days. With the advent of the European Medicine’s Agency new European Shortages Monitoring Platform (ESMP) which will manage medication shortages and the European Health Data space for cross border patient care, current levels of Digitalisation of Hospitals Medication management pathways will reduce the reliability and success of these new initiatives to respond effectively to future health care crises. It is therefore crucial that the European Union invests in the Digitalisation of Hospitals Medication management pathways for patient safety, healthcare professionals’ wellbeing and for hospital resilience.
  13. News Article
    Patients are struggling to understand their doctors because of confusing medical jargon, a study has found. Almost 80% of people do not know that the word 'impressive' actually means 'worrying' in a medical context. Critics said using the word borders on 'disrespectful' because 'we're describing something as impressive that is causing real harm for patients'. More than one in five of respondents could not work out the phrase 'your tumour is progressing', which means a patient's cancer is worsening. And the majority of participants failed to recognise that 'positive lymph nodes' meant the cancer had spread. The word 'impressive' means something admirable to most people. But when physicians describe a chest X-ray as impressive, they actually mean it is worrying. Some 79% of study participants did not get this meaning. Only 44 participants correctly understood that a clinician was actually giving them bad news. Read full story Source: Mail Online, 1 December 2022
  14. Content Article
    This study from Gotlieb et al. looked at how well adults understand common phrases clinicians use when communicating with patients. The study surveyed 215 adults in the USA and found that participants frequently misunderstood and often assigned meaning opposite to what the clinician intended. These findings suggest that use of common medical phrases may lead to confusion among patients affecting health outcomes.
  15. News Article
    The deputy chair of NHS England has said it should be as ‘demanding’ of medical cover in obstetrics and neonatal care as it is for emergency departments, to improve safety in the wake of repeated care scandals. Sir Andrew Morris, who was the long-serving chief executive officer of the well-regarded Frimley Health Foundation Trust, said the service would “expect a consultant to be on duty in an emergency department [from] 8am till 10pm, or midnight, seven days a week”. Speaking at NHS England’s public board meeting yesterday, Sir Andrew said: “We haven’t set that similar expectation out for [maternity care]. I know we’re saying we’re expecting that two ward rounds are undertaken, each day, seven days a week, but that is very different to the service I think is appropriate for this type of semi-emergency operation, that most trusts run. “I’d like us to be as demanding of organisations [in relation to obstetrics and neonatal] as we are for the emergency department.” Read full story (paywalled) Source: HSJ, 1 December 2022
  16. News Article
    When 85-year-old Koulla fell at home, her family immediately rang for an ambulance. She was in agonising pain - she had broken her hip. It was around 8pm. It took another 14 hours for an ambulance to get to her, leaving her pregnant granddaughter to care for her through the night. When they arrived the crews were able to give her pain relief and quickly transported her to the Royal Cornwall Hospital. But there the wait continued - there were around 30 ambulances queuing to handover patients to A&E staff. It was another 26 hours before she was taken inside to A&E. She then faced many hours in A&E before being taken for surgery. Koulla's daughter, Marianna Flint, 53, said: "It was awful. You feel helpless because you're giving your trust over to them to look after a family member who's in agony and who needs surgery." She has since received a written apology from the Royal Cornwall for the care provided to her mother in August. Ms Flint said: "I almost feel sorry for those looking after her. It's not down to them. There was no room inside to accept her in." Read full story Source: BBC News, 1 December 2022
  17. News Article
    Ambulance services across England are set to go on strike before Christmas as thousands of paramedics and call handlers voted for action. The announcement by union Unison comes as the Royal College of Nursing (RCN) confirmed 100,000 nurses across England, Wales and Northern Ireland will walk out on 15 and 20 December. The union is calling for action on pay and a big increase in staff numbers, warning that unless these things happen, services will continue to decline. Saffron Cordery, interim chief of NHS Providers, said on BBC radio four: “I think in terms of the ambulance strike, we know the challenges already of not having enough paramedics, call handlers available, because we’ve seen the challenges to ambulance handover times that we have at the moment in terms of not being able to transfer patients from ambulances into A&E departments and the challenges that brings when they can’t get back out on the road. “Additional challenges on top of that, I think, will make response times incredibly stretched.” Sources told The Independent that one option could be for services to maintain levels of staff to be able to respond to the most serious calls - category one and two calls - and deprioritise the less serious category three and four calls. This has previously been negotiated during smaller-scale strikes. However, senior sources suggested that on a larger scale it would be hard to not respond to category three calls, which might include an older person who has fallen. It is also unclear how 999 call centres would operate during strikes as this work would likely count as life-saving emergency care, The Independent understands. Read full story Source: The Independent, 2 December 2022
  18. News Article
    Intensive care doctors in Germany have warned that hospital paediatric units in the country are stretched to breaking point in part due to rising cases of respiratory infections among infants. The intensive care association DIVI said the seasonal rise in respiratory syncytial virus (RSV) cases and a shortage of nurses was causing a “catastrophic situation” in hospitals. RSV is a common, highly contagious virus that infects nearly all babies and toddlers by the age of two, some of whom can fall seriously ill. Experts say the easing of coronavirus pandemic restrictions means RSV is affecting a larger number of babies and children, whose immune systems aren’t primed to fend it off. Cases of RSV and other respiratory illnesses have also increased in the UK and in the US, which is also suffering from a shortages of antivirals and antibiotics. In Germany, hospital doctors are having to make difficult decisions about which children to assign to limited intensive care beds. In some cases, children with RSV or other serious conditions are getting transferred to hospitals elsewhere in Germany with spare capacity. “If the forecasts are right, then things will get significantly more acute in the coming days and week,” Sebastian Brenner, head of the paediatric intensive care unit at University Hospital Dresden, told German news channel n-tv. “We see this in France, for example, and in Switzerland. If that happens, then there will be bottlenecks when it comes to treatment.” Others warned that, in certain cases, doctors already were unable to provide the urgent care some children need. “The situation is so precarious that we genuinely have to say children are dying because we can’t treat them any more,” Dr. Michael Sasse, head of paediatric intensive care at Hanover’s MHH University hospital, said. Read full story Source: The Guardian, 1 December 2022
  19. News Article
    More than 1,000 referrals to admit very sick or premature babies to neonatal units were rejected in the last year due to a lack of beds, data obtained by HSJ has revealed. Nineteen trusts turned down a total of 2,721 requests to admit a baby to their level three neonatal intensive care unit – those for the most serious cases – specifically due to a lack of a bed, between 2019-20 and 2021-22, with 1,345 such refusals taking place in 2021-22. Experts told HSJ the issue – which appears to have led to families having to travel very long distances from their homes – was due to a shortage of staff, especially nurses, meaning insufficient beds (normally referral to as cots in neonatal care) can be opened. A British Association of Perinatal Medicine spokesperson told HSJ: “Neonatal intensive care units should run at less than 80% occupancy on average to allow for peaks and troughs in activity. There are a significant number which are having to run over that capacity limit which can cause flow problems – we’re a bit like an A&E that can’t stack the ambulances outside – once the baby is there, it has to come and we’re not able to control those admissions.” Read full story (paywalled) Source: HSJ, 1 December 2022
  20. News Article
    Whistleblowers at one of England's worst performing hospital trusts have said a climate of fear among staff is putting patients at risk. Former and current clinicians at University Hospitals Birmingham (UHB) NHS Trust allege they were punished by management for raising safety concerns, a BBC Newsnight investigation found. One insider said the trust was "a bit like the mafia". The trust said it took "patient safety very seriously". It said it had a "high reporting culture of incidents" to ensure accountability and learning. Staff concerns included a dangerous shortage of nurses and a lack of communication leading to some haematology patients dying without receiving treatment. The deaths of 20 patients in the haematology department of the Queen Elizabeth Hospital, which is run by the trust, led to a review in 2017 by consultant Emmanouil Nikolousis. Mr Nikolousis, who left the trust in 2020, told the BBC he was shocked by the failings he found and believes patients' lives could have been saved. A report by Mr Nikolousis criticised a lack of "ownership" of patients and a lack of communication among senior clinicians. In some cases this led to patients dying without having received treatment, he said. "Certainly there should have been different actions done," he said. "They could be saved. Certainly, when you don't have an action done, then you don't really know the outcome." Mr Nikolousis said he felt he had no option but to quit after his findings were ignored and his position was made "untenable". He left the NHS after 18 years. "They were trying, as they did with other colleagues, to completely sort of ruin your career," he said. Read full story Source: BBC News, 1 December 2022
  21. News Article
    The World Health Organization (WHO) announces that the Ministry of Food and Drug Safety, Republic of Korea, has achieved maturity level four (ML4), the highest level in WHO’s classification of regulatory authorities for medical products. WHO has formally assessed the medical product regulatory authorities of 33 countries, of which only the Republic of Korea is listed as attaining this level in regulation for both locally produced as well as imported medicines and vaccines. This achievement represents an important milestone for the Republic of Korea and for the world, signifying that the Ministry of Food and Drug Safety (MFDS), the national regulatory authority for medicines and vaccines, is operating at an advanced level of performance with continuous improvement Only about 30% of the world’s regulatory authorities have the capacity to ensure medicines, vaccines and other health products are produced to required standards, work as intended and do not harm patients. WHO’s benchmarking efforts identify regulatory authorities that are operating at an advanced level so that they can act as a reference point for regulatory authorities that lack the resources to perform all necessary regulatory functions, or which have not yet reached higher maturity levels for medical product oversight. “This is a great testament for Republic of Korea’s commitment for ensuring safe and effective medicines and vaccines, and investing in building a strong regulatory system,” said Dr Mariângela Simão, Assistant Director-General, Access to Medicines and Health Products. “We hope the achievement will be sustained and also help promote confidence, trust and further reliance on national authorities attaining this high level”. Read full story Source: WHO, 29 November 2022
  22. Content Article
    Royal Cornwall QI conference online book supporting the conference. The online brochure highlights all the quality improvement projects at Royal Cornwall Hospitals.
  23. News Article
    Public health leaders were slow to act on repeated warnings over Christmas 2020 that contact tracing and isolation should be triggered immediately after a positive lateral flow test result, leaked evidence to the Covid inquiry shows. A scathing “lessons learned” document written by Dr Achim Wolf, a senior test and trace official, and submitted to the inquiry, gives his account of a trail of missed opportunities to improve the NHS test-and-trace regime in the first winter and spring of the pandemic – before vaccines were available. It suggests that people will have unnecessarily spread the virus to friends and relatives in the first Christmas of the pandemic and subsequent January lockdown period because they were not legally required to isolate and have their contacts traced as soon as they got a positive lateral flow test. Instead, for around two months, those eligible for rapid testing were told to get a confirmatory PCR test after a positive lateral flow. About a third of those who subsequently got a negative PCR result were likely to have had Covid anyway. In the “lessons learned” document seen by the Guardian, Wolf says: “Over the winter months, the prevalence in individuals who had 1) a positive lateral flow; followed by 2) a negative PCR; may have been upwards of 30%. These individuals were then allowed to return to their high-risk workplaces.” The former head of policy at NHS test and trace highlights how it took too long to get clear advice from Public Health England about policy on contact tracing and isolation rules in the face of changing scientific evidence on the accuracy of lateral flows. Read full story Source: The Guardian, 30 November 2022
  24. News Article
    More than 200 people who died last week in England are estimated to have been affected by problems with urgent and emergency care, according to the president of the Royal College of Emergency Medicine. Dr Adrian Boyle, who is also a consultant in emergency medicine, told BBC Radio 4’s Today programme that a failure to address problems discharging patients to social care was a “massive own goal”. Ambulances had become “wards on wheels” while patients waited to get hospital treatment, Boyle said, adding that those most at risk “are the people that the ambulance can’t go to because it’s stuck outside the emergency department”. His comments came as the NHS launched 42 “winter war rooms” across England, designed to use data to respond to pressures on the health system. When asked about the project, Boyle said it was too early to tell if it was a good idea, adding: “You can paralyse yourself with analysis, it really is actually more simple and about building increased capacity.” He said the problem was best solved by focusing on hospital discharge and social care. “Fixing this starts at the back door of the hospital and being able to use our beds properly,” he said. “At the moment, there are 13,000 people waiting in hospitals, about 10% of the bed base, who are waiting to be discharged either to home, with a little bit more support, or to a care facility. And that’s just a massive own goal. We just need to reform the interface between acute hospitals and social care.” Read full story Source: The Guardian, 1 December 2022
  25. Content Article
    Behind the outcry about waiting times lies the anxiety that our cherished GP system will, in the words of one Gloucester doctor, ‘soon reach a threshold where there is a collapse’. We witness life on the frontline in this Guardian article.
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