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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    Pfizer has been fined £63 million after overcharging the NHS for a life-saving epilepsy drug which rose in price by 2,600%. The drug company was fined by the Competition and Markets Authority (CMA) for its involvement in a secret deal to hike the price of phenytoin sodium capsules, which cost the NHS tens of millions of pounds. Pfizer and a small British company, Flynn Pharma, were able to circumvent NHS price controls by de-branding the drug in 2012 and relaunching it under its generic name. The price then rose from £2.83 to £67.50 per pack, pushing up the cost from £2 million a year to £50 million. Internal emails obtained by the CMA showed that Pfizer officials raised concerns about the proposed scheme, with one manager writing: “The top line looks great, however, this would increase the price of phenytoin capsules to the NHS drastically and, to be frank, doesn’t feel right.” Andrea Coscelli, the outgoing chief executive of the CMA, said phenytoin was an “essential drug relied on daily by thousands of people throughout the UK to prevent life-threatening epileptic seizures”. He said the two companies had “illegally exploited their dominant positions to charge the NHS excessive prices and make more money for themselves — meaning patients and taxpayers lost out”. Read full story (paywalled) Source: The Times, 21 July 2022
  2. News Article
    Patients who contract Covid-19 are at increased risk of being diagnosed with cardiovascular disorders and diabetes in the three months following infection, although the risk then declines back to baseline levels, a large UK study has found. Researchers from King’s College London say patients recovering from Covid-19 should be advised to consider measures to reduce diabetes risk including adopting a healthy diet and taking exercise. The GP medical records from more than 428,650 Covid-19 patients were matched with the same number of controls and followed up to January 2022. All patients with pre-existing diabetes or cardiovascular disease were excluded from the study, published in the open access journal PLOS Medicine. According to the analysis, diabetes mellitus diagnoses were increased by 81% in acute covid-19 and remained elevated by 27% from 4 to 12 weeks after infection. Lead study author Emma Rezel-Potts said, “While it is in the first four weeks that covid-19 patients are most at risk of these outcomes, the risk of diabetes mellitus remains increased for at least 12 weeks. Clinical and public health interventions focusing on reducing diabetes risk among those recovering from covid-19 over the longer term may be beneficial.” The researchers said that people without pre-existing cardiovascular disease or diabetes who become infected with covid-19 do not appear to have a long term increase in incidence of these conditions. Read full story Source: BMJ, 22 July 2022
  3. Content Article
    COVID-19 has been associated with new-onset cardiovascular disease (CVD) and diabetes mellitus (DM), but it is not known whether COVID-19 has long-term impacts on cardiometabolic outcomes. This study from Rezell-Potts et al. aimed to determine whether the incidence of new DM and CVDs are increased over 12 months after COVID-19 compared with matched controls. The study found that CVD was increased early after COVID-19 mainly from pulmonary embolism, atrial arrhythmias, and venous thromboses. DM incidence remained elevated for at least 12 weeks following COVID-19 before declining. People without preexisting CVD or DM who suffer from COVID-19 do not appear to have a long-term increase in incidence of these conditions.
  4. Content Article
    In her opening statement, Baroness Heather Hallett, Chair of the UK Covid-19 Inquiry, has set out her approach to running it. The Inquiry will consider and report on the preparations and the response to the pandemic in England, Wales, Scotland and Northern Ireland. The Terms of Reference provide the broad outline of the issues the Inquiry will investigate.
  5. News Article
    Care waiting lists for children are rising at double the rate of the adult backlog, a top doctor has warned. The waiting list for children’s care, including surgeries, hit 360,000 in May, the latest NHS data shows, and the Royal College of Paediatrics and Child Health (RCPCH) warned it is set to get worse amid worsening summer pressures. In an exclusive interview with The Independent, Dr Camilla Kingdon, president of RCPCH, said children’s services hadn’t been adequately prioritised since taking a hit during the pandemic, which was compounded by an “extremely busy summer”. She said children’s services now faced a “perfect storm” as they struggled to meet demand due to the increased pressure of viruses not previously seen at high levels during summer, and staff being off sick with Covid. Dr Kingdon said: “I don’t think it’s a surprise at all, that the waiting lists are rising. I think the truth is that the rate of rise of the waiting list for children is more than double the rate of rise for adults.” An NHS spokesperson said: “It is right that hospitals have been prioritising patients with the most urgent clinical need. The number of people waiting the longest – which includes many children – has dropped by more than 80 per cent since January.” But Dr Kingdon warned the official waiting list data, published by NHS England, was a “gross underestimation” of the actual number of children waiting for care overall. She said: “We’re not even collecting the data adequately to be able to truly understand the extent of the problem.” Read full story Source: The Independent, 21 July 2022
  6. News Article
    NHS England is introducing a new ceiling on the amount spent within each integrated care system on agency staff — cutting it by at least 10% in each area in one year — as part of a drive to find further savings across the health service. Integrated Care Services (ICSs) have been told to cut spending on temporary staff by providers in their area by at least 10%, or £257m, on 2021-22 levels, taking expenditure down to a total of £2.3bn nationally. A letter to finance directors sent today, seen by HSJ says: “This will mean that some systems will need to go beyond their current financial plans to reduce agency expenditure.” The move is part of a wider efficiency crackdown from NHS England, with further national control measures to be introduced over the next 18 months. HSJ understands that the renewed drive will focus on five other areas in addition to agency spend: medicines, pathway redesign, corporate services, procurement and specialised commissioning. The extra savings ask comes on top of ICSs already committing to £5.5bn in efficiencies over 2022-23, which Nuffield Trust CEO Nigel Edwards said was “not a credible savings target”. Read full story (paywalled) Source: HSJ, 20 July 2022
  7. Content Article
    The Ockenden review into the failings in maternity care at Shrewsbury and Telford Hospital NHS Trust in the UK makes for sobering reading. The review focuses predominantly on the period from 2000 to 2019 and estimates that there were significant or major concerns in the care of nine women and more than 200 babies who died while receiving care at the Trust. Many more women and babies suffered serious injuries. It was clear that the Shrewsbury and Telford Hospital NHS Trust did not investigate, learn, change, or listen to families when adverse events occurred. The conclusions of the Ockenden review make it clear that safe staffing levels, a well trained workforce, an ability to learn from incidents, and a willingness and ability to listen to families are all crucial for safe maternity care.
  8. Content Article
    Two years into the COVID-19 pandemic, it is clear that gender differences exist, and that women, men, and gender minorities are differentially impacted by the pandemic.
  9. News Article
    Long NHS waiting times appear to be pushing people into paying thousands of pounds for private treatment. There were 69,000 self-funded treatments in the UK in the final three months of last year - a 39% rise on the same period before the pandemic. Experts said it was a sign of how desperate people had become. The BBC has seen evidence of people taking out loans and resorting to crowdfunding to pay for private treatment. The figures from the Private Healthcare Information Network (PHIN) do not include those who have private insurance - instead they are the people paying the full cost of treatment themselves, leaving them liable for huge bills. Patient groups warned there was a risk of a two-tier system being created, with the poorest losing out because they were the least likely to be able to afford to pay for treatment. Patient watchdog Healthwatch England said waits for treatment were one of the most common concerns flagged by patients, and warned the situation risked "widening health inequalities". Chief executive Louise Ansari said for most people going private "simply isn't an option", especially with the cost-of-living crisis. "People on the lowest incomes are the most likely to wait the longest for NHS treatment. This leads to a worse impact on their physical health, mental health and ability to work and care for loved ones." Read full story Source: BBC News, 21 July 2022
  10. News Article
    A shortage of maternity staff is putting women and babies at risk in Gloucestershire, inspectors have said. The county's maternity services have been downgraded by two levels, from good to inadequate, by the Care Quality Commission (CQC). Its report highlighted staff shortages, missed training, exhaustion among workers and concerns over equipment. Gloucestershire Hospitals NHS Foundation Trust issued an apology and said improvements have been made. CQC inspectors visited maternity wards, birth units and community midwives in Gloucester, Cheltenham and Stroud in April after receiving concerns about the "culture, safety and quality of services". They found the service did not have enough midwifery staff with the "right qualifications, skills, training and experience to keep women safe from avoidable harm or to provide the right treatment all the time". Read full story Source: BBC News, 22 July 2022
  11. News Article
    One of the NHS’s biggest hospital trusts is facing major problems after its IT system failed because of the extreme temperatures earlier this week. Guy’s and St Thomas’ trust (GSTT) in London has had to cancel operations, postpone appointments and divert seriously ill patients to other hospitals in the capital as a result of its IT meltdown. The situation means that doctors cannot see patients’ medical notes remotely and are having to write down the results of all examinations by hand. They are also unable to remotely access the results of diagnostic tests such as X-rays and CT and MRI scans and are instead having to call the imaging department, which is overloading the department’s telephone lines. GSTT has declared the problem a “critical site incident”. It has apologised to patients and asked them to bring letters or other paperwork about their condition with them to their appointment to help overcome doctors’ loss of access to their medical history. One doctor at GSTT, speaking on condition of anonymity, said: “This is having a major effect. We are back to using paper and can’t see any existing electronic notes. We are needing to triage basic tests like blood tests and scans. There’s no access to results apart from over the phone, and of course the whole hospital is trying to use that line. “Frankly, it’s a big patient safety issue and we haven’t been told how long it will take to fix. We are on divert for major specialist services such as cardiac, vascular and ECMO.” Read full story Source: The Guardian, 21 July 2022
  12. Content Article
    Timely written communication between primary and secondary healthcare providers is paramount to ensure effective patient care. In 2020, there was a technical issue between two interconnected electronic patient record (EPR) systems that were used by a large hospital trust and the local community partners. The trust provides healthcare to a diverse multiethnic inner-city population across three inner-city London boroughs from two extremely busy acute district general hospitals. Consequently, over a four-month period, 58,521 outpatient clinic letters were not electronically sent to general practitioners following clinic appointments. This issue affected 27.9% of the total number of outpatient clinic letters sent during this period and 42,251 individual patients. This paper from Patel et al. describes the structure, methodological process, and outcomes of the review process established to examine the harm that may have resulted due to the delay.
  13. News Article
    Healthcare systems across Australia are buckling in the wake of COVID waves and the flu season. Pictures of ambulances piling up outside hospitals have become commonplace in the media. Known as “ramping”, it’s the canary in the coalmine of a health system. As a major symptom of a health system under stress, state governments across Australia are investing unprecedented amounts into ambulance services, emergency departments (EDs) and hospitals. South Australia has committed to an increased recruitment of 350 new paramedics. Likewise, New South Wales has committed to 1,850 extra paramedics. Victoria, meanwhile, has committed an additional A$162 million for system-wide solutions to counter paramedic wait times, on top of the A$12 billion already committed to the wider health system. This could begin to alleviate the system pressures that lead to ambulance ramping. But what happens when the paramedics return yet again to ED with another patient? Will they simply end up ramped again? We also need to consider better care in the community – and paramedics could play a role in this too. Read full story Source: The Conversation, 21 July 2022
  14. News Article
    A new patient medical records system at a Spokane Veterans Affairs hospital in the US has caused nearly 150 cases of patient harm, according to a federal watchdog agency. An inspection by the VA Office of the Inspector General (OIG) found that a new Cerner electronic health record (EHR) system, now owned by Oracle, failed to deliver more than 11,000 orders for specialty care, lab work and other services at Mann-Grandstaff VA Medical Center, the first VA facility to roll out the new technology. The OIG review found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of the intended care or service location, effectively causing the orders to disappear without letting clinicians know they weren't delivered. The intent of the unknown queue is to capture orders entered by providers that the new EHR cannot deliver to the intended location because the orders were not recognized as a “match” by the system, according to the VA watchdog. From facility go-live in October 2020 through June 2021, the new EHR failed to deliver more than 11,000 orders for requested clinical services. Those lost orders, often called referrals, resulted in delayed care and what a VA patient safety team classified as dozens of cases of "moderate harm" and one case of "major harm." The clinical reviewers conducted 1,286 facility event assessments and identified and classified 149 adverse events for patients. Read full story Source: Fierce Healthcare, 20 July 2022
  15. Content Article
    The government has published the first ever Women's Health Strategy for England to tackle the gender health gap.
  16. News Article
    Families who lost loved ones during the pandemic have demanded to play a central role in the UK’s Covid-19 inquiry, which launches its investigative phase tomorrow. The inquiry has already consulted with different groups, businesses, academics and officials from a variety of sectors involved in the pandemic response to review which areas warrant scrutiny and how to structure proceedings. This includes Covid-19 Bereaved Families for Justice, a campaign group of over 6,000 people who have lost a loved one to coronavirus. The group has repeatedly sought assurances from the inquiry it will be granted a ‘core participant’ status once applications open. This which would allow families to give evidence, ask questions during proceedings, access all disclosed documents, and recommend people to be interviewed. However, Elkan Abrahamson, a lawyer who is representing the group in the inquiry, said it was unclear how the inquiry would select core participants and expressed concern that the bereaved families won’t play a central role. “The feeling from the bereaved at the consultation stage was that the chair was sympathetic. They were happy with how that went,” Mr Abrahamson said. “[But] given we represent the largest group of bereaved in the UK, we’re not experiencing a sense of co-operation that we would normally expect to have reached by this stage. Their lawyers are happy to meet with us, but the questions we ask them aren’t being properly answered.” Read full story Source: The Independent, 20 July 2022
  17. News Article
    NHS leaders have sometimes been “shouting into the void” about their fears of the health service being overwhelmed by Covid because of the absence of a single national command centre for the pandemic response, a new report argues. The Tony Blair Institute for Global Change has published a report which recommends short and long term actions for dealing with Covid and future health emergencies. It says the government should have previously, and should now, set up “a national centre for response” to have overriding national responsibility for managing Covid and future crises. The government should also shift away from traditional methods of communication, to instead listen to “communities… beliefs and fears” about Covid, and adjust messages to respond to these. The report has been authored by the institute’s head of health Henry Dowlen, who was seconded to work on several pandemic projects such as a setting up a Nightingale Hospital and coordinating regional and national response work. He said that if government did not change course then the NHS, along with other services and parts of society, would remain in a “vicious cycle” of operational problems. Read full story (paywalled) Source: HSJ, 20 July 2022
  18. Content Article
    The UK’s current strategy is outlined in its “Living with Covid-19” plan, which has three key pillars: vaccines, testing and treatment. In April 2022, the Tony Blair Institute for Global Change undertook a critical analysis of this plan: what worked well, what didn’t, and what needed to change to manage Covid more effectively, and to protect society and the economy. The recommendations were incremental steps amounting to a responsible and proactive strategy. Unfortunately, as we see from the recent rapid rise in cases – most involving people who are being infected for the first time – as well as from the increasing hospitalisations and the rise in deaths, the strategy shows what living with Covid means in reality. To support the government, this paper sets out immediate and practical measures to safely guide the country through the latest Covid wave and to outline the longer-term shifts that will better prepare it for public-health emergency management in the future – including by restoring trust with the public. 
  19. Event
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    This online half day conference is very definitely NOT a repeat of the highly successful and very popular previous Clinical Negligence conferences we have held over the last three years. It's a completely new conference with a panel of 8 speakers, including 3 QCs and covering a selection of new and important subjects ranging from: a clinical negligence case law update for experts and lawyers, to the future of clinical negligence litigation and the material contribution test in causation The conference can be streamed live to your desktop, laptop or phone or you can watch the recording whenever you want. In either case you will receive a recording of the complete conference. Who should attend? The conference will appeal to solicitors, barristers, medical professionals, expert witnesses, NHS Trusts and Private Health Providers, insurers and associations. Topics Opening address delivered by Alexander Hutton QC: "The future of clinical negligence litigation". Clinical negligence case law update for experts and lawyers. The expert/lawyer relationship: Managing expectations. Divisible/indivisible injury and the material contribution test in causation. Interim payments of damages. Secondary victims – the law following Paul v Wolverhampton NHS FT. Diagnosis and management of strokes in the emergency and primary care settings - with a closer examination of the case of Pickering v Cambridge University Hospitals NHS Foundation Trust [2022] EWHC 1171 (QB). Understanding sepsis, and running sepsis claims. hub members can receive a 20% discount. Please email info@pslhub.org for discount code. Register
  20. Event
    until
    The International Alliance of Patients’ Organizations (IAPO) and Patient Academy for Innovation and Research (PAIR Academy) in partnership with Dakshama Health are launching a series of webinars to introduce the Strategic Framework of the Global Patient Safety Challenge - Medication Without Harm. The theme of the 5th webinar of the medication without harm webinar series is "Medication safety in high-risk situations”. This webinar will emphasise how to address high-risk situations and reduce the risk of medication-related harm, within WHO’s Global Patient Safety Challenge: Medication Without Harm, to improve medication safety. The patient safety series of webinars will focus on the strategic framework of the Global Patient Safety Challenge, which depicts the four domains of the challenge: patients and the public, health care professionals, medicine, and systems and practices of medication, and the three key action areas—namely polypharmacy, high-risk situations, and transitions of care, The series of webinars will share challenges, technical strategies, tools, and patient experiences in implementing the Strategic Framework of the Global Patient Safety Challenge to reduce medication-related harm. Register #medicationwithoutharm #medicationsafety #medications #patientafety #safemeds
  21. News Article
    Women and girls across England will benefit from improved healthcare following the publication of the first ever government-led Women’s Health Strategy for England today. Following a call for evidence which generated almost 100,000 responses from individuals across England, and building on 'Our Vision for Women’s Health', the strategy sets bold ambitions to tackle deep-rooted, systemic issues within the health and care system to improve the health and wellbeing of women, and reset how the health and care system listens to women. The strategy includes key commitments around: New research and data gathering. The expansion of women’s health-focused education and training for incoming doctors. Improvements to fertility services. Ensuring women have access to high-quality health information. Updating guidance for female-specific health conditions like endometriosis to ensure the latest evidence and advice is being used in treatment. To support progress already underway in these areas, the strategy aims to: Provide a new investment of £10 million for a breast screening programme, which will provide 25 new mobile breast screening units to be targeted at areas with the greatest challenges in uptake and coverage. This will: - provide extra capacity for services to recover from the impact of the coronavirus (COVID-19) pandemic - boost uptake of screening in areas where attendance is low - tackle health disparities - contribute towards higher early diagnosis rates in line with the NHS Long Term Plan. Remove additional barriers to IVF for female same-sex couples. There will no longer be a requirement for them to pay for artificial insemination to prove their fertility status and NHS treatment for female same-sex couples will start with 6 cycles of artificial insemination, prior to accessing IVF services, if necessary. Improve transparency on provision and availability of IVF so prospective parents can see how their local area performs to tackle the ‘postcode lottery’ in access to IVF treatment Recognise parents who have lost a child before 24 weeks through the introduction of a pregnancy loss certificate in England. Ensure specialist endometriosis services have the most up-to-date evidence and advice by updating the service specification for severe endometriosis, which defines the standards of care patients can expect. This sits alongside the National Institute for Health and Care Excellence (NICE) review of its guideline on endometriosis. Read full story Source: Gov.UK, 20 July 2022
  22. Content Article
    Presentation from NHS Supply Chain at the Safer Healthcare & Biosafety Network meeting on safer sharps.
  23. News Article
    Nearly half (49%) of all deaths of people with a learning disability in 2021 were deemed to be avoidable, a major annual report has found. By comparison, just 22% of deaths were classified as avoidable among the overall general population in 2020. A new report, led by King’s College London and produced for NHS England – identified that of those avoidable deaths among people with learning disabilities, 65.5% died in hospital. The learning from life and death reviews programme (LeDeR) report also revealed that the Midlands and North West showed the greatest difference in avoidable to unavoidable deaths at 53%, compared to 48% in London. And when looking at individual long-term conditions, 8% of avoidable deaths were related to cancer, 17% to diabetes, 14% to hypertension, and 17% to respiratory conditions. It also found that: More than 50% of people with a learning disability died in areas rated as some of the most deprived in England Around six out of 10 people with a learning disability die before age 65, compared to 1 in 10 from the general public On average, men with a learning disability die 22 years younger than men from the general population. Read full story Source: Healthcare Leader, 18 July 2022
  24. News Article
    A mother has said an NHS hospital failed to offer her daughter adequate pain relief in a pattern of poor treatment that left the teenager suicidal. Ella Copley, 17, from Tingley, West Yorkshire, has suffered from ME (myalgic encephalomyelitis), sometimes known as chronic fatigue syndrome, for seven years. She has been in Leeds General Infirmary since March, when she was taken there by ambulance with an infection later diagnosed as sepsis. Her mother, Joanne McKee, 49, said the treatment Ella had received “feels like neglect and abuse”. She has posted videos on social media of the teenager screaming in pain when medicine is given by nasogastric tube. “I don’t think they believe that her pain is real at all,” she said. McKee said doctors had told Ella she was “hypersensitive”, and suggested that she stroke a piece of material against her skin as part of a desensitisation programme. “I have just never, ever known anything so dismissive,” McKee said. In an interview with Times Radio, she added: “No one has any understanding of her conditions. That really is the issue." The charity Action for ME has written a letter to the hospital’s chief executive raising concerns over Ella’s case. In it, Sonya Chowdhury, chief executive of the charity, said she was “aware of several other situations that bear similarity with Ella’s illness and care”. Questions have been raised over the treatment of Maeve Boothby-O’Neill, who died in October last year. Her death will be the subject of an inquest in Exeter next month. Read full story (paywalled) Source: The Times, 18 July 2022
  25. Content Article
    Most doctors enter their training with a desire to help people. When a patient asks us for assistance, and what is requested is within our power, we generally say yes. If what they want is not safe or evidence based—another home detox from alcohol, or a drug that is blacklisted in our formulary—we have good reasons for declining. When the main reason for saying no is that we are just too busy, however, it is far harder. Our ability to say no raises questions of equity and patient safety; as there are not enough GPs to cope with patients’ demands, we need to be careful how we spend our time. If we want to continue to look after our patients safely, we must also start learning to say no in other spheres, politely pushing back against the transfer of work from hospitals to general practice.
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