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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Women are waiting nearly nine years for an endometriosis diagnosis in the UK, according to research that found health professionals often minimise or dismiss symptoms. The study by the charity Endometriosis UK suggests waiting times for a diagnosis have significantly deteriorated in the past three years, increasing to an average of eight years and 10 months, up 10 months since 2020. In Scotland, the average diagnosis time has increased by four months. The report, based on a survey of 4,371 people who have received a diagnosis, shows that 47% of respondents had visited their GP 10 or more times with symptoms before being diagnosed, and 70% had visited five times or more. The chief executive of Endometriosis UK, Emma Cox, said: “Taking almost nine years to get a diagnosis of endometriosis is unacceptable. Our finding that it now takes even longer to get a diagnosis of endometriosis must be a wake-up call to decision-makers to stop minimising or ignoring the significant impact endometriosis can have on both physical and mental health.” The report includes examples of patients’ experiences, with many being told that their pain was “normal”. One said: “I was constantly dismissed, ignored and belittled by medical professionals telling me that my symptoms were simply due to stress and tiredness. I persevered for over 10 years desperate for help.” Another said she had been told she was “being dramatic” after going to her GP as a teenager with painful periods. Another said: “A&E nurses told me that everyone has period pain so take paracetamol and go home.” Read full story Source: The Guardian, 4 March 2024
  2. News Article
    Harry Miller was a popular teenager, appreciated for his sharp humour, ability to get on with anyone and eagerness “for the next adventure”. In the autumn of 2017, he was struggling with difficult thoughts and feelings of anger. Harry, who was 14 and lived in south-west London, confided his inner turmoil to friends and family. “I’m just having these anger rages,” he told his mother one day. “It’s like I just go crazy suddenly and I can’t control it. I don’t know what’s going on.” Two years previously, Harry had been prescribed the drug montelukast for his asthma. Unbeknown to his parents, a range of psychiatric reactions had been reported in association with montelukast treatment, including aggression, depression and suicidal thoughts. Harry’s parents, Graham and Alison Miller were not properly warned of the potential side effects. Their son was referred to the NHS child and adolescent mental health services in January 2018, but he missed an appointment because it was sent to the wrong person. On 11 February 2018, Harry was found dead in the family home, with an inquest later recording a verdict of suicide. He was described in a tribute by friends at St Cecilia’s Church of England school in Southfields, south-west London, as a “super star burning brightly”. Two years after his death, his father read an online warning about the adverse reactions involving montelukast by the Medicines and Healthcare Products Regulatory Agency (MHRA). It said these could very rarely include suicidal behaviour. Graham Miller said: “It is an absolute outrage that parents are being given psychoactive substances to give to their children without proper warning of the risk.” This weekend, the MHRA has confirmed that the drug is under review. A montelukast UK action group is calling for more prominent warnings of the drug’s possible side effects. Read full story Source: BBC News, 3 March 2024
  3. News Article
    A 73-year-old patient has said he was neglected at an NHS hospital and left to cry for help in "excruciating pain" during an ordeal that lasted months. Martin Wild was admitted to Salford Royal last year due to a spinal infection and claims he was denied pain relief and left lying in his own urine. Consultant Glyn Smurthwaite said Martin was "the most neglected acute patient I have ever seen". The trust that runs the hospital has apologised for failings in his care. Mr Wild came home from Salford Royal Hospital in January after an eight-month stay because of an infection following a private spinal operation. He said he was forced to phone 999 from his hospital bed when first admitted to the acute medical ward in May 2023 after struggling to get staff to give him pain relief and his Parkinson's medication. "I was left on my own in excruciating pain, with little pain relief, and I was laying on this bed for over a week before I saw a consultant." Mr Wild was discharged despite warning staff he was not well enough and no one could look after him at home, and ended up being readmitted days later via A&E. He said his poor care continued during his second stay, and Mr Wild recalled that he was shaking so much in pain that he knocked bottles of urine on to his bed after they had been left on the table with his food. Mr Wild was left lying in the urine-soaked sheets for hours before they were changed. Read full story Source: BBC News, 3 March 2023
  4. Content Article
    Women of colour frequently report that their race has impacted the quality of care they receive. In this study, women of colour who experienced a traumatic birth described the racist and gendered stereotypes ascribed to them (uneducated, negligent, (in)tolerant to pain, and dramatic) and how those stereotypes impacted the obstetrical care they received. Ultimately these experiences caused long-term harm to their mental health, decreased trust in healthcare, and reduced the desire to have children in the future.
  5. Content Article
    Hospital nurse staffing, and the proportion of nurses with bachelor’s education, are associated with significantly fewer deaths after routine surgery, according to research published in the Lancet. A team of researchers conducted the study across nine European countries and found that a better educated nursing workforce reduced unnecessary deaths. Every 10%increase in the number of bachelor’s degree educated nurses within a hospital is associated with a 7% decline in patient mortality. Patients in hospitals, in which 60% of nurses had bachelor’s degrees and nurses cared for an average of six patients, had almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients. The study shows that, in hospitals in England, an average only of 28% of bedside care nurses had bachelor’s degrees, among the lowest in Europe, which averaged 45%. The study shows that increasing the production of graduate nurses is necessary if the NHS is to realise the potential of lower patient mortality and fewer adverse patient outcomes.
  6. Content Article
    Health inequalities are avoidable, unfair and systematic differences in health between different groups of people. Here we examine the key data on this complex and wide-ranging issue.
  7. News Article
    A hospital trust has admitted that a young autistic boy should still be alive had they delivered the appropriate level of care. In an exclusive interview with ITV News, the day before the inquest into his death, Mattheus Vieira's heartbroken parents described him as "special", adding: "And special in a good way, not just special needs." "People may think because he was autistic he was difficult, but it's not the case, he was very easy. "He was the boss of the house, we just miss his presence." Mattheus, aged 11, was taken to King's Lynn Hospital, in Norfolk, with a kidney infection. He struggled to cope with medical staff taking observations, and his notes recorded him as "uncooperative". His dad, Vitor Vieira, told ITV News: "He doesn't like to be touched, even a plaster he doesn't like. "And they say 'Oh he does not co-operate'. He was an autistic boy, what do you expect? Mr Vieira believes staff did not understand his son's behaviour. Mattheus was non verbal and so unable to articulate his distress. Observations were dismissed as "inaccurate" by some medical staff. In fact, they were accurate and indicated that his kidney infection had developed into septic shock. He suffered a cardiac arrest and died, aged 11. Read full story Source: ITV News, 26 February 2024
  8. Content Article
    Strategies to reduce medication dosing errors are crucial for improving outcomes. The Medication Education for Dosing Safety (MEDS) intervention, consisting of a simplified handout, dosing syringe, dose demonstration and teach-back, was shown to be effective in the emergency department (ED), but optimal intervention strategies to move it into clinical practice remain to be described. This study aimed tov describe implementation of MEDS in routine clinical practice and associated outcomes. The study was conducted in five stages (baseline, intervention 1, washout, intervention 2, and sustainability phases). The 2 intervention phases taught clinical staff the MEDS intervention using different implementation strategies. The study found that both MEDS intervention phases were associated with decreased risk of error and that some improvement was sustained without active intervention. These findings suggest that attempts to develop simplified, brief interventions may be associated with improved medication safety for children after discharge from the ED
  9. Content Article
    The South East London Long Covid programme has released 10 short animated films to help people with their recovery.  The films offer guidance, tools, and tips on how to help manage symptoms and reduce the risk of ongoing issues.
  10. News Article
    Thirteen more NHS hospitals have identified a potentially unsafe form of concrete in their buildings, causing closures and disruption to wards. The government has updated its list of hospitals that have confirmed reinforced autoclaved aerated concrete on their sites, with the total now at 54. This includes at least two trusts – Sheffield Teaching Hospitals and Hampshire Hospitals – which in September said their sites did not contain the material, after the sudden closure of schools with the concrete sparked a wave of headlines over it. The material was used widely between the 1960s and 1980s and can be prone to collapse. The impact and risk of the concrete identified varies greatly between sites. HSJ has asked trusts who run the newly identified sites where it has been found, as well as the risks and impact from the discovery. Read full story (paywalled) Source: HSJ, 29 February 2024
  11. Content Article
    Virtual wards provide hospital-level care to patients in their own homes. There are many different models of virtual wards. Some cover specific conditions (frailty, acute respiratory infections, heart failure wards), while others have a much broader range of patients. In April 2022, NHS England launched its national virtual ward programme with the long term aim of providing 40 to 50 virtual ward beds per 100,000 people in England. So far, every integrated care board in England has introduced virtual wards. Further aims of this programme include improving patient choice and experience, avoiding risks associated with inpatients stays and improving hospital flow by reducing lengths of stay and freeing up beds. Virtual wards have the potential to improve outcomes for both patients and the health care system. But we need high-quality data, careful monitoring and robust evaluations to understand if this is the case – and for which patients and in what contexts. This will provide learning and drive improvement.   This Health Foundation working paper analyses aggregate national data on virtual wards to describe what virtual wards currently look like across England and discuss the effects of virtual wards on patients, staff and hospital capacity, as well as the gaps in the evidence.
  12. Content Article
    Healthwatch and national organisations representing patients and NHS leaders express concerns over Royal Mail plans to delay bulk mail of NHS appointment letters from two days to three days. 
  13. Content Article
    It is well known that the NHS is suffering from staff shortages, with 121,000 full-time equivalent (FTE) vacancies and only 26% of the workforce stating there are enough staff at their organisation. The reasons why staff are leaving are well documented (burnout, lack of work–life balance, low pay etc), and the direct impact on patients is obvious – staff shortages are one of the main reasons why there is a backlog of care. But these headlines mask nuance. They hide the areas where staff shortages are even more acute than the average, and they obscure the indirect impact on patients. Where are these areas, what are the impacts, and will the NHS Long Term Workforce Plan help?
  14. News Article
    NHS board members must speak up against discrimination, challenge others constructively and help foster a safe culture, under a new NHS England assessment framework. The new leadership competency framework, published today, sets out six domains which board members are required to assess themselves against as part of an annual “fitness” appraisal. Each domain (see below) contains competencies directors must exhibit, such as: Speak up against any form of racism, discrimination, bullying, aggression, sexual misconduct or violence, even when [they] might be the only voice; Challenge constructively, speaking up when [they] see actions and behaviours which are inappropriate and lead to staff or people using services feeling unsafe, or staff or people being excluded in any way or treated unfairly; and Ensure there is a safe culture of speaking up for [their] workforce. Each competency statement gives board members a multiple choice to assess themselves against, ranging from “almost always” to “no chance to demonstrate”. Organisations have been told to incorporate the six competency domains into role descriptions from 1 April, and use them as part of board member appraisals. Read full story (paywalled) Source: HSJ, 28 February 2024
  15. Content Article
    This framework is for chairs, chief executives and all board members in NHS systems and providers, as well as serving as a guide for aspiring leaders of the future. It is designed to: support the appointment of diverse, skilled and proficient leaders support the delivery of high-quality, equitable care and the best outcomes for patients, service users, communities and our workforce help organisations to develop and appraise all board members support individual board members to self-assess against the six competency domains and identify development needs.
  16. News Article
    Child and adolescent eating disorder services have never achieved NHS waiting time targets, and are not able to meet significant demand, according to analysis by the Royal College of Psychiatrists. Psychiatrists can identify and address many of the root causes of eating disorders, including neurodevelopmental conditions such as autism and ADHD. However, a current lack of capacity prevents this from happening. Due to a lack of resources, even children who meet the threshold for specialist eating disorder services are often in physical and mental health crisis by the time they are seen. Delays in treatment cause children with eating disorders physical and mental harm. NHS England set a target for 95% of children and young people with an urgent eating disorder referral to be seen within a week, and for 95% of routine referrals to be seen within four weeks. These standards have not been achieved nationwide, since they were introduced in 2021. RCPsych analysis of the latest data shows that just 63.8% of children and young people needing urgent treatment from eating disorder services were seen within one week. Only 79.4% of children and young people with a routine referral were seen within four weeks. The College also warns that there is an unacceptable gap between the number of children being referred to specialist eating disorders services, and those being seen. This is driven by a shortfall in the number of trained therapists and eating disorders psychiatrists. For Eating Disorders Awareness Week, the Royal College of Psychiatrists is calling on Government and Integrated Care Boards to invest in targeted support for children and young people to reverse this eating disorders crisis. The call is backed by the UK’s eating disorder charity Beat. Read full story Source: Royal College of Psychiatrists, 29 February 2024 Further reading on the hub: For Eating Disorders Awareness Week, Patient Safety Learning has pulled together 10 useful resources shared on the hub to help healthcare professionals, friends and family support people with eating disorders.
  17. News Article
    Staff have assaulted patients and falsified medical records following deaths, according to a shocking new report into a scandal-hit mental health hospital where Nottingham killer Valdo Calocane was a patient. Multiple incidents of staff physically assaulting patients and workers feeling too scared to report problems at Highbury Hospital have been uncovered by the Care Quality Commission (CQC). The watchdog revealed police have investigating the deaths of at least two patients in which staff involved were later found by the hospital to have falsified their medical records in a new report, published on Friday. The news comes after The Independent revealed Nottinghamshire Healthcare Foundation Trust, which runs Highbury Hospital, had suspended more than 30 staff members following allegations of mistreating patients and falsifying records of medical observations. The trust also faces a further CQC review, commissioned by health secretary Victoria Atkins, following the conviction of killer Valdo Calocane who was a patient of Highbury Hospital’s community service teams. This review is due to be published later this year. Read full story Source: The Independent, 1 March 2023
  18. News Article
    Whistleblower Dr Chris Day has won the right to appeal when a a Deputy High Court Judge Andrew Burns of the Employment Appeal Tribunal granted permission to appeal the November 2022 decision of the London South Employment Tribunal on six out of ten grounds at a hearing in London. The saga which has now being going on for almost ten years began when Dr Day raised patient safety issues in intensive care unit at Woolwich Hospital in London. The Judge said today this was of the “utmost seriousness” and were linked to two avoidable deaths but their status as reasonable beliefs were contested by the NHS for 4 years using public money. In a series of twists and turns at various tribunals investigating his claims Dr Day has been vilified by the trust not only in court but in a press release sent out by the trust and correspondence with four neighbouring trust chief executives and the head of NHS England, Dr Amanda Pritchard and local MPs. This specific hearing followed a judgement in favour of the trust by employment judge Anne Martin at a hearing which revealed that David Cocke, a director of communications at the trust, who was due to be a witness but never turned up, destroyed 90,000 emails overnight during the hearing. A huge amount of evidence and correspondence that should have been released to Dr Day was suddenly discovered. The new evidence showed that the trust’s chief executive, Ben Travis, had misled the tribunal when he said that a board meeting which discussed Dr Day’s case did not exist and that he had not informed any other chief executive about the case other than the documents that were eventually disclosed to the court. Read full story Source: Westminster Confidential, 26 February 2024
  19. News Article
    Great Ormond Street Hospital has written to the families of all children treated by one of its former surgeons after concerns were raised about his practice. Yaser Jabbar, a consultant orthopaedic surgeon, has not had a licence to practise medicine in the UK since 8 January, the medical register shows. Independent experts are now reviewing the concerns raised. The hospital trust said the Royal College of Surgeons (RCS) was asked to review its paediatric orthopaedic service following concerns raised by family members and staff. The RCS then raised concerns about Mr Jabbar, which the trust said were being taken "incredibly seriously" and would be reviewed by independent experts from other paediatric hospitals. A spokesman for the trust said: "We are sorry for the worry and uncertainty this may cause the families who are impacted. "We are committed to learning from every single patient that we treat, and to being open and transparent with our families when care falls below the high standards we strive for." The spokesperson said Mr Jabbar, reported to be an expert in limb reconstruction, no longer worked at the hospital. Read full story Source: BBC News, 28 February 2024
  20. News Article
    The NHS paid out tens of millions of pounds over maternity failings at a hospital trust which is the subject of a major inquiry. Including legal fees, £101m was paid in claims against Nottingham University Hospitals (NUH) between 2006 and 2023. NUH is facing the UK's largest-ever maternity review, with hundreds of baby deaths and injuries being examined. Experts say lives could be saved if the trust invested more in learning from its mistakes. The NHS paid the money in relation to 134 cases over failings at the Queen's Medical Centre (QMC) and City Hospital. The majority - £85m - was damages for families who were successful in proving their baby's death or injury was a result of medical negligence. Read full story Source: BBC News, 28 February 2024
  21. News Article
    GPs do not ‘face huge amounts of complexity’ and most of their appointments are ‘incredibly straightforward’, according to a former Conservative health minister. Speaking to BBC Radio 4 last week, Lord Bethell defended upcoming legislation that will bring physician associates (PAs) under GMC regulation, which could be struck down by the House of Lords this evening. Both the Doctors’ Association UK and the BMA had previously complained about the lack of debate in Parliament. Discussing the role of PAs on Friday, Lord Bethell said he had not seen ‘any evidence’ of patients being confused about whether they were seeing a doctor or an associate. "GPs don’t face huge amounts of complexity. Most interactions are incredibly straightforward. Certainly my own experience over the last 20 years of going to my GP, it really hasn’t required 10 years of training to deal with my small problems," he said. Lord Bethell added: ‘When they are complex, they should be escalated. But there’s a much wider group of people who have professional training who should be respected, celebrated – they shouldn’t be denigrated, they shouldn’t be in any way patronised by other professionals.’ Read full story Source: Pulse, 26 February 2024
  22. Content Article
    Salbutamol is a selective beta2-agonist providing short-acting (4-6 hour) bronchodilation with a fast onset (within 5 minutes) in reversible airways obstruction. The nebuliser liquids are licensed for use in the management of chronic bronchospasm unresponsive to conventional therapy, and in the treatment of acute severe asthma. A Medicines Supply Notification (MSN) issued on 14 February 2024, detailed a shortage of salbutamol 2.5mg/2.5ml and 5mg/2.5ml nebuliser liquid. The resolution date is to be confirmed. The supply issues have been caused by a combination of manufacturing issues resulting in increased demand on other suppliers. Terbutaline, salbutamol with ipratropium, and ipratropium nebuliser liquids remain available, however, they cannot support an increase in demand. Ventolin® (salbutamol) 5mg/ml nebuliser liquid (20ml) is out of stock until mid-April 2024 and cannot support an increased demand after this date.
  23. Content Article
    Patient harm, patient safety and their governance have been ongoing concerns for policymakers, care providers and the public. In response to high rates of adverse events/medical errors, the World Health Organization (WHO) advocated the use of surgical safety checklists (SSC) to improve safety in surgical care. Canadian health authorities subsequently made SSC use a mandatory organisational practice, with public reporting of safety indicators for compliance tied to pre-existing legislation and to reimbursements for surgical procedures. Perceived as the antidote for socio-technical issues in operating rooms (ORs), much of the SSC-related research has focused on assessing clinical and economic effectiveness, worker perceptions, attitudes and barriers to implementation. Suboptimal outcomes are attributed to implementations that ignored contexts. Using ethnographic data from a study of SSC at an urban teaching hospital (C&C), a critical lens and the concepts of ritual and ceremony, this paper examinse how it is used, and theorise the nature and implications of that use. Two rituals, one improvised and one scripted, comprised C&C’s SSC ceremony. Improvised performances produced dislocations that were ameliorated by scripted verification practices. This ceremony produced causally opaque links to patient safety goals and reproduced OR/medical culture. We discuss the theoretical contributions of the study and the implications for patient safety.
  24. News Article
    People experiencing Long Covid have measurable memory and cognitive deficits equivalent to a difference of about six IQ points, a study suggests. The study, which assessed more than 140,000 people in summer 2022, revealed that Covid-19 may have an impact on cognitive and memory abilities that lasts a year or more after infection. People with unresolved symptoms that had persisted for more than 12 weeks had more significant deficits in performance on tasks involving memory, reasoning and executive function. Scientist said this showed that “brain fog” had a quantifiable impact. Prof Adam Hampshire, a cognitive neuroscientist at Imperial College London and first author of the study, said: “It’s not been at all clear what brain fog actually is. As a symptom it’s been reported on quite extensively, but what our study shows is that brain fog can correlate with objectively measurable deficits. That is quite an important finding.” Read full story Source: The Guardian, 29 February 2024
  25. Content Article
    Poor memory and difficulty thinking or concentrating (commonly referred to as “brain fog”) have been implicated in syndromes occurring after Covid-19 — a situation that has led to suggestions that Covid-19 may have lasting cognitive consequences. However, objective data on cognitive performance are largely lacking, and how long such deficits may persist and which cognitive functions are most vulnerable are unclear. In this observational study, Hampshire et al. invited 800,000 adults in a study in England to complete an online assessment of cognitive function. The authors estimated a global cognitive score across eight tasks. They hypothesised that participants with persistent symptoms (lasting ≥12 weeks) after infection onset would have objectively measurable global cognitive deficits and that impairments in executive functioning and memory would be observed in such participants, especially in those who reported recent poor memory or difficulty thinking or concentrating (“brain fog”). They found that participants with resolved persistent symptoms after Covid-19 had objectively measured cognitive function similar to that in participants with shorter-duration symptoms, although short-duration Covid-19 was still associated with small cognitive deficits after recovery. Longer-term persistence of cognitive deficits and any clinical implications remain uncertain.
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