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Patient Safety Learning

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  1. Content Article
    Martin Bromiley is a commercial airline training Captain and founder of The Clinical Human Factors Group. This episode of the Leadership Enigma podcast is deeply personal, inspirational and thought provoking. Martin describes how he turned the loss of his wife after a surgical procedure into a mission to understand and help others embrace the need for non-technical behaviours especially during critical times. He chats about the aviation and healthcare industry in relation to themes such as deference to hierarchy, the checklist manifesto, confident humility and creating an environment where your team and organisation embrace the challenge to 'double their error rate.' Behaviours are the bedrock for living your values and creating a culture that is positive and sustainable.
  2. News Article
    The devastating impact of the Covid-19 pandemic on poor and low-income communities across America is laid bare in a new report that concludes that while the virus did not discriminate between rich and poor, society and government did. As the US draws close to the terrible landmark of 1 million deaths from coronavirus, the glaringly disproportionate human toll that has been exacted is exposed by the Poor People’s Pandemic Report. Based on a data analysis of more than 3,000 counties across the US, it finds that people in poorer counties have died overall at almost twice the rate of those in richer counties. Looking at the most deadly surges of the virus, the disparity in death rates grows even more pronounced. During the third pandemic wave in the US, over the winter of 2020 and 2021, death rates were four and a half times higher in the poorest counties than those with the highest median incomes. During the recent Omicron wave, that divergence in death rates stood at almost three times. Such a staggering gulf in outcomes cannot be explained by differences in vaccination rates, the authors find, with more than half of the population of the poorest counties having received two vaccine shots. A more relevant factor is likely to be that the poorest communities had twice the proportion of people who lack health insurance compared with the richer counties. “The findings of this report reveal neglect and sometimes intentional decisions to not focus on the poor,” said Bishop William Barber, co-chair of the Poor People’s Campaign which jointly prepared the research. “The neglect of poor and low-wealth people in this country during a pandemic is immoral, shocking and unjust.” Read full story Source: The Guardian, 4 April 2022
  3. News Article
    Ministers will be left in the dark on Covid spikes just as case numbers reach unprecedented levels if a “world-beating” surveillance programme is scrapped, scientists have warned. The React-1 study, which played a crucial role in detecting and tracking the spread of the Alpha variant in December 2020 ahead of the second lockdown, has been stopped as part of the government's plan to cut its Covid costs. But in its last report, the study found 6.37% of the population was infected between 8 and 31 March – the highest figure since it began in May 2020. More worryingly, the scientists behind the research said the prevalence rate has also reached new highs for people aged 55 and over, at 8.31 per cent. The Royal Statistical Society (RSS) said dismantling the project while cases were at record levels damaged preparedness and put public health at risk. The spread of Covid within hospitals is also fuelling staff shortages, bed closures and delayed discharges in multiple regions of the country. This is coinciding with delays in ambulance handovers and response times, NHS sources say. Information seen by The Independent revealed hundreds of beds are currently out of use at Newcastle upon Tyne Hospitals trust due to Covid outbreaks. A senior clinician said the “hospital is coming apart at the seams” and that, across the northeast, even “high” performing emergency departments were “crashing” and “stacking ambulances outside of hospital”. Read full story Source: The Independent, 6 April 2022
  4. News Article
    The national supply chain agency will bring management of significant areas of NHS spend in-house on a permanent basis in a major overhaul of its operating model, HSJ has been told. NHS Supply Chain’s current operating model, which has existed since 2018, has outsourced day-to-day management of the procurement of most of the goods and services bought by trusts as part of the “category towers” structure. Under this structure, 11 category towers each cover a different spend area with a service provider to manage the available products and services. But, in an exclusive interview, NHSSC chief Andrew New said the 11 categories would be reduced to eight. Three of the new categories — personal protective equipment, “medical capital” (which combines large capital diagnostics equipment with smaller scale diagnostics, pathology and point of care testing categories) and “medical clinically complex” surgical products and services — would be managed in-house. The new model will come into effect in 2023-24 following a procurement process to find new suppliers for the revamped category structure, which starts on 11 April 2022 with the publication of the contract notice. Read full story (paywalled) Source: HSJ, 4 April 2022
  5. News Article
    A 14-year-old autistic girl was unlawfully detained in hospital and restrained in front of scared young patients, a high court judge has found. On one occasion last month the teenager managed to break into a treatment room where a dying infant was receiving palliative care. She was restrained there by three security guards, Mr Justice MacDonald said in a judgment in the family court that ordered Manchester city council (MCC) to find the girl a suitable community care placement instead of what he described as the “brutal and abusive” and “manifestly unsuitable” hospital environment. Nurses witnessed the girl screaming “very loudly” and sounding “very scared” when repeatedly held down on her hospital bed so that she could not move her legs, arms or head, before being tranquillised. Other children on the ward were frightened to witness the frequent battles between the girl and security guards, the judge said. The judge noted that the teenager made “regular and determined” efforts to run away, sometimes using screwdrivers to try to unlock doors and windows, and running away from her family on walks. He described the teenager as having an autistic spectrum disorder and a learning disability. She demonstrated “complex and extreme behaviour” that could not be controlled even within a school environment involving six adults to one child supervision, he added. Despite this, the council and NHS trust decided to have the girl be detained in hospital on a general paediatric ward “solely as a place of safety”, without applying for the necessary court order to do so, the judge found. She did not require any medical treatment, the judge said. Read full story Source: The Guardian, 5 April 2022
  6. News Article
    United Lincolnshire Hospitals NHS Trust has been ordered to pay a total of £111,204 in fines and legal costs after pleading guilty to failing to provide safe care and treatment to an elderly patient, causing them avoidable harm, following a sentencing hearing on Friday, 25 March at Boston Magistrates’ Court. The case was taken by the Care Quality Commission (CQC) under regulations 12 and 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The case against United Lincolnshire Hospitals NHS Trust involved the care of an elderly patient, Iris Longmate, who was admitted to the Greetwell Ward at Lincoln County Hospital on 20 February 2019. On March 3, 2019 Iris fainted and fell unsupervised from a commode, and was found face down on the floor in her room. Iris sustained spinal injuries and a cut to the head as a result of the fall, but then also suffered significant burns to her thigh and left arm as a result of being pressed against a radiator whilst being assessed by staff following the fall. Iris was subsequently transferred to Queens Medical Centre for assessment and treatment. She sadly contracted pneumonia in hospital and died on March 14, 2019. United Lincolnshire Hospitals NHS Trust pleaded guilty to a single offence of failure to provide safe care and treatment causing avoidable harm to Iris, for which the trust was fined £100,000. The court also ordered the trust to pay £170 victim surcharge and £11,034 costs to the CQC. The trust was found to not have taken all reasonable steps to ensure that safe care and treatment was provided, resulting in avoidable harm to Iris. In pleading guilty to the offence of causing avoidable harm to Iris, the trust also acknowledged that other patients on the Greetwell Ward had also been exposed to a significant risk of avoidable harm. Fiona Allinson, CQC’s deputy chief inspector of hospitals, said: "This death is a tragedy. My thoughts are with the family and others grieving for their loss." "People have the right to safe care and treatment, so it’s unacceptable that patient safety was not well managed by United Lincolnshire Hospitals NHS Trust," she said. "Had the trust addressed the issues with the exposed heating pipes before Iris fell, she wouldn’t have suffered such awful burns injuries." Read full story Source: Medscape, 2 April 2022
  7. News Article
    Patients in nine hospitals in Ireland were often treated in the wrong places, sometimes corridors, in situations where it was “unclear” who was supposed to be providing their care, a clinical review has found. It warned of the potential for people to receive inappropriate specialist input and recommended specific wards be used to avoid so-called “safari rounds” where consultants must seek out scattered patients. The independent review team consisted of clinical and management experts from Scotland and England who undertook a programme of visits between August and November, 2019. “The review team witnessed widespread boarding and outliers – any bed, anytime, anywhere and including mixed gender,” the document said. “This does not create extra capacity, leads to safari rounds, increases length of stay, introduces harm by non-specialist care and increases staff absenteeism.” Although acknowledging often excellent work by staff, the report was commissioned to examine non-scheduled care at nine hospitals found to be “under the greatest pressures” during the winter season of 2018/2019. These had “significant numbers” of patients waiting for long periods on trolleys. Read full story Source: The Irish Times, 4 April 2022
  8. Content Article
    The iterative processes that engineers and technicians use to address problems could have been applied by decision-makers throughout the COVID-19 pandemic writes Rick Schrenker.
  9. News Article
    THE majority of blood tests taken at Basildon Hospital to identify life-threatening illnesses have been contaminated in a “major failure”. An investigation has been launched by health bosses, with staff shortages allegedly causing the issue with “blood cultures”. Blood cultures, which look for germs or fungi in the blood and more deadly bacteria are routinely carried out ahead of operations. However, latest figures show that 70% of tests taken in the year up to January 2022 were found to be contaminated, leading to treatment being delayed as patients are re-tested. The normal limit of contaminated tests would be below 3%. The issue was raised at a joint board meeting of the clinical commissioning groups, which oversee local healthcare, on 24 March. Katherine Kirk, chairman of quality and governance committee at the Basildon and Brentwood group, said: “If I’m understanding this right and it’s about the effectiveness of blood tests, what’s going on? It’s clearly a major failure.” Read full story Source: The Echo, 4 April 2022
  10. News Article
    The NHS in England is struggling to make progress on its flagship target to diagnose three-quarters of cancer cases at an early stage, MPs are warning. The Health and Social Care Committee said staffing shortages and disruption from the pandemic were causing delays. Some 54% of cases are diagnosed at stages one and two, considered vital for increasing the chances of survival. By 2028, the aim is to diagnose 75% of cases in the early stages, but there has been no improvement in six years. It means England - as well as other UK nations - lag behind comparable countries such as Australia and Canada when it comes to cancer survival. If the lack of progress continues, the committee warned that it could lead to more than 340,000 people missing out on an early cancer diagnosis. The Department of Health said it recognised "business as usual is not enough" and said it was developing a new 10-year cancer plan. But a spokesman said progress was already being made, with a network of 160 new diagnostic centres being opened.R Read full story Source: BBC News, 5 April 2022
  11. News Article
    An algorithm which can predict how long a patient might spend in hospital if they’re diagnosed with bowel cancer could save the NHS millions of pounds and help patients feel better prepared. Experts from the University of Portsmouth and the Portsmouth Hospitals University NHS Trust have used artificial intelligence and data analytics to predict the length of hospital stay for bowel cancer patients, whether they will be readmitted after surgery, and their likelihood of death over a one or three-month period. The intelligent model will allow healthcare providers to design the best patient care and prioritise resources. Bowel cancer is one of the most common types of cancer diagnosed in the UK, with more than 42,000 people diagnosed every year. Professor of Intelligent Systems, Adrian Hopgood, from the University of Portsmouth, is one of the lead authors on the new paper. He said: “It is estimated that by 2035 there will be around 2.4 million new cases of bowel cancer annually worldwide. This is a staggering figure and one that can’t be ignored. We need to act now to improve patient outcomes. “This technology can give patients insight into what they’re likely to experience. They can not only be given a good indication of what their longer-term prognosis is, but also what to expect in the shorter term. “If a patient isn’t expecting to find themselves in hospital for two weeks and suddenly they are, that can be quite distressing. However, if they have a predicted length of stay, they have useful information to help them prepare. “Or indeed if a patient is given a prognosis that isn’t good or they have other illnesses, they might decide they don’t want a surgical option resulting in a long stay in hospital.” Read full story Source: University of Plymouth, 30 March 2022
  12. News Article
    Detectives have begun an investigation into the deaths of two babies at the hospital trust at the centre of the largest maternity scandal in NHS history. The babies died in separate incidents last year at the Shrewsbury and Telford Hospital NHS Trust, both during birth. One of them was a twin. The cases were among 600 examined by West Mercia police alongside an inquiry by Donna Ockenden, a senior midwife and manager, into failings at the trust. Her report revealed last week that 201 babies had died and 94 suffered brain damage as a result of avoidable mistakes. Nine mothers also died because of errors in care. Detectives are working with prosecutors to determine whether charges should be brought over the two deaths last year, after years of warnings that maternity services were in crisis. West Mercia police said they were investigating the trust as an organisation as well as individuals. The trust could face a charge of corporate manslaughter if it is found that the way the hospital organised and managed its services caused a death that amounted to a “gross breach” of its duty of care. If found guilty, the trust would face an unlimited fine. Individuals charged with gross negligence manslaughter could go to jail if convicted. The move by the police comes amid growing fears that the unsafe care identified in the report could be taking place in maternity services in other parts of the country. Read full story (paywalled) Source: The Times, 3 April 2022
  13. News Article
    Children are having to wait up to five years for an NHS autism appointment, according to figures obtained by the Observer that lay bare the crisis in children’s mental health services. Figures acquired under the Freedom of Information Act show that 2,835 autistic children referrals at Coventry and Warwickshire Partnership NHS Trust have still not had a first appointment an average of 88 weeks after being referred. The longest wait at the time the response was sent in January stood at 251 weeks – nearly five years. Meanwhile, 1,250 children with attention deficit hyperactivity disorder (ADHD) referrals at the trust have yet to have a first appointment, having waited an average of 46 weeks – and 195 weeks in the worst case. Across 20 NHS trusts that provided figures, children with outstanding autism referrals have waited nearly six months on average for their first appointment. Cathy Pyle’s daughter, Eva, spent 20 months waiting for an autism assessment from her local NHS child and adolescent mental health services (CAMHS) in Surrey, having already had to wait 11 months for a mental health assessment after she became increasingly distressed during her first year of secondary school, culminating in self-harm. “The sensory aspects of her autism are really significant,” Pyle told the Observer. “So she found the crowding in the corridors, the jostling, being pushed and shoved – she found the noises really, really unbearable.” Dr Rosena Allin-Khan MP, Labour’s shadow cabinet minister for mental health, said: “The NHS does an incredible job with the resources that it has, however, long waits for treatment have a considerable impact on patients and families. It’s unacceptable that a six-month wait has become the standard for autism referrals, with many others waiting years to be seen, on the Conservatives’ watch. Waiting so long for treatment will have a detrimental impact on a child’s development.” Read full story Source: The Guardian, 4 April 2022
  14. Content Article
    Dr Tejal Gandhi, has been a leader in patient and workforce safety for more than 20 years. Dr. Gandhi talked with Patient Safety Beat following publication of her essay, “Don’t Go to the Hospital Alone: Ensuring Safe, Highly Reliable Patient Visitation,” in the Joint Commission Journal on Quality and Patient Safey.
  15. Content Article
    “Don't go to the hospital alone” has been the advice that safety experts have promoted for many years as a way that patients can help protect themselves. Family members provide an important safety net for patients in the hospital, and across the entire continuum of care—another slice of the Swiss cheese in our defenses against errors. As safety professionals, we hate to have to rely on that safety net, knowing that not all patients and families are able to provide it. Yet, given what we know about the frequency of medical errors, we still recommend it because families provide an additional cross-check of our care. But the COVID-19 pandemic has stripped away the layer of protection provided by families. At the start of the pandemic, visitation was heavily curtailed or stopped entirely due to the risks of spreading the virus. These decisions were not made lightly—concerns about protecting patients and the workforce drove them. Risks of visitation have included risks of infection to visitors and staff, particularly when not enough personal protective equipment (PPE) was available, and added strain on nurses to manage the presence of visitors and visitors’ compliance with PPE protocols. These infection concerns have not borne out, especially after adequate PPE supplies became available.1.,2. Those decisions at the start of the pandemic were necessary, given the uncertainties and the PPE shortages. However, now is the time to learn from that experience and reassess the risks and benefits of limited visitation. Further reading It’s time to rename the ‘visitor’: reflections from a relative Visiting restrictions and the impact on patients and their families: a relative's perspective Q&A: Dr. Tejal Gandhi on refocusing COVID visitation policies through a safety lens
  16. Content Article
    Hertfordshire Partnership University NHS Foundation Trust's Quality Account has been designed to report on the quality of their services in line with regulations. The aim in this report is to describe in a balanced and accessible way of how the Trust provides high-quality clinical care to service users, the local population and commissioners.
  17. News Article
    An independent investigation into the death of a man with autism and learning difficulties in NHS care may never be published in full as his sister has rejected several drafts as inaccurate, telling NHS England they were ‘totally unethical’. Anthony Dawson died from a burst gastric ulcer in Ashmount, a residential care home run by Surrey and Borders Partnership Foundation Trust, in May 2015. The jury at an inquest into his death found there were gross failings in his care and his death was contributed to by neglect. NHS England commissioned an independent investigation into the incident from Sancus Solutions in June 2017. But seven years after Mr Dawson’s death the investigation’s report has yet to be published, despite several reports being submitted. His sister, Julia Dawson, has written to NHS chief executive Amanda Pritchard in recent weeks saying: “The investigation has not had my brother at its heart which we were assured would be the case” and that its reports had been “totally unethical”. Ms Dawson has asked that only the executive summary of the latest draft of the investigation be published, alongside a statement saying that she feels it has inaccuracies and misses out important points. She says that successive drafts have misrepresented her brother’s situation and failed to address what she believes was the real cause of his death – the frequent use of NSAIDs (ibuprofen) without any measures taken to protect his stomach. This ultimately led to the undiagnosed gastric ulcer bursting. An expert witness told the inquest into his death that treatment with proton pump inhibitors and stopping NSAIDs would have eradicated the ulcer. Read full story (paywalled) Source: HSJ, 4 April 2022
  18. News Article
    RaDonda Vaught's conviction for a fatal medical error has already damaged patient safety and should serve as a wake-up call for health system leaders to improve harm prevention efforts, the Institute for Healthcare Improvement has said. Ms. Vaught was convicted 25 March of criminally negligent homicide and abuse of an impaired adult for a fatal medication error she made in December 2017 while working as a nurse at Vanderbilt University Medical Center in Nashville, Tenn. "We know from decades of work in hospitals and other care settings that most medical errors result from flawed systems, not reckless practitioners," IHI said. "We also know that systems can learn from errors and improve, but only when those systems encourage reporting, transparently acknowledge their mistakes and are held accountable for those errors." The organization said criminal prosecution of errors over-focuses on the individual and diverts attention from necessary system-level issues and improvements. "Were this practice to be repeated in future cases of a serious or fatal error, there will be more damage, less transparency, less accountability and more lives lost," IHI said. "Instead, this case should be a wake-up call to health system leaders who need to proactively identify system faults and risks and prevent harm to patients and those who care for them."
  19. News Article
    Seaman Danyelle Luckey “didn’t die in combat or any military operation. She died from gross negligence of the medical providers on the ship she served, the USS Ronald Reagan,” said her father, Derrick Luckey. Danyelle Luckey died from sepsis on 10 October 2016. The 23-year-old had been on the ship for two weeks, and had been going back and forth to medical from 3 to 9 October with worsening symptoms. “Her death was very preventable. She died in excruciating pain, instead of being properly treated,” Derrick Luckey told lawmakers during a hearing about patient safety and the quality of care in the military medical system. “If the medical providers had given her a simple treatment of antibiotics instead of turning her away, she would be alive today,” he said. Luckey and Army veteran Dez Del Barba, who said he lost part of his left leg and suffered 70% muscle and tissue damage after his strep infection went untreated, urged lawmakers to make changes so others in the military community don’t have to suffer.Both contend this could have been avoided if proper medical care, such as antibiotics, had been provided. And both said they haven’t been able to get any information on investigations, or any actions to hold anyone accountable.Read full story Source: Yahoo News, 31 March 2022
  20. Event
    Find out more information about the Georgetown University’s Executive Master’s in Clinical Quality, Safety & Leadership programme at this virtual event. Register
  21. Content Article
    In this video, Dr Zubin Damania discusses the recent criminal conviction of US nurse RaDonda Vaught for a medical error and why this is terrible for patient safety, moral and the future of nursing and medicine.
  22. Content Article
    The following questionnaire will take about 8 minutes to complete and is designed to explore your professional experience of using the electronic patient record (EPR) system(s) where you work.  By participating in this research, you will help the NHS understand how your EPR system is working for you, including where it is performing well and where more can be done to enhance your experience.
  23. Content Article
    In March 2015, Bill Kirkup published his report on avoidable harm in maternity services at the Morecambe Bay NHS Trust. His introduction carried a warning: “It is vital that the lessons, now plain to see, are learnt... by other Trusts, which must not believe that ‘it could not happen here.’” With the publication of the Ockenden report, we now know that one of those other Trusts was the Shrewsbury and Telford NHS Hospital Trust.  “For more than two decades,” Donna Ockenden wrote, “they [famiies] have tried to raise concerns but were brushed aside, ignored and not listened to.” But why should patients and families have had to show that kind of courage in the first place? Instead of seeing patient feedback as a foundation stone of high quality, evidence based care, healthcare providers too often see it as a threat writes Miles Sibley in this BMJ Editorial.
  24. News Article
    Clinically vulnerable people infected with Covid are being denied access to potentially life-saving antiviral medicine, patients, health officials and charities say. Around 1.3 million people with underlying health conditions in England have been identified by the NHS as at-risk and sent letters explaining they will be assessed for antiviral treatment if infected with Covid. The NHS said “tens of thousands of the most vulnerable patients” have received the medication to date, but told The Independent it was “aware of some local issues” in which clinically vulnerable people have struggled to access the antivirals. It comes at a time of record-breaking infection levels. Patients seeking the treatment, which suppresses an infection to prevent disease escalation and hospitalisation, have reported being turned away by GPs and hospital doctors, while others say they’ve been “pushed from pillar to post” in an attempt to access the medication. An NHS manager told The Independent that only 15% of eligible patients cared for by Kent and Medway Clinical Commissioning Group received antiviral medication in February. Anthony Nolan, the blood cancer charity, and Kidney Care UK both said they had received reports that Covid Medicine Delivery Units (CMDUs), which are responsible for ensuring antiviral medication reaches patients, were overwhelmed and struggling to provide treatment. “Weekends are a particular problem and it causes a lot of stress,” said Fiona Loud, a policy director a Kidney Care UK. “We have had reports from people in different parts of the country.” Paxlovid, molnupiravir and remdesivir are available via the NHS as antiviral medicine. All three have been shown to be effective in reducing the risk of hospitalisation among infected vulnerable patients. Antibody treatment, administered intravenously, is also available. Read full story Source: The Independent, 4 April 2022
  25. News Article
    Children and young people who are anxious, depressed or are self-harming are being denied help from swamped NHS child and adolescent mental health services, GPs have revealed. Even under-18s with an eating disorder or psychosis are being refused care by overstretched CAMHS services, which insist that they are not sick enough to warrant treatment. In one case, a crisis CAMHS team in Wales would not immediately assess the mental health of an actively suicidal child who had been stopped from jumping off a building earlier the same day unless the GP made a written referral. In another, a CAMHS service in eastern England declined to take on a 12-year-old boy found with a ligature in his room because the lack of any marks on his neck meant its referral criteria had not been met. The shocking state of CAMHS care is laid bare in a survey for the youth mental health charity stem4 of 1,001 GPs across the UK who have sought urgent help for under-18s who are struggling mentally. CAMHS teams, already unable to cope with the rising need for treatment before Covid struck, have become even more overloaded because of the pandemic’s impact on youth mental health. Mental health experts say young people’s widespread inability to access CAMHS care is leading to their already fragile mental health deteriorating even further and then self-harming, dropping out of school, feeling uncared for and having to seek help at A&E. “As a clinician it is particularly worrying that children and young people with psychosis, eating disorders and even those who have just tried to take their own life are condemned to such long waits”, said Dr Nihara Krause, a consultant clinical psychologist who specialises in treating children and young people and who is the founder of stem4. “It is truly shocking to learn from this survey of GPs’ experiences of dealing with CAMHS services that so many vulnerable young people in desperate need of urgent help with their mental health are being forced to wait for so long – up to two years – for care they need immediately. Read full story Source: The Guardian, 3 April 2022
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