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Patient Safety Learning

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  1. Content Article
    In this episode of Speak Up, Listen Up, Follow Up, Dr Jayne Chidgey-Clark, National Guardian for the NHS, speaks to Chris Hopson and Saffron Cordery, Chief executive and Deputy Chief executive of NHS Providers, about speaking up’s role in work force retention and how they will use speaking up in their new roles.
  2. Content Article
    With talk of tax cuts proving popular in the race to become the next Conservative party leader, and pay rise expectations significantly higher than budgets allow, the NHS could be caught in the crossfire of conflicting demands. Sally Gainsbury describes how the health service is already having to deal with Covid, alongside rising levels of demand for care, with substantially less money than before.
  3. Content Article
    UK doctors have submitted an open letter to the BMA requesting their commitment to supporting and actively advocating for its members who are living with Long Covid.
  4. News Article
    A sexual assault survivor chooses sterilization so that if she is ever attacked again, she won’t be forced to give birth to a rapist’s baby. An obstetrician delays inducing a miscarriage until a woman with severe pregnancy complications seems “sick enough.” A lupus patient must stop taking medication that controls her illness because it can also cause miscarriages. Abortion restrictions in a number of states and the Supreme Court’s decision to overturn Roe v. Wade are having profound repercussions in reproductive medicine as well as in other areas of medical care. “For physicians and patients alike, this is a frightening and fraught time, with new, unprecedented concerns about data privacy, access to contraception, and even when to begin lifesaving care,” said Dr. Jack Resneck, president of the American Medical Association. Even in medical emergencies, doctors are sometimes declining immediate treatment. In the past week, an Ohio abortion clinic received calls from two women with ectopic pregnancies — when an embryo grows outside the uterus and can’t be saved — who said their doctors wouldn’t treat them. Ectopic pregnancies often become life-threatening emergencies and abortion clinics aren’t set up to treat them. It’s just one example of “the horrible downstream effects of criminalizing abortion care,″ said Dr. Catherine Romanos, who works at the Dayton clinic. Read full story Source: AP News, 16 July 2022
  5. News Article
    Carole Davies and her partner, Malcolm, looked at each other in shocked silent horror as her surgeon spoke to them. Carole, 76, from Stevenage, Hertfordshire, had endured weeks of agony after an NHS surgeon had inserted a polypropylene mesh implant to treat a slight incontinence problem. The mesh was meant to act as a scaffold to support her leaking bladder. Carole, then 60 and a recently retired personnel administrator, had returned to see the surgeon with her partner seven weeks after the surgery. She was in tears as she explained her debilitating pain. 'I told the surgeon that I could feel the mesh cutting into me, which was agonising,' Carole told Good Health. 'But he ignored this and said everything was OK. He told me: 'I just don't understand how you could be in pain. I will refer you to a psychiatrist.' Then he turned to Malcolm and said: 'I've made her nice and tight for you.' ' It was lewd and inappropriate but, as we can reveal, is shockingly by no means an isolated example — an insult, literally, not just to Carole but for many others, among the tens of thousands of British women who have suffered agonising complications from mesh-tape operations since they were first introduced in the late 1990s to treat incontinence or prolapse. To add insult to injury, these women often struggled for years to have their complaints taken seriously, while surgeons dismissed the idea that there was anything wrong. The Mail joined forces with campaigning group Sling The Mesh to highlight the issue, the Government set up an inquiry, led by Baroness Cumberlege, in July 2018. This led initially to a pause in the use of surgical mesh for the treatment of urinary incontinence. The inquiry has since called for this pause to be extended until strict requirements on safety and recompense are met. Nevertheless, an investigation by Good Health last month found that not only is mesh still being surgically implanted in women, but also that its use could well be on the rise again. Sling The Mesh has received dozens of messages from women detailing similarly appalling responses, the majority in the past five years, that surgeons had made to deny, belittle and denigrate their agonising pain, emotional trauma and — in some cases — ruined sex lives. You can read all the messages on the hub's community thread. Read full story Source: Mail Online, 18 July 2022 Further reading Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh - a Patient Safety Learning blog
  6. News Article
    Doctors’ leaders have reacted with incredulity to demands that all hospitals in England take “immediate steps” to find extra space for patients so that no ambulance waits longer than 30 minutes. A letter from NHS England sent to the heads of NHS trusts, integrated care boards, and ambulance trusts acknowledged that this will not be easy “and that it may place additional burden on staff at an already challenging time. The letter was sent on 15 July, in response to the increased pressure on ambulance services over the past year and in light of the current heatwave. It said, “All systems that are currently unable to offload ambulances within 30 minutes should now take further steps to create capacity within acute hospitals to ensure the rapid release of vehicles. This will require risk based decisions to be made about both the use of estate and deployment of clinical workforce.” Vishal Sharma, chair of the consultants committee at the BMA, said, “The government should be ashamed that it has come to this. If hospitals had the space or the staff to allow them to care for these patients, they wouldn’t be waiting in ambulances at the hospital door in the first place. The sad fact is that after decades of underinvestment, our hospitals are under-resourced, under-bedded, and understaffed.” Read full story Source: BMJ, 18 July 2022
  7. News Article
    NHS England will ask GP practices to make ‘reasonable adjustments’ for patients with a learning disability or autism such as giving them ‘priority appointments’. They could also be asked to provide ‘easy-read appointment letters’ to the group, the Department of Health and Social Care (DHSC) said yesterday in a new strategy on strengthening support for autistic people and those with a learning disability. It said the measures aim to support Government plans to reduce reliance on mental health inpatient care, with a target to reduce the number of those with a learning disability or autism in specialist inpatient care by 50% by March 2024 compared with March 2015. The policy paper said: ‘We know that people experience challenges accessing reasonably adjusted support which may prevent them from having their needs met.’ It added: ‘To make it easier for people with a learning disability and autistic people to use health services, there is work underway in NHS England to make sure that staff in health settings know if they need to make reasonable adjustments for people." NHS England is also developing a ‘reasonable adjustments digital flag’ that will signal that a patient may need reasonable adjustments on their health record, it said. It plans to make this flag, which is currently being tested, available across all NHS services, it added. Read full story Source: Pulse 15 July 2022
  8. News Article
    Mental health patients who arrive at emergency departments (ED) in crisis are increasingly facing ‘outrageous’ long waits for an inpatient bed, with some being forced to wait several days. HSJ research suggests ED waits of more than 12 hours have ballooned in 2022, and are now around two-and-a-half times as high as pre-Covid levels. Early intervention for patients in mental health crisis is deemed to be crucial in their care and recovery. The Royal College of Emergency Medicine said the findings are a “massive concern”, while the Royal College of Psychiatrists described them as “unacceptable”. RCEM president Katherine Henderson said the experience of mental health patients in accident and emergency departments “is not what it should be from a caring healthcare system”. She said: “We have massive concern for this patient group. We feel they are getting a really poor deal at the moment. “The bottom line is there are not enough mental health beds. There are not enough community mental health services to support patients and perhaps therefore prevent a crisis and the need for beds in the first place. “Mental health crisis first responder teams work – a mental health practitioner working with the ambulance service can prevent the need for an ED visit.” Read full story (paywalled) Source: HSJ, 19 July 2022
  9. Content Article
    Today may be the most difficult day the NHS has ever experienced. The headlines will focus on the pressures created by the heatwave and that most visible sign of healthcare failure – ambulances queuing outside hospitals. But, as we know all too well, this brutal situation is the culmination of many factors, which include but are not limited to prolonged periods of underfunding in the past decade, lack of an adequate workforce plan, and a cowardly and short-sighted failure to undertake social care reform, writes Dr Kamran Abbasi, editor of the BMJ, and HSJ editor, Alastair McLellan, in this joint editorial.
  10. Content Article
    Patient Safety is a healthcare discipline that aims to prevent and reduce risks, errors, and harm that occur to patients during the provision of health care. As per WHO, millions of patients are harmed every year due to unsafe medication practices, 2.6 million deaths annually in low-and middle-income countries alone. Today, patient harm due to unsafe care is a large and growing global public health concern and is one of the leading causes of death and disability worldwide. Most of this patient harm is avoidable. The Asia Pacific Patient Safety Network's mission is to advocate for patient safety, where everyone receives safe and high-quality medical care while reducing unavoidable harm due to unsafe care across the globe.
  11. Content Article
    Safety at design is giving due consideration to safety at the conceptual stage of your design. We mostly do not look at this and what we end up completing the design of a product with high ergonomics risks to the end users. What should we consider and how should we go about this? These and many more are will looked at in this presentation from Ehi Iden, chief executive of Occupational Health and Safety Managers.
  12. News Article
    Press release: London, UK, 18 July 2022 In a letter shared with Patient Safety Learning, Keith Conradi, outgoing Chief Investigator at the Healthcare Safety Investigation Branch (HSIB), has raised serious concerns with the Secretary of State about the lack of interest shown in the patient safety activities of HSIB at the highest levels of the Department of Health and Social Care and NHS England. Keith Conradi states that successive leaders of NHS England have shown “little interest” in the work of HSIB. He also highlights concerns about NHS England’s engagement in several HSIB investigations delayed by the pandemic, stating that a lack of participation has “reduced the safety impact of their output”. The letter calls for the Department of Health and Social Care to take a safety management system approach to safety, like other safety critical industries such as aviation. Keith Conradi notes that currently where patient safety is done well in the NHS, this is “because of the drive and enthusiasm of individuals rather than through a state organised structured approach”. Commenting on this letter, Patient Safety Learning’s Chief Executive Helen Hughes said: “We believe that HSIB can play an important role in improving patient safety in the NHS, but not without system-wide commitment and support for their work. It is disappointing to hear of this apparent lack of interest in their activities by NHS England. We were also deeply alarmed by concerns about a lack of engagement by NHS England in HSIB safety investigations reducing their impact. This is simply not acceptable and flies in the face of the NHS Patient Safety Strategy’s vision of seeking to continuously improve patient safety. We hope that NHS England will seriously rethink its approach to how it works with the national patient safety investigator, and that the new Secretary of State and incoming new Prime Minister seek to reset and re-invigorate our national approach to improving patient safety.” Notes to editors Patient Safety Learning is a charity and independent voice for improving patient safety. We harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of harm. We support safety improvement through policy, influencing and campaigning and the development of ‘how to’ resources such as the hub, our free award-winning platform to share learning for patient safety. HSIB is the independent national investigator for patient safety in England. It seeks to improve patient safety through professional safety investigations that do not apportion blame or liability.
  13. News Article
    A paediatrician has been struck off for falsely diagnosing children with cancer to scare their parents into paying for expensive private treatment. Dr Mina Chowdhury, 45, caused "undue alarm" to the parents of three young patients - one aged 15 months - by making the "unjustified" diagnoses so his company could cash in by arranging tests and scans, a medical tribunal found. Chowdhury, who worked as a full-time consultant in paediatrics and neonatology at NHS Forth Valley, provided private treatment at his Meras Healthcare clinic in Glasgow. But the clinic made losses, despite "significant" potential income from third-party investigations and referrals for treatment – with patients charged a mark up fee of up to three times the actual cost. In all three cases, Chowdhury gave a false cancer diagnosis, without proper investigation, before recommending “unnecessary and expensive” private tests and treatment in London. Parents previously told the tribunal of their shock and upset at receiving Chowdhury’s diagnoses during consultations between March and August 2017. He told the parents of a 15-month-old girl - known as Patient C - that a lump attached to the bone in her leg was a "soft tissue sarcoma" and a second lump had developed. Chowdhury urged them to see a doctor in London who could arrange an ultrasound scan, a MRI scan and biopsy in a couple of days, saying: "If things are happening it is best to get on top of them early." He also warned that it would be "confusing" to return to the NHS for treatment. But the parents spoke to an A&E doctor and an ultrasound scan revealed that the lumps were likely fat necrosis. Patient C later was discharged after her bloods tests came back as normal. The child’s mother told the tribunal that she and her husband had been "very upset" at Chowdhury’s diagnosis. She was also left "angry" after she later read Dr Chowdhury’s consultation notes and realised they were a "total falsification" of what was discussed. Read full story Source: Medscape, 18 July 2022
  14. News Article
    Patients are at risk of a missed cancer diagnosis due to a reliance on paper records, an NHS trust has admitted after a man died due to his tumour being overlooked. Michael Lane, 50, from Shrewsbury, was “failed” by Shrewsbury and Telford Hospital Trust, his family has said after his cancer scan result was misplaced leaving him with a growing kidney tumour for 10 years. The trust is yet to fully launch an electronic record system a year after an investigation into Mr Lane’s death warned other patients were at risk due to the gap in paper records. Mr Lane went into Shrewsbury and Telford Hospital for a scan following a referral for suspected cancer in 2011. The radiographer flagged a small tumour but the scan was overlooked, placed within his paper records and never reported as being a concern. In an investigation report carried out by the trust in May 2021, seen by The Independent, the hospital admitted that had his tumour been seen and operated on earlier he may have survived. The report also admitted there were ongoing risks within the trust due to gaps in its electronic records system. It said: “The implementation of an IT solution will not prevent sad cases such as that of Mr Lane where the scan report that was missed took place before the widespread availability of such systems, however, it is clear that until we have an electronic requesting and sign-off system we remain at risk of new cases of missed results and harm occurring as a result of the ongoing reliance of paper-based results.” Read full story Source: The Independent, 17 July 2022
  15. News Article
    Medical experts in cases involving doctors should have a mandatory duty to consider systems issues such as inadequate staffing levels to avoid them being scapegoated for wider failures, the Medical Protection Society (MPS) has said. The MPS, which supports the the professional interests of more than 300,000 healthcare professionals around the world, says medical expert reports focus on scrutinising the actions of the individual doctor even when failings are a result of the setting in which they work. Its report on the issue, shared with the Guardian before publication, points out that for doctors “adverse opinion can lead to loss of career or liberty”. It references the case of Dr Hadiza Bawa-Garba who was convicted of gross negligence manslaughter in 2015 and handed a 24-month suspended sentence for her part in the death of six-year-old Jack Adcock from sepsis. She was later struck off by the General Medical Council before the court of appeal overturned the GMC’s decision. Dr Rob Hendry, the MPS medical director, said: “In giving an opinion on whether or not the care provided by a doctor has fallen short of a reasonable standard, it would seem fair to the doctor that the medical expert considers all relevant circumstances. Any individual performance concerns must of course be addressed, but doctors should not be scapegoats for the failings of the settings in which they work. Sadly, we see this all too often in cases against doctors … “Many expert reports focus solely on the actions of the individual without considering the wider context. In reality, patient harm arising from medical error is rarely attributable to the actions of a single individual. Inadequate staffing levels, lack of resources, or faulty IT systems are just some issues which can contribute to adverse incidents. Doctors confront these issues every day and have little influence over them.” Read full story Source: The Guardian, 18 July 2022
  16. News Article
    Catherine O’Connor, who was born with spina bifida and used a wheelchair all her life, was looking forward to the surgery to fix her twisted spine. Tragically, after a catastrophic loss of blood, she died on the operating table at Salford Royal Hospital in Manchester. She died in February 2007 but only now has an NHS-commissioned report concluded the “unacceptable and unjustifiable” actions of her surgeon, John Bradley Williamson, “directly contributed” to her death. Williamson pressed on with the surgery despite being explicitly told he needed a second consultant surgeon. Her case is one of more than a hundred of Williamson’s being reviewed by Salford Royal Hospital amid allegations by whistleblowers of a cover-up by managers and a “toxic culture” within his surgery team. An internal list produced by concerned clinicians as long ago as 2014 describes some of Williamson’s patients being left paralysed or in severe pain as a result of misplaced spinal screws and others being rushed back to theatre for life-saving surgery. Separately, leaked minutes of a meeting between staff and the hospital’s new chief executive in December 2021 described a “snapshot” of five of Williamson’s patients which “clearly identified significant areas of clinical care, avoidable harm and avoidable death”. They added: “Concerns around Mr Williamson continue to be raised and remain unaddressed.” Read full story (paywalled) Source: The Times, 17 July 2022
  17. News Article
    A senior hospital nurse said she could not discharge 180 patients due to a lack of "care and support" at home. Norfolk and Norwich University Hospital said among the people that did not need to be in hospital was a patient who had been there for 145 days. Claire Fare, senior discharge matron, said delays "impact on the whole of the flow" of patients. Norfolk County Council's social care department blamed the "national care crisis" for the problems. In June, the hospital, which has about 1,200 beds, pleaded for family and friends to help look after fit patients to ease demand. Melanie Syson, the hospital's discharge coordinator, said there was a person in the hospital ready for discharge that had been there for more than four months. "She is medically fit to be discharged but we are waiting for support to be ready at home," she said. Ms Syson added: "The length of stay of the patients seems to be getting longer." To help cope with the delays, the hospital opened a "home-first unit" in January for patients who did not need acute care but it was unable to discharge. The unit focuses on rehabilitation to try to prevent the patients coming back into hospital or requiring more care at home. Stephanie Ward, the ward sister, said it aimed to "give patients the time they need to do things themselves as much as they can". Read full story Source: BBC News, 15 July 2022
  18. Content Article
    The NHS is not in a place where it can lose staff, but many workers in the health service have faced almost unimaginable difficulties during the pandemic. How worried should we be about NHS staff health and wellbeing? Nigel Edwards and Andy Cowper look at how bad the situation is and what can be done to improve things.
  19. Content Article
    Mesh survivors Katherine Cousins and Mary McLaughlin talk about their ongoing fight for justice for women suffering due to vaginal mesh.
  20. Content Article
    This article discusses how medication safety can be improved in Canada. It explores the complexities of aging, what can go wrong with medication, 'Best Possible Medication Histories', the role of pharmacists and paramedics, engaging with patients and their families, and improving communication across the healthcare system.
  21. Content Article
    The government recently appointed Dame Lesley Regan, professor of obstetrics and gynaecology at Imperial College London, as the first women’s health ambassador for England. The new role has been created to help close the gender health gap. Shakila Thangaratinam, Professor of Maternal and Perinatal health, University of Birmingham, reflects on what Dame Regan should focus on in this blog for The Conversation.
  22. Content Article
    Despite under-reporting, health workers (HWs) accounted for 2-30% of the reported COVID-19 cases worldwide. In line with data from other countries, Jordan recorded multiple case surges among HWs. This study from Tarif et al. looked at infection prevention and control risk factors in HWs infected with Covid-19. Study findings confirmed the role of hand hygiene as one of the most cost-effective measures to combat the spreading of viral infections.
  23. Content Article
    Discussion on issues relating to vaginal mesh implants from 29 Jun 2022.
  24. News Article
    Serious incidents causing patient harm have increased steeply compared to previous years at an ambulance service whose nursing director still expects will “fail” next month under mounting service pressures. There were 98 patient harm incidents at West Midlands Ambulance Service in June, official data obtained by HSJ suggests, up from 49 in the same month last year. The figures show that from April-June this year, 262 harm incidents have been logged – a 240% on 77 in the same period in 2019 and a 71% on 153 last year. Nursing director Mark Docherty, who previously warned the service was facing a “Titanic moment” and would “all fail” around a specific date of 17 August, said much of the increase can be attributed to worsening hospital handover delays. More than 700 people at one time waited for ambulances “that were not going to turn up” on Monday, according to Mr Docherty, who described the situation as a “really dangerous place to be”. Mr Docherty explained how the harm incidents, including deaths, resulted from growing delays: ”You can’t underplay the risk. If you’ve got 750 patients like we did on Monday waiting, none of those patients have been assessed. “Sadly, amongst them there will have been patients with stroke who won’t be treated because they’ve waited too long." Read full story (paywalled) Source: HSJ, 15 July 2022
  25. Content Article
    The LeDeR programme, funded by NHS England and NHS Improvement, was established in 2017 to improve healthcare for people with a learning disability and autistic people. LeDeR aims to: Improve care for people with a learning disability and autistic people. Reduce health inequalities for people with a learning disability and autistic people. Prevent people with a learning disability and autistic people from early deaths. LeDeR summarises the lives and deaths of people with a learning disability and autistic people who died in England in annual reports. The 2021 reports were made by researchers at King’s College London collaborating with academic partners at the University of Central Lancashire and Kingston-St George’s University, London, copies of which can be accessed from the link below along with a video summary of the findings and “TakeHome” posters.
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