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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    the U.S. Food and Drug Administration (FDA) announced it is seeking public comment on a potential change that would require opioid analgesics used in outpatient settings to be dispensed with prepaid mail-back envelopes and that pharmacists provide patient education on safe disposal of opioids. This potential modification to the existing Opioid Analgesic Risk Evaluation and Mitigation Strategy would provide a convenient, additional disposal option for patients beyond those already available such as flushing, commercially available in-home disposal products, collection kiosks and takeback events. Patients commonly report having unused opioid analgesics following surgical procedures, thereby creating unfortunate opportunities for nonmedical use, accidental exposure, overdose and potentially increasing new cases of opioid addiction. Since many Americans gain access to opioids for the first time through friends or relatives who have unused opioids, requiring a mail-back envelope be provided with each prescription could reduce the amount of unused opioid analgesics in patients' homes. Data show educating patients about disposal options may increase the disposal rate of unused opioids and that providing a disposal option along with education could further increase that rate. Mail-back envelopes have several favorable characteristics. They do not require patients to mix medications with water, chemicals or other substances nor use other common at-home disposal techniques. Opioid analgesics sent back to Drug Enforcement Administration-registered facilities in mail-back envelopes do not enter the water supply and landfills (instead, they are incinerated). The nondescript mail-back envelopes provided would be postage paid, offering patients a free disposal option. Additionally, there are long-standing regulations and policies in place to ensure that mail-back envelopes are fit for that purpose and can safely and securely transport unused medicines from the patient's home to the location where they will be destroyed. "The FDA is committed to addressing the opioid crisis on all fronts, including exploring new approaches that have the potential to decrease unnecessary exposure to opioids and prevent new cases of addiction. Prescribing opioids for durations and doses that do not properly match the clinical needs of the patient not only increases the chances for misuse, abuse and overdose, but it also increases the likelihood of unnecessary exposure to unused medications," said FDA Commissioner Robert M. Califf, M.D. "As we explore ways to further address this issue more broadly, the mail-back envelope requirement under consideration for these unused medications would complement current disposal programs and provide meaningful and attainable steps to improve the safe use and disposal." Read full story Source: Cision, 20 April 2020
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    Sodium chloride and Metronidazole - two different liquids for intravenous infusion stored together in similar packaging.
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  5. News Article
    A healthcare worker caught Covid on two separate occasions over the course of just 20 days, a new study has shown. It is believed to be the shortest recorded time between two infections since the start of the pandemic. Since the arrival of the highly infectious Omicron variant, reinfections have become far more prominent. The 31-year-old woman from Spain first became infected with Delta in December 2021 – 12 days after she had received her Covid booster vaccine. Lab analysis showed that she had initially been infected by the Delta variant, followed by Omicron. Her case, which is being presented to the European Congress of Clinical Microbiology and Infectious Diseases in Portugal, is believed to represent the shortest recorded time between two separate infections. Dr Gemma Recio of the Institut Catala de la Salut in Spain, who is one of the study’s authors, said: “This case highlights the potential of the Omicron variant to evade the previous immunity acquired either from a natural infection with other variants or from vaccines". “In other words, people who have had Covid-19 cannot assume they are protected against reinfection, even if they have been fully vaccinated." Read full story Source: The Independent, 21 April 2022
  6. News Article
    A woman has described how she spent more than six hours of her 100th birthday waiting in agony for an ambulance after slipping and fracturing her pelvis while getting ready for a family lunch. Irene Silsby was due to be picked up by her niece, Lynne Taylor, for a celebration to mark her centenary on 9 April. But she fell in the windowless bathroom of her care home in Greetham, Rutland, and staff called an ambulance at 9am after she managed to summon help. “All I remember is I was in terrible pain,” said Silsby from her hospital bed on Saturday. When asked of the ambulance delay, she said: “It’s disgusting. I don’t know how I stood it so long, the pain was so severe.” Taylor expected to meet the ambulance as she arrived 45 minutes later. But when she reached the care home, the manager said it would be a 10-hour wait, she said. What was to be her aunt’s first trip outside the care home in more than five months turned into her lying on a cold floor surrounded by pillows and blankets to keep her warm and quell some of the discomfort. Taylor, 60, recalled her aunt saying: “They’re not coming to me because they know I’m 100 and I’m not really worth it any more.” Taylor said she had never felt so scared, frustrated and worried. After calling 999 and expressing her outrage, she was told that life-threatening conditions were being prioritised. “I thought she was going to die,” she said. “I didn’t think that any frail, tiny, 100-year-old body could put up with that level of pain on the floor.” Read full story Source: The Guardian, 20 April 2022
  7. News Article
    A father whose son took his own life in July 2020 is calling for an "urgent overhaul" of the way some counsellors and therapists assess suicide risk. His son Tom had died a day after being judged "low risk", in a final counselling session, Philip Pirie said. A group of charities has written to the health secretary, saying the use of a checklist-type questionnaire to predict suicide risk is "fundamentally flawed". The government says it is now drawing up a new suicide-prevention strategy. According to the latest official data, 6,211 people in the UK killed themselves in 2020. It is the most common cause of death in 20-34-year-olds. And of the 17 people each day, on average, who kill themselves, five are in touch with mental health services and four of those five are assessed as "low" or "no risk", campaigners say. Tom Pirie, a young teacher from Fulham, west London, had been receiving help for mental-health issues. He had repeatedly told counsellors about his suicidal thoughts - but the day before he had killed himself, a psychotherapist had judged him low risk, his father said. Tom's assessment had been based on "inadequate" questionnaires widely used despite guidelines saying they should not be to predict suicidal behaviour, Philip said. The checklists, which differ depending on the clinicians and NHS trusts involved, typically ask patients questions about their mental health, such as "Do you have suicidal thoughts?" or "Do you have suicidal intentions?" At the end of the session, a score can be generated - placing the individual at low, medium or high risk of suicide, or rating the danger on a scale between 1 and 10. Read full story Source: BBC News, 20 April 2022
  8. News Article
    Patients who have “lost hope” of ever seeing a doctor are falling off NHS waiting lists due to poor record-keeping by the SNP government, Scotland’s public spending watchdog has revealed. Stephen Boyle, the auditor-general, said there was no record of patients who drop off the waiting list to go private or who simply give up. Humza Yousaf, the health secretary, said he was aware of “a small number of people” who had gone abroad for transplants, including one of his own constituents. He admitted there was no way of knowing the scale of the issue, or whether the organs were obtained legally. Boyle said: “I don’t wish to be blasé and say it is straightforward, but it really should not be an insurmountable problem to have a clear vision and strategy, reviewed and commented on, with an annual transparent plan to track progress. “The government themselves don’t have the complete data we think they should have to make some of the decisions about the delivery of health and social care services and reform.” Gillian Mackay, an SNP MSP, said some constituents told her that they have been put on a waiting list and “they hear nothing more about when they will be seen, or how they will be prioritised”. Boyle said the NHS needs to “manage patients’ expectations about how long they will have to wait”. He said: “Everybody who is waiting for services needs to have a clear expectation of when they will receive those services, whether it is [for] cancer, or other treatments on clinical prioritisation. There is clear missing part in transparency.” Read full story (paywalled) Source: The Times, 19 April 2022
  9. News Article
    Growing numbers of patients in the UK are paying for private medical treatment because of the record delays people are facing trying to access NHS care, a report has revealed. They are using their own savings to pay for procedures that involve some of the longest waiting times in NHS hospital, such as diagnostic tests, cataract removals and joint replacements. The increase in the willingness to self-pay is closely linked to a desire for private treatments that was increasing even before Covid struck in March 2020. But many private hospitals were unable to meet that demand for much of the pandemic because coronavirus disrupted so much normal healthcare. Dr Tony O’Sullivan, an ex-NHS consultant and a co-chair of the campaign group Keep Our NHS Public, said: “The government’s deliberate and sustained running down of the health service has resulted in a two-tier system. The NHS is now in a permanent state of distress, leaving patients desperate for care, and – if they can afford it – feeling as if they have no choice but to go private, undermining the very vision of equality and care a well-funded NHS was so famous for. “Hard-working people would not need to line shareholders pockets in this way if the NHS had not been underfunded, understaffed and neglected for so long.” Read full story Source: The Guardian, 20 April 2022
  10. Content Article
    Diabetes UK are calling on government for a recovery plan to tackle 'devastating’ diabetes care delays – before it’s too late   Diabetes is serious and people living with diabetes have been ‘pushed to the back of the queue’ during the coronavirus pandemic and a national recovery plan is needed to support front-line healthcare teams in getting vital services back on track.    Diabetes UK warn that despite the tireless efforts of the NHS through the pandemic, many people living with the condition are still struggling to access the care they need, putting them at risk of serious complications, which can lead to premature death.   This new report published by Diabetes UK as part of our Diabetes Is Serious campaign, shows the scale of the problem and sets out a series of calls to UK Government to tackle it.  
  11. News Article
    Ambulance trusts are seeing rising numbers of serious incidents resulting from delays in reaching patients, research by HSJ has uncovered. Serious incidents are defined by the NHS as a patient safety failure “where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified.” East Midlands Ambulance Service Trust saw 71 serious incidents in 2021-22 compared with 38 in the financial year before. The trust’s board papers attribute the increase in SIs related to delayed responses since June 2021 to “sustained pressure on the service” and the resulting growing handover times at accident and emergency departments. Of 14 SIs reported in February and the first half of March 2022, seven were due to “prolonged waits for an ambulance response”. West Midlands University Ambulance Service Foundation Trust has also seen an increase in SIs. Its board papers report that half of the SIs are due to “delays in reaching patients resulting in harm, serious harm, and deaths”. It has given the issue of “hospitals, breaches, delays and turnaround times” the maximum rating of 25 on its risk register. Long delays – especially for category two patients, where average performance last month was above an hour – are causing increasing concern. Stroke Association chief executive Juliet Bouverie said the organisation was hearing “shocking accounts from stroke survivors who have waited hours for an ambulance… We are extremely worried that stroke survivors’ lives and recoveries are being put at extreme risk.” Read full story (paywalled) Source: HSJ, 20 April 2022
  12. News Article
    The prevalence of sexually transmitted diseases (STDs) and deaths from drug overdoses increased in the US over the past two years, showing the pandemic’s effect on public health. “Even in the face of a pandemic, 2.4 million cases of chlamydia, gonorrhoea, and syphilis were reported,” the US Centers for Disease Control and Prevention (CDC) said. STDs declined during the early months of the pandemic in 2020 but then increased rapidly. Cases of gonorrhoea increased by 10% during 2020 compared with 2019. Cases of primary and secondary syphilis increased by 7% and congenital syphilis in newborns increased by 13%.2 New data suggest that primary and secondary syphilis—the most infectious stages of the disease—continued to increase during 2021, the CDC said. Jonathan Mermin, director of CDC’s national centre for HIV, viral hepatitis, STD, and tuberculosis prevention, said, “The unrelenting momentum of the STD epidemic continued even as prevention services were disrupted.” His colleague, Leandro Mena, director of CDC’s division of STD prevention, said, “The pandemic increased awareness of a reality we’ve long known about STDs. Social and economic factors—such as poverty and health insurance status—create barriers, increase health risks, and often result in worse health outcomes for some people.” Another disturbing trend during the pandemic has been the increase of deaths from drug overdoses, especially among teenagers. Just over 100 000 Americans died of drug overdoses during the year to April 2021, according to the CDC’s national centre for health statistics—an increase of 28.5% from the previous year. Read full story Source: BMJ, 19 August 2022
  13. Content Article
    Dr Robert D. Glatter, medical advisor for Medscape Emergency Medicine, Dr Megan Ranney, professor of emergency medicine and the academic dean at Brown University School of Public Health and Dr Jane Barnsteiner, emeritus professor at the University of Pennsylvania School of Nursing, discuss the tragic case involving RaDonda Vaught, who was an ICU nurse who was recently convicted in Tennessee of criminally negligent homicide and gross neglect following a medical error due to administration of the wrong medication that led to a patient's death.
  14. News Article
    A hospital has admitted clinical negligence over maternity care failings that led to the potentially avoidable death of a 10-day-old baby, The Independent has learned. Kingsley Olasupo and his twin sister Princess were born on 8 April 2019 at Royal Bolton Hospital. Kingsley died 10 days later following a catalogue of mistakes, which included failing to screen him for sepsis. Kingsley and his sister were born premature at 35 weeks. Three days later he was admitted to the special care unit due to a low temperature and “poor” feeding. Despite being reviewed by two doctors he was not screened for an infection and not given antibiotics. His condition deteriorated and on 12 April he was diagnosed with bacterial meningitis and sepsis. Days later scans revealed he had severe brain damage and would not survive. Kingsley’s family said they had been “torn apart” by their son’s death and had pursued the trust to ensure a full independent investigation was carried out and lessons learnt. BFT launched an investigation into Kingsley’s care after Mr Olasupo and Ms Daley raised concerns over their son’s death. According to the trust’s investigation report, seen by The Independent, failings in care included that Kingsley was not screened for sepsis despite several “red flags”. Had this been done he would have been given antibiotics. When midwives first escalated concerns to the neonatal team no physical medical review of Kingsley took place. The investigation also found neonatal staff did not carry out daily reviews, and reviews that were done were incomplete and contained “inaccurate” and “misleading” information. Other failings included: “Ineffective” assessment of Kingsley’s wellbeing on the postnatal ward Poor communication between staff and poor handover processes No consideration was given to the fact Kingsley was not feeding well Inadequate recording of observations. Read full story Source: The Independent, 20 April 2022
  15. News Article
    Health officials say they are now investigating unexplained cases of hepatitis in children in four European countries and the US. Cases of hepatitis, or liver inflammation, have been reported in Denmark, Ireland, the Netherlands, Spain and the US, health officials say. Last week UK health authorities said they had detected higher than usual cases of the infection among children. The cause of the infections is not yet known. The European Centre for Disease Control (ECDC) did not specify how many cases have been found in the four European countries in total. But the World Health Organization (WHO) said less than five had been found in Ireland, and three had been found in Spain. It added that the detection of more cases in the coming days was likely. Investigations into the cause of the infections are ongoing in all of the European countries where cases have been reported, said the ECDC. In the US, Alabama's public health department said nine cases have been found in children aged one to six years old, with two needing liver transplants. Investigations into similar cases in other states are taking place, it added. Read full story Source: BBC News, 20 April 2022
  16. Content Article
    The Japan Council for Quality Health Care (JQ) has been conducting various activities, such as the Project to Collect Medical Near-Miss/Adverse Event Information and the evaluation of medical services provided at hospitals, in order to maintain public confidence in healthcare services and improve the quality of the services. In response to rising awareness and expectations of the general public as well as medical institutions concerning promotion of patient safety and medical adverse event prevention, the JQ has been actively engaged in the said activities. The JQ Division of Adverse Event Prevention has been undertaking the Project to Collect Medical Near-Miss/Adverse Event Information to prevent medical adverse events and to promote patient safety since 2004. As a neutral third-party organisation, the JQ has been publishing collected medical near-miss/adverse event information and the analyses of data in the form of periodic reports, annual reports and monthly fax newsletters for medical professionals, administrative organisations and the general public. The reports can also be browsed on JQ's website.
  17. News Article
    Pregnant women have been an "afterthought" during the coronavirus pandemic and some of their deaths were "preventable", a leading scientist has told Newsnight. Data shows there have been at least 40 maternal deaths from Covid in the UK. Almost all were unvaccinated and more than half happened after pregnant women were advised to take-up the vaccine. The regulator says vaccines during pregnancy are "safe". Professor Marian Knight, who investigates every maternal death in the UK, said lifesaving messaging is still "struggling" to reach pregnant women, a year on since all of them were advised to get vaccinated. Professor Knight said: "This has perhaps been the first year where my job has made me cry because that was a preventable situation." During the first months of the vaccine rollout, only pregnant health or care workers or those in at-risk groups were advised by the Joint Committee on Vaccination and Immunisation to "consider" the jab due to a "lack of evidence". In April 2021, the advice was updated to cover all pregnant women after real-world data raised no safety concerns. By December 2021, a year after the rollout began, pregnant women were deemed to be more at risk of falling seriously ill from Covid and were put on the priority list for jabs. Professor Knight, the maternal lead for pregnancy monitoring group MBRRACE-UK, said changing initial advice wasn't helpful, but stresses the JCVI had little choice because pregnant women were not included in Covid vaccine trials. "It's a complicated message," she said. "The message 'don't get vaccinated because we haven't got any information' is very subtly different from 'don't get vaccinated because it's not safe'. You may think, 'I can't get vaccinated because I'm pregnant, it must not be safe'. Whereas actually we don't yet have enough information." Read full story Source: BBC News, 20 April 2022
  18. News Article
    Pregnant women should be tested for Group B Strep to save the lives of dozens of babies every year, campaigners have warned. Group B Strep is the most recurrent cause of life-threatening illness in newborn babies, with an average of two babies a day identified with the infection. Each week, one of these babies goes on to die while another develops an ongoing long-term disability. More than one in five women carry Group B Strep, a common bacteria that normally causes no harm and no symptoms. However, its presence in the vagina or rectum means babies can be exposed to it during labour and birth. Pregnant women in Britain are not routinely tested for its presence, but a trial led by the University of Nottingham is examining whether such a move would be effective. Campaigners have called for more hospitals to join the pilot to ensure it is successful. Jane Plumb, chief executive of campaign group Group B Strep Support, said: “It’s taken over 20 years of campaigning to get this trial commissioned. It’s devastating that only 30 of the 80 hospitals needed have signed up. We can’t let this trial fail. “We need to fight for the 800 babies per year that are infected with this too-often-deadly infection. We need more hospitals to take part. We need to rally together and get this trial over the finish line.” Ms Plumb said the majority of Group B Strep infections in babies are preventable. “If we don’t know, then they can’t be offered the protective antibiotics in labour,” she said. “Families so often tell us that the first time they hear of Group B Strep is after their baby falls ill. For a mostly preventable infection, this is unforgivable – and must change. “We want to encourage every hospital to take part. We need people to ask for their MP’s support. This is an opportunity to save so many babies’ lives, but we only have six months to get hospitals on board. It really is now or never.” Read full story Source: The Independent, 19 April 2022
  19. News Article
    A significant relaxation of infection control guidance has been announced in a bid to free up more capacity to tackle substantial waiting lists and demand for emergency care. New guidance issued jointly by the Department of Heath and Social Care, the UK Health Security Agency, NHS England and health bodies in the devolved nations, recommends the relaxation of isolation requirements for inpatients who either test positive for Covid-19 or are considered close contacts of people with the virus. The isolation period for inpatients with Covid-19 can now be reduced from 10 days to seven if they have two negative lateral flow tests. The tests must be taken on two consecutive days from day six of the isolation period onwards, and the patient must also “[show] clinical improvement”. A letter from NHSE released to trust chiefs, sent last Thursday, also recommends the “[return] of pre-pandemic physical distancing in all areas,” including emergency departments, ambulances and “all primary care, inpatient and outpatient settings.” It also recommends the returning to pre-pandemic cleaning procedures outside Covid-19 areas. Read full story (paywalled) Source: HSJ, 19 April 2022
  20. News Article
    Thousands of lives are being put at risk due to delays and disruption in diabetes care, according to a damning report that warns patients have been “pushed to the back of the queue” during the Covid-19 pandemic. There are 4.9 million people living with diabetes in the UK, and almost half had difficulties managing their condition last year, according to a survey of 10,000 patients by the charity Diabetes UK. More than 60% of them attributed this partly to a lack of access to healthcare, which can prevent serious illness and early mortality from the cardiovascular complications of diabetes, rising to 71% in the most deprived areas of the country. One in three had no contact with healthcare professionals about their diabetes in 2021, while one in six have still not had contact since before the pandemic, the report by the charity said. Diabetes UK said that while ministers have focused on tackling the elective surgery backlog, diabetes patients have lost out as a result, and there is now an urgent need to get services back on track before lives are “needlessly lost”. Chris Askew, the chief executive of Diabetes UK, called for a national diabetes recovery plan. “Diabetes is serious and living with it can be relentless,” he said. “If people with diabetes cannot receive the care they need, they can risk devastating, life-altering complications and, sadly, early death. “We know the NHS has worked tirelessly to keep us safe throughout the pandemic, but the impacts on care for people living with diabetes have been vast. While the UK government has been focused on cutting waiting lists for operations and other planned care, people with diabetes have been pushed to the back of the queue.” Read full story Source: The Guardian, 20 April 2022
  21. Content Article
    The Safety Culture Programme for Maternity & Neonatal Board Safety Champions was commissioned by NHSE/I Women’s Health Policy team. The programme was co-designed with stakeholders including Board Safety Champions, Leaders from the Maternity and Neonatal system and Maternity Voices Partnership through March 2021. The programme is underpinned by the NHSE/I framework developed by the Maternity Transformation Programme Board. The aim of the framework and the programme (concluded on 25 March 2022) is to create the conditions for a culture of safety and continuous improvement across perinatal services to improve the quality, safety and experience of care. View the presentation slides from the recent Aqua event and an overview of the HSIB Investigation Programmes highlighting the differences between the National Investigations Programme and the Maternity Investigations Programme.
  22. Content Article
    Quality and Outcomes Framework (QOF) might be back this month – but for practices the work never went away, practices managers have told Management in Practice. NHS England announced the resumption of the payments system last December after QOF was part-suspended in 2021/22 to free up time for Covid vaccinations. But while the QOF system was on hold, many practices have carried on with QOF targets throughout the pandemic, continuing to measure their performance against these indicators.. Now the programme has officially returned, despite concerns that the system does not take into account the significant impact of the pandemic on long-term conditions, and could financially penalise practices. Practice managers are, once again, having to get to grips with targets, and needing to organise appointments for patients most in need of a face-to-face review, while dealing with day-to-day work pressures and staff shortages. Here practice managers share their thoughts on the comeback of QOF, what it will mean for them and their practices, and whether its return is too much, too soon.
  23. Content Article
    Whatever your standpoint on whether the pandemic is over, or what “living with the virus” should mean, it is clear some manifestation of Covid-19 will be with us for some time to come. Not least for the estimated 1.7 million people in the UK living with Long Covid. This is a now a large, well-documented, convergent cluster of clear physiological symptoms, and it is common to every part of the globe affected by Covid-19. Many sufferers are now disabled and deprived of their former passions, while some are unable to resume their former professions. Doctors and scientists the world over now consider this a recognised part of the Sars-CoV-2 symptom profile. We thought that the number of Long Covid cases developing might be lower when most cases were breakthrough cases in the vaccinated, or infections in vaccinated or partially vaccinated children. Sadly, far from any subsidence in new Long Covid cases, the big, ongoing caseloads of the Delta, Omicron and BA.2 waves have brought a large cohort of new sufferers. These waves have disproportionately affected primary and secondary schools, and many of the new sufferers are children. In this Guardian article, Danny Altmann discusses why a failure to recognise the need for a response to Long Covid could be a blunder we rue for decades to come
  24. Content Article
    Children born to women who take valproate during pregnancy are at significant risk of birth defects and persistent developmental disorders. As such, it is vital that women and girls are dispensed valproate safely. The General Pharmaceutical Council is reminding all pharmacy professionals of what they must do to ensure women and girls receive the right information about valproate and the risk of birth defects. The update includes
  25. News Article
    Thousands of people unable to work because of the effects of Long Covid are feared to be missing out on financial support, with patients struggling to access and apply for the government’s disability benefits scheme. More than 300,000 people in the UK have been left with debilitating, persistent symptoms after catching the virus – but figures show only a tiny fraction of these have successfully claimed benefits. Politicians and campaign groups warn not enough has been done to remove barriers to applying for financial aid. “A vast number of severely impaired people are simply not getting the help they need and are entitled to,” said Dr Jo House, a spokesperson for Long Covid Support, which has around 50,000 members, the majority of whom are in the UK. Jenny Ceolta-Smith, of Long Covid Support’s employment group, said there were “multiple barriers in place” when applying for the disability benefit. She said the assessment process failed to take into account the episodic and fluctuating nature of the condition. “They might be able to perform a one-off activity, but then not do so later in the day,” she said. Read full story Source: The Independent,19 April 2022
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