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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Sean Mansell had a medical history of alcohol dependence syndrome. On the 5 July 2021, the West Midlands Ambulance Service received a 999 call at 19.23 hours from a neighbour of who reported that Shaun couldn't walk. The call was allocated a category 3 disposition which had a target response time frame of 120 minutes. An ambulance arrived on scene at 03.38 on the 6 July which was 8 hours and 15 minutes later and not within the response time frame. This was due to the fact that demand outstripped available resources. A welfare call was undertaken at 21.28 hours by a paramedic who had been asked to go into the control room to assist with welfare calls due to the high volume of 999 calls outstanding. The paramedic had not received prior training on how to complete these calls. The welfare call was conducted with the neighbour. No contact was made directly with Shaun during the 8 hour delay which led to a missed opportunity to identify a change in his condition. When the ambulance arrived, Shaun had passed away on the sofa in his front room. There was evidence of blood loss on the floor next to him and around his mouth. The police did not find any suspicious circumstances. A post mortem examination found the cause of death to be acute gastrointestinal haemorrhage and liver disease due to chronic alcoholism. The medical evidence was not able to determine if the delay in the arrival of the ambulance contributed to the death because there was no certainty of timeline about the bleeding. 
  2. News Article
    Nurses have spoken of the shocking abuse they face from patients as the NHS struggles to cope with a rise in demand for care. Both patients and staff are becoming increasingly frustrated with the situation the NHS is in, with staff shortages and a patient backlog of six million people causing already stretched services extra strain. "As we are the faces that the public see we do get the brunt of a lot of their anger as they are becoming increasingly frustrated with the situation that the NHS is in," one nurse wrote on Nursing Standard’s Facebook page. "Staff are equally frustrated with the whole situation and knackered from working long hours and covering for the many staff still absent." Nurses given the task of conveying ‘unwelcome messages about the limitations of resources’ Another said: "Working in an ED abuse occurs on a daily basis… it is not acceptable but even when you Datix these incidents nothing gets done, staff are reduced to tears and frightened to walk into patient waiting areas, it is not acceptable." It comes as former chief inspector of social services Lord Herbert Laming accused health service managers of putting nursing staff in the public firing line during a House of Lords debate on reducing abuse of nurses in the NHS. Read full story Source: 12 April 2022, Nursing Standard
  3. News Article
    A phone first system adopted by most GP surgeries at the start of the pandemic is "here to stay", the Royal College of GPs (RCGPs) in Northern Ireland has said. However, the RCGP has also accepted patient access needs to improve. The system was introduced in spring 2020. According to GPs, the move, which came without either consultation or prior information, was necessary to minimise the risk of infection of Covid-19. Two years on, there is concern among some members of the public that the system is not working. Speaking to BBC News NI, Dr Ursula Mason accepted that the system wasn't working but said there were not enough GPs to see people. She added that the telephone system, which was being "refined" and "improved" was the best way to manage "growing demand" and to "prioritise the sickest patients to be seen first". "The telephone system allows us to see many more patients, to deal with demand in a better way so I think the telephone system is here to stay," added Dr Mason. "There will be some changes to upgrade it, but it will form a significant part of how we manage demand."
  4. News Article
    Patients are being put at risk in the UK because very few sexually transmitted infection (STI) tests offered online meet official standards, experts have warned. The NHS provides free in-person tests for STIs via its network of sexual health and genitourinary medicine clinics. Patients can also order tests via the internet from both NHS-commissioned and private providers, a practice that has become increasingly popular during the pandemic. However, new research in the Sexually Transmitted Infections journal published by the BMJ found that few online STI test services meet national recommended standards, with independent sector providers the least likely to be compliant. Online tests involve the user ordering a kit and either self-sampling by posting the specimen for laboratory analysis, or self-testing by interpreting the test themselves. The research found that the commercial self-sample providers, which advertised to those with symptoms, did not differentiate by STI symptom severity, and eight – seven private and one NHS-commissioned provider – offered no advice on accessing preventive treatment after exposure to HIV as recommended. Self-test providers did not appear to offer any form of order of treatment for patients and five offered tests that were intended for professional use only. The research concluded: “Regulatory change is required to ensure that the standard of care received online meets national guidelines to protect patients and the wider population from the repercussions of underperforming or inappropriate tests." “If we do not act now, patients will continue to receive suboptimal care with potentially significant adverse personal, clinical and public health implications.” Read full story Source: The Guardian, 12 April 2022
  5. News Article
    Health officials are investigating 74 cases of hepatitis - or liver inflammation - in children across the UK since the start of this year. They say one potential cause of the illness could be adenoviruses, but they have not ruled out Covid-19 as a cause. Officials are examining 49 cases in England, 13 in Scotland and 12 across Wales and Northern Ireland. The UK Health Security Agency (UKHSA) said parents should be on the lookout for symptoms such as jaundice. Dr Meera Chand, director of clinical and emerging infections at UKHSA, said officials were looking at a wide range of possible factors which could be causing children to be admitted to hospital with liver inflammation. "One of the possible causes that we are investigating is that this is linked to adenovirus infection. However, we are thoroughly investigating other potential causes," she said. Other possible explanations being investigated include Covid-19, other infections or an environmental trigger. Read full story Source: BBC News, 13 April 2022
  6. News Article
    Mums who have given birth at Sheffield's largest maternity unit have revealed all about the "horrible" conditions, with some parents saying they feared for their baby's lives. One mum - a midwife herself - was so concerned about her unborn baby's welfare that she and her partner temporarily moved to London just weeks before her due date. "I felt like my son and I might have died if we had the pregnancy in Sheffield," she said. Several mums have spoken to Yorkshire Live about their stories after a scathing report uncovered the scale of the issues on the Jessop Wing. CQC inspectors highlighted all manner of major issues about the care given at Sheffield Teaching Hospital's specialist maternity unit, including examples of emergency help not arriving when staff called for it. Distraught mums said they were left naked and covered in bodily fluids while others complained about being ignored for hours despite begging for pain relief. Dangerously low staffing levels exposed patients to the risk of serious harm, while midwives themselves revealed a toxic environment of a "bullying and intimidating culture" from senior management. As a Trust spokesperson said "we are very sorry" and vowed to make big improvements, we spoke to some of the families worst affected by the problems as they explained how "basic dignity and care have gone out the window". Read full story Source: 12, April 2022, Yorkshire Live
  7. News Article
    More than four hours after an ambulance was called, Richard Carpenter, 71, who had had a suspected heart attack, began to despair. “Where are they?” he asked his wife, Jeanette. “I’m going to die.” She tried to reassure her husband that the crew must surely be close. Perhaps they were struggling to find their rural Wiltshire home in the dark. “But I could see I was losing him,” she said. She gave her husband CPR and urged him: “Don’t leave me.” But by the time the paramedics arrived another hour or so later, it was too late. Jeanette Carpenter, 70, a stoical and reasonable person, accepts it might have been impossible to save her husband. “But I think he would have had more of a chance if they had got here sooner,” she said. It is the sort of sad story that is becoming all too common. Across England, but in particular in the south-west, ambulances are too often not getting to patients in a timely manner. Before Covid, said one ambulance worker – who asked not to be named – he would do between six and 10 jobs in a shift. Now if the first person he is called to needs to go to hospital, he expects this will be his one job for the whole shift. “At some hospitals we are waiting outside hospitals for 10, 11 or 12 hours,” he said. “There’s nothing more demoralising than hearing a general broadcast going out for a cardiac arrest or road accident and there’s no resources to send. It’s terrible to think someone’s loved one needs help and we can’t do anything because we’re stuck at a hospital.” Read full story Source: The Guardian, 10 April 2022
  8. Content Article
    Annegret Hannawa investigated communication during Covid-19. She asked the questions: to what extent did communication by the Swiss traditional news media and by the Swiss Government, communication in the social media, and interpersonal communication affect Swiss residents' (1) trust, (2) willingness to vaccinate, (3) engagement in conspiracy theories, and (4) mental health? This video gives a short summary of the first results.
  9. Content Article
    The official voice of the Foundation for Patient Safety - CHILE, to spread knowledge and share advances in clinical practices, which allow us to provide safe and quality care, in all areas of health care, from high complexity to home care. Download the latest issue below. (In Spanish, but option to translate to English when you download.)
  10. News Article
    Ministers should reconsider England’s “living with Covid” plans, health leaders have said, while accusing the government of ignoring the ongoing threat for ideological reasons. The NHS Confederation, which represents organisations across the healthcare sector, has accused No 10 of having “abandoned any interest” in the pandemic, despite a new Omicron surge putting pressure on an already overstretched NHS. “The brutal reality for staff and patients is that this Easter in the NHS is as bad as any winter,” said Matthew Taylor, the chief executive of the NHS Confederation. "We do not have a living-with-Covid plan, we have a living-without-restrictions ideology. “But instead of the understanding and support NHS staff received during 2020 and 2021, we have a government that seems to want to wash its hands of responsibility for what is occurring in plain sight in local services up and down the country. No 10 has seemingly abandoned any interest in Covid whatsoever. “NHS leaders and their teams feel abandoned by the government and they deserve better.” Taylor later told BBC Breakfast: “In our view, we do not have a ‘living with Covid’ plan, we have a ‘living without restrictions’ ideology, which is different. We need to put in place the measures that are necessary to try to alleviate the pressures on our health service while this virus continues to affect [it].” Read full story Source: BBC News, 11 April 2022
  11. News Article
    A trust which is facing major governance issues is failing to respond to hundreds of complaints properly, with patients and families waiting more than twice as long as the NHS target for responses to their concerns, an external review has found. Cornwall Partnership Foundation Trust, which is subject to regulatory action by NHS England, was found to be “not classifying complaints, concerns and comments accurately”, while staff had “no formal training”, meaning complaints were “not investigated appropriately”. Last year, the trust was embroiled in a governance scandal in which NHSE investigated multiple allegations of finance and governance failings, resulting in the departure of former CEO Phil Confue. Rachel Power, chief executive of the advocacy group Patients Association, told HSJ patient complaints often contain “vital intelligence” on how trusts can improve services and “essential warnings about any area where things might be going wrong”. According to the review, the backlog had stemmed from several factors. These included more work being needed on investigations that had not been thorough enough, and the relevant service teams not responding to enquiries by the complaints team. Additionally, there was a “lack of formal monitoring and review” to ensure complaint points were reported appropriately and consistently, and an “apparent lack of accountability by local teams for complaints” triaged through the trust’s patient liaison and complaints team. Read full story (paywalled) Source: HSJ, 12 April 2022
  12. News Article
    Overstretched hospitals are stopping routine Covid tests for new patients as “brutal” pressures mount on doctors and nurses, The Independent understands. On Monday there were 1,702 new Covid admissions to hospitals in England as of 9 April – with 16,442 positive patients occupying beds – the NHS leaders warn their ability to tackle the backlog in planned care is at risk. Despite pleas from NHS chiefs to measures such as mask-wearing back into force, ministers said there were no plans to change guidance. The Independent understands at least two major hospitals, in Newcastle and York, have dropped testing of all patients without symptoms in order to alleviate pressure on beds – raising fears that Covid could spread on unchecked wards. Other hospitals are also likely to do the same as bed pressures worsen. Sources have told The Independent some trusts have begun to drop “red” Covid only wards, while some are considering not separating patients in A&E. One expert, critical care doctor Tom Lawton, who analyses hospital-acquired infection data, said that stopping patient testing in hospitals was “worrying” and that the NHS would be putting “blinkers on” just as in-hospital infections were “as high as they’ve ever been”. Read full story Source: The Independent, 11 April 2022
  13. Content Article
    The newly released Ockenden report into maternity services at Shrewsbury and Telford NHS trust is at least the fourth similar report in recent years, with two more in progress. Many messages are not new, and these are not isolated findings. Women and families accessing care throughout the UK continue to feel ignored. Many families remain concerned that they are not receiving full and frank investigations and explanations after the death or injury of a mother or baby. Repeated headlines understandably undermine women’s confidence in services when they should be able to trust that they will receive safe, high quality care writes Marian Knight and Susanna Stanford in this BMJ Editorial.
  14. News Article
    Criticism of NHS managers over the treatment of whistleblowers has been reignited by Donna Ockenden’s damning review of maternity services at Shrewsbury and Telford Hospital Trust. Her findings come seven years after the “Freedom to speak up?” report from Sir Robert Francis QC, which found that NHS staff feared repercussions if they blew the whistle on poor practice. He recommended reforms to change the culture and support whistleblowers. The Public Interest Disclosure Act 1998 makes it unlawful to subject workers to negative treatment or dismiss them because they have raised a whistleblowing concern, known as a “protected disclosure”. But critics say little has changed since the Francis review. According to Protect, a whistleblowing charity, 64% of those contacting it for advice said that they had been victimised, dismissed or forced to resign. Shazia Khan, founding partner at Cole Khan Solicitors, says that instead of being afforded protection, whistleblowers are “targeted as a form of retaliation by trust senior management and disciplined on trumped up charges to shut them down”. Those seeking to vindicate their rights before an employment tribunal, Khan adds, will often be “priced out of justice” by well-resourced NHS trust lawyers who at public expense “deploy a menu of tactics” to defend cases. When Peter Duffy, a consultant urologist at University Hospitals of Morecambe Bay Foundation NHS Trust, reported on allegedly unsafe practices by colleagues in 2016, he was demoted, falsely accused of financial irregularities, and threatened with a six-figure adverse costs order by Capsticks, the hospital’s law firm. “All my witnesses dropped out after the medical hierarchy told them that the department might be dissolved if the case went badly,” Duffy says, which meant there was no one to rebut the trust’s evidence. Read full story (paywalled) Source: The Times, 7 April 2022
  15. News Article
    Several large teaching hospitals are among those which saw the steepest declines in the proportion of staff who would recommend the care of their organisation, according to the NHS staff survey results. Norfolk and Norwich University Hospitals Foundation Trust, University Hospitals Birmingham, Liverpool University Hospitals FT and Nottingham University Hospitals Trust saw declines of 12 percentage points or more in 2021 — for the proportion of staff saying they would be happy for a friend or relative to be treated at their organisation. This was double the average drop in the acute sector. In a message to staff, Sue Musson, chair of Liverpool University Hospitals Trust, said about her trust’s overall results: “On behalf of the trust board, I want to apologise to everyone that the experience of working at the trust is so deeply unsatisfactory for so many colleagues. “It would be wrong to suggest that there are quick fixes to these issues. The promise I can give you today is a genuine commitment to listen and learn; we particularly need to understand what would make the difference for colleagues across the trust, recognising that there may well be different answers in different parts of the organisation. “We will seek to learn from the trusts that have demonstrated the best staff experience scores and to implement best practices at pace. We will also be seeking support and input from national and staff side colleagues.” Read full story (paywalled) Source: HSJ, 11 April 2022
  16. Content Article
    Adverse drug reactions (known as ADRs) can occur both in the home, and within the healthcare setting, when combinations of medications produce unexpected side effects. Unfortunately this means that in the most serious cases fatalities can occur. However ADRe has helped all service users by addressing life-threatening problems, reducing pain or improving quality of life. With preventable ADRs responsible for 5-8% unplanned hospital admissions in the UK, and costing the NHS up to £2.5bn pa, it is crucial that healthcare organisations take advantage of tools which can help improve how medicines are managed. ADRe has been developed with the aid of nursing professionals to help nursing staff take a structured approach to the monitoring of medicines, identifying any ADRs service users may be experiencing, and then making changes to improve a patients' health and wellbeing.
  17. Event
    until
    At this Bevan Brittan webinar, Dr Bell, a Consultant in Intensive Care and Anaesthesia will cover the following: 1. Background on scenarios in which consideration is given to treatment limitations. 2. Factors influencing decision-making. 3. The evolution of conflict. 4. Clinical perspective on the role of the courts. Register
  18. Content Article
    Following the Shrewsbury maternity scandal where "at least 201 babies would have survived with better care", outgoing CQC chief inspector of hospitals Ted Baker said the NHS should listen to criticism to be able to change. Ted Baker said the NHS faced a resistance to being challenged and "for anyone to refuse to listen to criticisms of what the NHS does I think is a big mistake." Listen to Ted Baker's, CQC's outgoing chief inspector, full interview on Times Radio.
  19. News Article
    On 25 March2022, a Tennessee jury convicted RaDonda Vaught, a nurse at Vanderbilt University Medical Center, of criminally negligent homicide and impaired adult abuse in a 2017 medication administration error that tragically resulted in a patient death. The Washington State Nurses Association have issued a joint statement adamantly opposed to criminalization of patient care errors. "Focusing on blame and punishment solves nothing. It can only discourage reporting and drive errors underground. It not only undermines patient safety; it fosters an environment of fear and lack of respect for health care workers." "The Vaught case has drawn intense national attention and concern. We join with health care workers and patient safety experts around the country and the world in rejecting the criminalization of medical errors. Further, we are committed to redoubling our efforts to achieve health care environments that are safe for patients and health care workers alike. This includes the ongoing, critical fight to achieve safe staffing standards in Washington state." Read full statement Source: Washington State Nurses Association, 8 April 2022
  20. News Article
    Medical devices are one major weak point in health care cybersecurity, and both the US Congress and the Food and Drug Administration took steps towards closing that gap this week —Congress with a proposed bill and the FDA with new draft guidelines for device makers on how they should build devices that are less likely to be hacked. Devices like infusion pumps or imaging machines that are connected to the internet can be targets for hacks. Those attacks can siphon off patient data or put their safety directly at risk. Experts consistently find that devices in use today have vulnerabilities that could be exploited by hackers. The new document is still just a draft, and device makers won’t start using it until it’s finalised after another round of feedback. But it includes a few significant changes from the last go-around — including an emphasis on the whole lifecycle of a device and a recommendation that manufacturers include a Software Bill of Materials (SBOM) with all new products that gives users information on the various elements that make up a device. An SBOM makes it easier for users to keep tabs on their devices. If there’s a bug or vulnerability found in a bit of software, for example, a hospital could easily check if their infusion pumps use that specific software. The FDA also put out legislative proposals around medical device cybersecurity, asking asking Congress for more explicit power to make requirements. “The intent is to enable devices to be that much more resilient to withstand the potential for cyber exploits or intrusion,” Schwartz says. Manufacturers should be able to update or patch software problems without hurting the devices’ function, she says. Read full story Source: The Verge, 8 April 2022
  21. News Article
    The number of GPs in England has fallen every year since the government first pledged to increase the family doctor workforce by 5,000, a minister has admitted. There were 29,364 full-time-equivalent GPs in post in September 2015, when the then health secretary, Jeremy Hunt, first promised to increase the total by 5,000 by 2020. However, by September 2020 the number of family doctors had dropped to 27,939, a fall of 1,425, the health minister Maria Caulfield disclosed in a parliamentary answer. And it has fallen even further since then, to 27,920, she confirmed, citing NHS workforce data. In the 2019 general election campaign, Boris Johnson replaced Hunt’s pledge with a new commitment to increase the number of GPs in England by 6,000 by 2024. However, Sajid Javid, the health secretary, admitted last November that this pledge was unlikely to be met because so many family doctors were retiring early. Organisations representing GPs say their heavy workloads, rising expectations among patients, excess bureaucracy, a lack of other health professionals working alongside them in surgeries, and concern that overwork may lead to them making mistakes are prompting experienced family doctors to quit in order to improve their mental health and work-life balance. The British Medical Association (BMA) said the figures Caulfield cited showed that the lack of doctors in general practice was “going from bad to worse for both GPs and patients”, and it warned that patients were paying the price in the form of long waits for an appointment. “Despite repeated pledges from government to boost the workforce by thousands, it’s going completely the wrong way,” said Dr Kieran Sharrock, the deputy chair of the BMA’s GP committee. “As numbers fall, remaining GPs are forced to stretch themselves even more thinly, and this of course impacts access for patients and the safety of care provided.” Read full story Source: The Guardian, 11 April 2022
  22. News Article
    An ambulance service has raised concerns over the record number of ‘hours lost’ to handover delays at an acute hospital on its patch, which it says is happening despite the number of arrivals being at its lowest level in seven years. West Midlands Ambulance Service University Foundation Trust has said the situation at Royal Stoke Hospital presents a “significant risk to patient safety”, but “we don’t currently see actions being taken that are reducing this risk”. It comes amid rising frustrations from ambulance chiefs around the country at a perceived lack of support from acute hospitals around handover delays. Ambulance response times for some of the most serious 999 calls have ballooned in recent months, in part due to lengthy handover delays at emergency departments. In a letter sent to a member of the public on 31 March, Mark Docherty, director of nursing at WMAS, said: “WMAS [is] experiencing difficulties as a direct result of delays in patient handovers at acute hospitals. We have been highlighting our concerns for over six years as the situation has become progressively worse every year." Read full story (paywalled) Source: HSJ, 10 April 2022
  23. News Article
    Patients continue to experience avoidable harms from unsafe care because the NHS fails to learn from its mistakes, a report that tracked what actions the NHS took following safety reviews over several decades has found. Patient Safety Learning looked at the findings of a variety of investigations, including widespread public inquiries, Healthcare Safety Investigation Branch (HSIB) reports, Prevention of Future Deaths reports, incident reports, and complaints and legal action by patients and their families. It found an “implementation gap” in learning lessons and taking action to prevent future harms. It highlighted an absence of a systemic and joined up approach to safety; poor systems for sharing learning and acting on that learning; lack of system oversight, monitoring, and evaluation; and unclear patient safety leadership. Helen Hughes, chief executive of Patient Safety Learning, said, “Time and time again there is a lack of action and coordination in responding to recommendations, an absence of systems to share learning, and a lack of commitment to evaluate and monitor the effectiveness of safety recommendations. “This is a shocking conclusion that is an affront to all those patients and families who have been assured that ‘lessons have been learnt’ and ‘action will be taken to prevent future avoidable harm to others.’ The healthcare system needs to understand and tackle the barriers for implementing recommendations, not just continually repeat them.” The report calls for “systemwide commitment and resources, with effective and transparent performance monitoring” for patient safety inquiries and reviews and HSIB reports to ensure that the accepted recommendations translate into action and improvement. Read full story Source: BMJ, 8 April 2022
  24. Event
    ECRI has released its newest list of the Top 10 patient safety concerns confronting healthcare organisations. Healthcare providers, regardless of their practice setting, can start with our Top 10 list and use it to guide their own discussions about patient safety and improvement initiatives. This top 10 report highlights patient safety concerns across the continuum of care because patient safety strategies increasingly focus on collaborating with other provider organizations, community agencies, patients or residents, and family members. Each patient safety concern on this list may affect more than one setting. Join ECRI to learn more about the identified concerns and how your organisation can begin to address them. Register
  25. News Article
    Two thousand ventilators being used in UK hospitals are at risk of suddenly shutting down due to electrical faults that have led to a global safety alert. Hospitals have been ordered to source replacement ventilators after Philips Respironics said its breathing support devices could suddenly stop working, in some cases without activating a warning alarm. The Medicines and Healthcare products Regulatory Agency (MHRA) said the problem related to “a number of electrical faults in the devices, which can result in an unexpected shutdown, leading to loss of ventilation”. It said there had been five reported cases of shutdowns in the UK so far, none of which involved patient harm. Globally, there have been 389 reports of failures, including one where the patient died and four where they were seriously injured. In six of the total cases, the warning alarm didn’t sound. Philips Respironics is one of several manufacturers that increased production of ventilators during the pandemic. The MHRA brought in a fast approval process for ventilators and other medical devices in response to Covid-19. The MHRA said the root cause of the problem was not yet known and remained under investigation, but that Philips Respironics currently had “no permanent solution” to correct it. Helen Hughes, chief executive of Patient Safety Learning, said there was a “significant patient safety concern” that some Philips devices could remain in use until replacements were sourced. Read full story Source: The Guardian, 9 April 2022 National Patient Safety Alert: Philips Health SystemsV60, V60 Plus and V680 ventilators – potential unexpected shutdown leading to complete loss of ventilation
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