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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    In January 2020, the World Health Organization declared Covid-19 a global health emergency. Healthcare systems around the world faced enormous pressures as hospital admissions increased. Amongst others, med-tech companies experienced a vast increase in demand for Covid-19 related products, alongside declining demand for non-essential products, and so had to adapt their supply chains to ensure the sustained, timely delivery of medical devices. In addition, teams had to navigate disruptions to global supply chains due to various border lockdowns and tighter trade and export restrictions worldwide. Prior to the unprecedented demands of the pandemic, med-tech supply chain management was not a hot topic in the news, or generally known amongst the public. However, it has recently gained traction across the news worldwide as supply chain managers have worked relentlessly to re-establish the equilibrium within this ever-changing landscape. The med-tech industry should look to continue to re-build their supply chains, so that they can be more agile and flexible, and respond to potential future issues efficiently and effectively.
  2. News Article
    Every health and care system — including those carrying huge deficits going into the pandemic — will be told to deliver financial balance in 2022-23, according to draft guidance seen by HSJ. For the last two years, local NHS organisations have effectively seen all their spending covered by the government under temporary Covid measures. But a more typical financial regime is now due to begin in April, with systems expected to deliver services from within funding envelopes set at the start of the year, and to be held to account on this. Some integrated care systems went into the pandemic with deficits of more than £100m, and will likely struggle to reach a balanced position. But draft guidance circulated to local leaders in recent months by NHS England says: “NHS England and NHS Improvement intend to use additional powers in the legislation to set a financial objective for each integrated care board [the local commissioning body] and its partner trusts to deliver a financially balanced system, namely a duty on break even.” However, it is unclear what the consequences will be for an ICS that fails to meet what is described as a “new joint legal duty”. Read full story (paywalled) Source: HSJ, 31 March 2022
  3. Content Article
    In this blog, Patient Safety Learning analyses the results of the NHS Staff Survey 2021, specifically focusing on responses relating to reporting, speaking up and acting on safety concerns. It reflects on the importance of staff feeling able to speak up about patient safety incidents and the implications when this is not the case. It describes the NHS’s current approach to creating a patient safety culture and emphasises the need for NHS England and NHS Improvement, in partnership with the National Guardian and Care Quality Commission, to bring forward robust and specific commitments to drive this work forward.
  4. News Article
    Sajid Javid has issued an apology for the maternity service failings reported at Shrewsbury and Telford Hospital NHS Trust. The health secretary spoke in the Commons on Wednesday after an independent inquiry into the UK’s biggest maternity scandal found that 201 babies and nine mothers could have - or would have - survived if the NHS trust had provided better care. Speaking in the Commons, the health secretary said Donna Ockenden - a maternity expert who led the report - told him about “basic oversights” at “every level of patient care” at the trust. He said the report “has given a voice at last to those families who were ignored and so grievously wronged”. Javid said the report painted a tragic and harrowing picture of repeated failures in care over two decades which led to unimaginable trauma for so many people. Rather than moments of joy and happiness for these families their experience of maternity care was one of tragedy and distress and the effects of these failures were felt across families, communities and generations. The cases in this report are stark and deeply upsetting. Mr Javid offered reassurances that the individuals who are responsible for the “serious and repeated failures” will be held to account. Read full story and Sajid Javid's statement Source: The Independent, 30 March 2022
  5. News Article
    A policy ‘at the heart’ of NHS England’s efforts to improve maternity care is under question after being sharply criticised by an independent inquiry, and is the subject of major tensions within NHSE and midwifery, HSJ understands. The Ockenden report into major care failings at Shrewsbury and Telford Hospital Trust included 15 “immediate actions” for all maternity services in England, which government has accepted and said it would begin implementation. However, one of these relates to the “continuity of carer” model, which NHS England has championed since 2017, when it was described as “at the heart of” its national plans for improving maternity care and outcomes. The model intends to give women “dedicated support” from the same midwifery team throughout their pregnancy, with claimed benefits including improved outcomes, with a particular focus on some minority groups. However, Ms Ockenden indicated its implementation in recent years had stretched staffing, and therefore harmed quality and safety overall, and also appeared to question whether the model was evidenced. Some midwifery leaders are advocates for the model, but others have described how it can result in awful working patterns, with concerns it is causing some staff to leave the profession. Royal College of Midwives director for professional midwifery Mary Ross-Davie told HSJ: “With the right resources and the right number of midwives, CoC can have a positive impact on maternity care – but in too many trusts and boards this is simply not the situation. We are really pleased, therefore, to see that the review team has echoed the RCM’s recommendations around the suspension of continuity of carer where too few staff puts safe deployment at risk.” She said the model was “something to which many maternity services aspire, particularly for women who need enhanced monitoring throughout their pregnancy to deliver better outcomes for them and their baby”. Helen Hughes, chief executive of Patient Safety Learning charity, said that although it had heard positive feedback that the model can improve outcomes, there must also be a “robust assessment of the safety impact of implementing such changes and the sources and staffing in place to deliver this”. “Otherwise the core intentions and benefits will be lost,” Ms Hughes said. Read full story (paywalled) Source: HSJ, 31 March 2022 Further reading Midwifery Continuity of Carer: What does good look like? Midwifery Continuity of Carer: Frontline insights The benefits of Continuity of Carer: a midwife’s personal reflection
  6. Content Article
    NHS Resolution has published a set of three reports which explore clinical issues that contribute to compensation claims within Emergency Departments.
  7. News Article
    The reasons behind the most catastrophic blunders in emergency departments have been laid bare in a NHS Resolution report highlighting some of the biggest pay outs for NHS A&E errors. NHS Resolution conducted a deep dive into compensation claims concerning emergency departments in England, including 16 cases which saw more than £1 million handed out after life-changing or deadly errors. The average “high-value claim” was £2,069,029, with many of them related to spinal cord injuries which, left undetected, can have a life-long impact on patients. The report detailed the case of a woman who suffered permanent neurological damage and now has bladder, bowel and sexual dysfunction symptoms, as well as loss of mobility, after a spinal condition was misdiagnosed as sciatica. The report also looked at 86 deaths which resulted in average pay outs of more than £45,000. After reviewing 220 claims between 2014 and 2018, the authors highlighted a number of “common themes”, including: diagnostic errors, including missing signs a patient was deteriorating a failure to recognise the significance of repeat attendance at A&E delays in care problems with communication, including problems with different hospital departments talking to each other. Read full story Source: In Your Area News, 29 March 2022
  8. News Article
    Everyone with type 1 diabetes in England should be offered some form of continuous glucose monitoring (CGM) technology to support their care, the National Institute for Health and Care Excellence (NICE) has recommended. Updated draft guidelines published on 31 March recommend that all adults with type 1 diabetes should be offered a choice of either real time or intermittent (flash) CGM through a sensor attached to the skin as part of their ongoing NHS care. NICE also recommends that all young people aged 4 years and over with type 1 diabetes should be offered real time CGM and that some people with type 2 diabetes who use insulin intensive therapy (4 or more injections a day) should have access to Flash. Read full story (paywalled) Source: BMJ, 31 March 2022 Read NICE guidelines here.
  9. News Article
    A shortage of more than 2,000 midwives means women and babies will remain at risk of unsafe care in the NHS despite an inquiry into the biggest maternity scandal in its history, health leaders have warned. A landmark review of Shrewsbury and Telford hospital NHS trust, led by the maternity expert Donna Ockenden, will publish its final findings on Wednesday with significant implications for maternity care across the UK. The inquiry, which has examined more than 1,800 cases over two decades, is expected to conclude that hundreds of babies died or were seriously disabled because of mistakes at the NHS trust, and call for changes. But NHS and midwifery officials said they fear a growing shortage of NHS maternity staff means trusts may be unable to meet new standards set out in the report. “I am deeply worried when senior staff are saying they cannot meet the recommendations in the Ockenden review which are vital to ensuring women and babies get the safest possible maternity care,” said Gill Walton, chief executive of the Royal College of Midwives (RCM). The number of midwives has fallen to 26,901, according to NHS England figures published last month, from 27,272 a year ago. The RCM says the fall in numbers adds to an existing shortage of more than 2,000 staff. Experts said the shortage was caused by the NHS struggling to attract new midwives while losing existing staff, who felt overworked and fed up at being spread too thinly across maternity wards. Read full story Source: The Guardian, 29 March 2022
  10. Content Article
    The Patient Safety Movement are looking for patients, family members, health workers and administrators to reach out if they have an experience related to harm or death due to a medication error in the operating room. While the specific numbers may be debated, that medication errors, while rare in the operating, could have catastrophic consequences. The Patient Safety Movement are interested in hearing your perspective concerning this issue. Please email events@patientsafetymovement.org if you have a story that you’d like to share. If you are worried about anonymity please submit your story at the link below.
  11. Content Article
    In this blog Patient Safety Learning sets out its initial response to the report of the Independent review of maternity services at Shrewsbury and Telford Hospital NHS Trust (also known as the Ockenden Maternity Review).
  12. Content Article
    RaDonda Leanne Vaught faced criminal charges over a fatal medication error she made in 2017. Her trial has raised important questions over medical errors, reporting and process improvement, as well as who bears responsibility for widespread use of tech overrides in hospitals.  There is debate over whether automated dispensing cabinet overrides are a reckless act or institutionalised as ordinary given the widespread use of IT workarounds among healthcare professionals. The Nashville District Attorney's Office described this override as a reckless act and a foundation for Ms. Vaught's reckless homicide charge, while some experts have said cabinet overrides are used daily at many hospitals.
  13. News Article
    NHS staff are significantly less likely to recommend their organisations as places to work or believe they employ enough people to deliver effective care, the service’s annual staff survey has revealed. The 2021 survey results, published today, showed regression across a broad range of questions, including in areas such as motivation, morale, workload pressures and staff health. One of the biggest drop-offs in survey scores related to the question asking whether there were enough staff in their organisation for respondents to do their job properly. Only 27.2% of those surveyed said staffing was adequate, a fall of 11% points from the previous year (38.4%). Only 59.4%nof staff said they would recommend their organisation as a place to work. This represented a 7% point decline from the previous year (66.8%). The rating had steadily improved since 2017 when it was at 59.7%. While a decline was seen across all sectors, the steepest drop was found among ambulance trusts. Ambulance trusts performing worse compared to other sectors appeared to be a recurring theme across the survey. Read full story (paywalled) Source: 30 March 2022
  14. News Article
    A damning report into hundreds of baby deaths has condemned the trust at the centre of the biggest maternity scandal in the history of the NHS for blaming mothers while repeatedly ignoring its own catastrophic blunders for decades. The independent inquiry into maternity practices at Shrewsbury and Telford hospital NHS trust uncovered hundreds of cases in which health officials failed to undertake serious incident investigations, while deaths were dismissed or not investigated appropriately. Instead, grieving families were denied access to reviews of their care and mothers were blamed when their babies died or suffered horrific injuries. A combination of an obsession with natural births over caesarean sections coupled with a shocking lack of staff, training and oversight of maternity wards resulted in a toxic culture in which mothers and babies died needlessly for 20 years while “repeated failures” were ignored again and again. Tragically, it meant some babies were stillborn, dying shortly after birth or being left severely brain damaged, while others suffered horrendous skull fractures or avoidable broken bones. Some babies developed cerebral palsy after traumatic forceps deliveries, while others were starved of oxygen and experienced life-changing brain injuries. The report, led by the maternity expert Donna Ockenden, examined cases involving 1,486 families between 2000 and 2019, and reviewed 1,592 clinical incidents. “Throughout our final report we have highlighted how failures in care were repeated from one incident to the next,” she said. “For example, ineffective monitoring of foetal growth and a culture of reluctance to perform caesarean sections resulted in many babies dying during birth or shortly after their birth. “In many cases, mother and babies were left with lifelong conditions as a result of their care and treatment. The reasons for these failures are clear. There were not enough staff, there was a lack of ongoing training, there was a lack of effective investigation and governance at the trust and a culture of not listening to the families involved. “There was a tendency of the trust to blame mothers for their poor outcomes, in some cases even for their own deaths. What is astounding is that for more than two decades these issues have not been challenged internally and the trust was not held to account by external bodies. “This highlights that systemic change is needed locally, and nationally, to ensure that care provided to families is always professional and compassionate, and that teams from ward to board are aware of and accountable for the values and standards that they should be upholding. Going forward, there can be no excuses.” Read full story Source: The Guardian, 30 March 2022
  15. Content Article
    The Independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust was commissioned in 2017 to assess the quality of investigations relating to newborn, infant and maternal harm at the Trust. When it commenced this review was of 23 families’ cases, but it has subsequently grown to cover cases of maternity care relating to 1,486 families, the majority of which were patients at the Trust between the years 2000 and 2019. Some families had multiple clinical incidents therefore a total of 1,592 clinical incidents involving mothers and babies have been reviewed with the earliest case from 1973 and the latest from 2020.
  16. News Article
    The children’s inpatient unit at an ‘outstanding’ mental health trust has been downgraded to ‘inadequate’ by the Care Quality Commission (CQC), amid a surge in demand for its services. The CQC previously rated child and adolescent mental health wards at Hertfordshire Partnership University Foundation Trust as “outstanding” in May 2019. But after an inspection in November and December 2021, these services were downgraded to “inadequate” overall and for the key categories of safety and leadership. Although inspecting a core service, the CQC said its visit was “not wide-ranging enough” to update overall trust ratings, so HPFT remains “outstanding” overall. Teenagers aged from 13 to 18 and admitted to Forest House, a 16-bed unit in Radlett providing HPFT’s only inpatient service for children and adolescents, told CQC inspectors they felt “unsafe”, dissatisfied with their care, and had experienced bullying by fellow patients. Leadership in the service had “significantly deteriorated” since previous inspections, CQC chiefs wrote in a report published today, and this was having a “knock-on effect in all areas of care being provided”. Staff morale was low and access to clinical psychologists limited, with a reduced ability to provide therapeutic interventions, inspectors added. Read full story (paywalled) Source: HSJ, 30 March 2022
  17. News Article
    Public satisfaction with the NHS has dropped to its lowest level for 25 years after a sharp fall during the pandemic, a survey suggests. The British Social Attitudes poll, seen as the gold standard measure of public opinion, found 36% of the 3,100 asked were satisfied in 2021. That is a drop from 53% the year before - the largest fall in a single year. Only once have satisfaction levels been lower since the poll started in 1983. That was in 1997, and shortly after that the Blair government started increasing the budget by record amounts. The public said it was taking too long to get a GP appointment or hospital care, and there was not enough staff. Satisfaction with GP care and hospital services were both at their lowest levels since the survey began. Dan Wellings, senior fellow at the King's Fund, described them as "extraordinary". He said the NHS initially saw a "halo" effect early on in the pandemic, with satisfaction rates being maintained as the NHS battled through the first wave. But he said it was clear that had now gone. "People are often struggling to get the care they need. These issues have been exacerbated by the extraordinary events of the past two years, but have been many years in the making following a decade-long funding squeeze, and a workforce crisis that has been left unaddressed for far too long." Read full story Source: BBC News, 30 March 2022
  18. News Article
    Official draft guidance has encouraged trusts to grow their ‘private patient opportunities’, despite facing huge backlogs of NHS work. The NHS England document, leaked to HSJ, includes instructions to local leaders for the new financial year starting in April. It said: “Trusts should continue to actively explore and develop opportunities to grow their external (non-NHS) income… Private patient services continue to be a significant source of material opportunity in the NHS.” It adds that NHS England and NHS Improvement will work with trusts to “identify and scale-up NHS export opportunities and support development of private patient opportunities to generate revenue and provide benefits for NHS staff and local patients and services”. It comes as the NHS faces huge backlogs of elective patients waiting for treatment. NHSE’s own plan to recover from Covid said the waiting list could rise to 14 million, up from the current 6 million. Sally Gainsbury, senior policy analyst at the Nuffield Trust, said the guidance was “capitalising” on the surge in people paying for private treatment during the pandemic. Ms Gainsbury said: “It is a concern that with over 6 million patients on the NHS waiting list, NHS England is actively encouraging NHS trusts to expand their private patient activity." “Scarce NHS capacity should be focused and prioritised on treating NHS patients and bringing these unacceptable waits down, not capitalising on the growth in the private treatment market on the back of this unprecedented backlog of care.” Read full story Source: HSJ, 29 March 2022
  19. News Article
    Thousands of Britons have avoided being diagnosed with type 2 diabetes thanks to an NHS programme aimed at early intervention. The Diabetes Prevention Programme identifies people at risk of developing the condition and gives them a nine-month plan to change their lifestyles. Researchers at the University of Manchester found that the programme resulted in 18,000 fewer people in England being diagnosed with type 2 diabetes between 2018 and 2019 — a 7% reduction. It focuses on eating and exercise habits and enables participants to join peer support groups and receive instruction from health coaches. The programme also offers a digital service that helps participants monitor their progress using wearable technology and mobile phone apps. Emma McManus, a research fellow at the university, said that diabetes was a “growing problem” for the country. The NHS spends about 10 per cent of its annual budget on treating it. “However, if you change your lifestyle, the risk of developing type 2 diabetes reduces,” she said. “Our research has shown that the programme has been successful in reducing the number of new cases of diabetes.” Emma Elvin, a senior clinical adviser at Diabetes UK, said: “This research adds to the evidence that many type 2 diabetes cases can be delayed or prevented with the right support and further highlights how the NHS diabetes prevention programme can be a real turning point for people at risk of type 2 diabetes.” Read full story (paywalled) Source: The Times, 28 March 2022
  20. News Article
    An ambulance trust has appointed a former senior trust executive to lead an independent investigation into the circumstances surrounding the unexplained death of a staff member, HSJ has learned. East of England Ambulance Service Trust also shared the terms of reference for the investigation withHSJ, which follows the trust being forced to launch a similar probe in 2020 after three young staff members died in 11 days in December 2019. The latest investigation is into the death of Nick Lee, 46, from Ovington in west Norfolk, who died on 3 December 2021. Mr Lee was an operations manager for the trust in the west Norfolk area and had worked for the trust for nearly 20 years. The cause of death is yet to be officially established. Margaret Pratt has been appointed by the trust to lead the investigation. A trust statement issued to HSJ said: “The purpose of the investigation is to look at the events leading up to the death, review the circumstances of the death and consider whether there is anything that the trust can learn to contribute to improving the support provided to staff.” The investigation follows a prolonged period of years in which the trust has been dogged by high-profile and deeply ingrained cultural and bullying problems. Read full story (paywalled) Source: HSJ, 29 March 2022
  21. Content Article
    Jail can never be a safe place to be pregnant but the flouting of rules makes things worse. No woman should suffer as I did, writes Anna Harley in this Guardian article.
  22. News Article
    The Royal College of Emergency Medicine (RCEM) estimated 36 Scots died as a direct result of avoidable delays in the week to 30 March. It comes as the number of people in hospital with Covid reached another record high, the worst cancer waiting times were reported since records began in 2006, and the Royal College of Nursing issued a warning that patient care is under “serious threat” from record-high staffing shortages. The RCEM said it would “welcome” a decision to extend the legal requirement to wear face coverings in Scotland to protect the NHS. “Anything that can continue to reduce the spread and therefore try and relieve as much pressure as possible in the healthcare system would be welcomed,” said RCEM Vice President in Scotland Dr John Thomson. Dr Thomson, an emergency medicine consultant at Aberdeen Royal Infirmary, said the government must understand the “unconscionable” harm coming to patients. “We have clear evidence that prolonged weeks in an emergency department lead directly to patient deaths,” he said. “Good evidence that, irrespective of what the medical problem is that they present with, that long wait alone is associated with death. “We can measure that quite clearly. One in 72 patients who wait in an emergency department beyond eight hours will die as a direct result. “In the last week alone we would estimate there were 36 avoidable deaths due to waits beyond eight hours. That's unconscionable.” A&E’s in Scotland are facing the “biggest patient safety crisis for a generation”, he said. Read full story Source: The Scotsman, 29 March 2022
  23. News Article
    Two national reviews are taking place into hospital discharge policy, it has emerged, amid major changes to funding and legislation. One review, led by the Department of Health and Social Care, is developing discharge policy for once the Health and Care Bill comes into force; and a second is reviewing the “clinical criteria to reside”. Delayed discharge has been a major problem in the acute and emergency care system this winter, with the number of long-staying patients significantly up on previous years. It has been blamed for long patient waits for ambulances, to get into emergency departments, and to be admitted; and for interrupting elective care recovery. An NHSE letter confirmed that the government’s national “discharge taskforce” was developing “best practice in improving discharge processes and addressing barriers to timely discharge”, in preparation for the new system. It went on: “This includes improving hospital processes to support discharge; minimising delays in the transfer of care from an acute hospital on to follow-up care services; minimising long lengths of stay in rehabilitation at home or in bedded care and ensuring social care services are available at the right time for people with ongoing care requirements. Further resources and support will be shared as learning from these systems becomes clear.” Read full story (paywalled) Source: HSJ, 28 March 2022
  24. News Article
    We have the technology to start a new era in medicine by precisely matching drugs to people's genetic code, a major report says. Some drugs are completely ineffective or become deadly because of subtle differences in how our bodies function. The British Pharmacological Society and the Royal College of Physicians say a genetic test can predict how well drugs work in your body. The tests could be available on the NHS next year. It would have helped Jane Burns, from Liverpool, who lost two-thirds of her skin when she reacted badly to a new epilepsy drug. She was put on to carbamazepine when she was 19. Two weeks later, she developed a rash and her parents took her to A&E when she had a raging fever and began hallucinating. The skin damage started the next morning. Jane told the BBC: "I remember waking up and I was just covered in blisters, it was like something out of a horror film, it was like I'd been on fire." Jane's experience may sound rare, but Prof Mark Caulfield, the president-elect of the British Pharmacological Society, said "99.5% of us have at least one change in our genome that, if we come across the wrong medicine, it will either not work or it will actually cause harm." "We need to move away from 'one drug and one dose fits all' to a more personalised approach, where patients are given the right drug at the right dose to improve the effectiveness and safety of medicines," said Prof Sir Munir Pirmohamed, from the University of Liverpool. Read full story Source: BBC News, 29 March 2022
  25. News Article
    New artificial intelligence software being rolled-out in NHS hospitals will be able to predict daily A&E admissions weeks in advance. The software, which launched in 100 hospitals across England on Monday, analyses data, including Covid infections rates, 111 calls and traffic to predict the number of patients that will seek emergency care. It also takes into consideration public holidays, such as New Year’s Eve, when A&E is more likely to be busy. The AI software is being rolled after trials showed an “impressive” ability to forecast admissions up to three weeks in advance. The NHS believes it will help tackle the record waiting list and allow hospitals to more easily manage their patient and bed capacity, prepare for busier days and staff up when needed. Nine trusts were given the software to use during the pandemic which notified them of expected spikes in cases, staff levels and numbers of beds and equipment necessary. However, hospitals receiving the new equipment have also been warned uncertainties within the data mean the system should be used as a “starting point to consider an operational response, not as a definite signal for action.” Read full story Source: The Independent, 28 March 2022
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