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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    "Absolutely soul destroying" is how one paramedic describes his job. He is not alone. Over the past few months, BBC Wales has been contacted by employees from the Welsh Ambulance Service who paint a dire picture of a service under immense pressure. Ambulance waiting times have climbed and climbed throughout the pandemic. The impact that has on patients is well known - but what about those on the other side? Mark, who did not want to disclose his real name or show his face for fear that he would lose his job, described the stress of his shifts with a radio strapped to his chest, hearing "red calls waiting, red calls waiting". "That is the potential of somebody's life waiting in the balance - and you can't get there. It's absolutely soul-destroying. We wouldn't treat animals this way, why are we treating humans?", he said. Mark said the job has always come with pressure and anxiety. But over the course of the pandemic that has intensified and he has "never known as many people looking for other jobs as they are at the moment". The stress has become so bad that he is now on antidepressants. Read full story Source: BBC News, 25 March 2022
  2. News Article
    The UK's top public health doctor says anyone with a persistent cough and fever should not dismiss it as Covid - and should consider other infectious illnesses like tuberculosis (TB). Dr Jenny Harries' warning comes as provisional data shows there were 4,430 cases recorded in England in 2021, despite sharp declines in recent years. Charities are calling for more funding to tackle the disease around the world. They say the pandemic and conflicts have set back progress worldwide. In 2020, global deaths because of tuberculosis ranked second to Covid for any infectious disease. The charity Stop TB Partnership warns the war in Ukraine could have "devastating impacts on health services", including the country's strong national TB treatment programme. The charity is urging all countries to put facilities in place urgently so refugees can be given the care they need. In the UK a requirement for Ukrainians to take a TB test before arrival has been waived for those who are coming to the country on the family scheme visa. Refugees arriving on the scheme will get medical care and testing via GPs. Meanwhile Dr Jenny Harries, chief executive of the UK Health Security Agency, said delayed diagnosis and treatment, particularly during the pandemic, will have increased the number of undetected cases in England. Read full story Source: BBC News, 24 March 2022
  3. Content Article
    In this blog Patient Safety Learning’s Chief Executive, Helen Hughes, discusses the connection between procurement, supply chains and patient safety, ahead of an upcoming Safety for All Campaign webinar on this topic.
  4. Content Article
    Putting patients in tents outside hospitals is a completely unacceptable ‘solution’ to the ambulance handover problems and the funding would be far better spent on staff in the community, says Royal College of Emergency Medicine president Katherine Henderson in this HSJ opinion piece.
  5. News Article
    The government’s upcoming Covid-19 public inquiry must include the effect of the pandemic on children and young people, a group of leading doctors and scientists have said. The draft terms of reference for the inquiry were published on 15 March but made no specific mention of children or young people other than a single reference to “restrictions on attendance at places of education." “There is no doubt that school closures and broader lockdowns harmed children,” said the letter to the Times signed by 50 people including Russell Viner, former president of the Royal College of Paediatrics and Child Health, and Andrew James, president of the Royal College of Psychiatrists. “Educational losses have been most marked in children from deprived families and in vulnerable children.” They pointed out that mental health problems increased from being experienced by one in nine children and young people before the pandemic to one in six during 2020 and 2021. Childhood obesity rates last year were at least 20% above previous years. One of the signatories to the letter, education committee chair Robert Halfon, has also written directly to the inquiry chair Heather Hallet.3 “The closure of schools and the restrictions placed on education settings has been nothing short of a national disaster for children and young people, not only in terms of their educational attainment but also with regards to their mental health and wellbeing, their life chances, and their safety,” he wrote. Read full story Source: BMJ, 24 March 2022
  6. News Article
    Pregnant women with suspected pre-eclampsia will now be offered a test on the NHS to detect the condition. Pre-eclampsia affects some women, usually during the second half of pregnancy or soon after their baby is born. It can lead to serious complications if it is not picked up during maternity appointments, with early signs including high blood pressure and protein in the urine. In some cases, women can develop a severe headache, vision problems such as blurring or flashing, pain just below the ribs, swelling and vomiting. Tests have been available to help rule out the condition but midwives will now use tests designed to pick up a positive diagnosis. In new draft guidance, the National Institute for Health and Care Excellence (NICE) said midwives could use one of four blood tests to help diagnose suspected preterm pre-eclampsia. Jeanette Kusel, the acting director for medtech and digital at NICE, said: “These tests represent a step-change in the management and treatment of pre-eclampsia. New evidence presented to the committee shows that these tests can help successfully diagnose pre-eclampsia, alongside clinical information for decision-making, rather than just rule it out. “This is extremely valuable to doctors and expectant mothers as now they can have increased confidence in their treatment plans and preparing for a safe birth.” Read full story Source: The Guardian, 25 March 2022
  7. News Article
    GP practices are set to face new targets for responding to patient complaints under standards being piloted by the health ombudsman. All ‘straightforward’ complaints should be dealt with within six months and 95% within three, while 80% of ‘complex’ complaints should be completed within six months and half within three, under the proposals. The new Parliamentary and Health Service Ombudsman (PHSO) complaint standards are currently being piloted in every sector of the NHS – including one GP practice – and were due to be implemented across the NHS this year. However, a PHSO spokesperson told Pulse that due to delays caused by the pandemic, the full rollout is now planned for the beginning of next year, with the ombudsman to implement the standards from April 2023. The proposed complaints standards said staff should ensure they ‘consistently meet expected timescales for acknowledging a complaint’ and ‘respond to complaints at the earliest opportunity’, providing ‘regular updates throughout’. They should also give ‘clear timeframes’ for how long investigating the complaint will take and ‘agree timescales with everyone involved’, including the complainant. An accompanying draft model complaint handling procedure said that complaints will be acknowledged within three working days either verbally or in writing. Read full story Source: Pulse, 24 March 2022
  8. News Article
    The Care Quality Commission is to prosecute an acute trust after a patient was injured when allegedly exposed to “avoidable harm”. United Lincolnshire Hospitals Trust is due to appear tomorrow afternoon at Boston Magistrates’ Court. The alleged incident took place at Lincoln County Hospital, the CQC said. Although the CQC declined to comment further, Lincolnshire Live reported the alleged incident involved 91-year-old Iris Longmate and relates to a failure to provide safe care and treatment on or before 3 March 2019. The local publication added court papers claimed “at the same time ULHT also failed to give safe care and treatment to patients on Greetwell Ward, who were ‘being exposed to a significant risk of avoidable harm occurring’”. Proceedings are being brought under sections 22 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These rules require providers to take reasonable steps to minimise risks to people’s health and safety during treatment, and make it a criminal offence if a provider fails to comply and a patient suffers avoidable harm or is exposed to a risk of this happening. Read full story (paywalled) Source: HSJ, 24 March 2022
  9. News Article
    The use of temporary treatment areas for patients arriving via ambulance at over-crowded A&Es is ‘borderline immoral’ and ‘a danger to patient safety and dignity’, the Royal College of Emergency Medicine has warned. The college said NHS England had told regional bosses to prepare to errect more of the so-called “tents” outside their major emergency departments as part of plans to get a grip on ambulance handover delays, which have reached record highs in the last two weeks. Senior figures also told HSJ that trusts have been instructed by NHS England to call the overflow facilities “temporary external structures” and not tents – a move also criticised by RCEM president Katherine Henderson. Dr Henderson told HSJ: “Using tents is just wrong on every level… We’ve been down this route before. It doesn’t work. It’s a huge distraction, and I think what upsets me the most about it is it creates the appearance that people are taking action when it’s not the action that will deal with the problem.” In an opinion piece for HSJ, Dr Henderson says: “We find ourselves in the completely unacceptable situation where the ‘solution’ to ambulance handover problems is to put up tents or sheds in front of emergency departments – euphemistically being called ‘temporary external structures’. “Trust leaders and NHS England must not be afraid to stand up and make this case – putting patients in tents is a bad, borderline immoral bodge job to treat the symptom rather than cause, and our patients need to see some real leadership to protect them." Read full story (paywalled) Source: HSJ, 25 March 2022
  10. News Article
    An NHS trust has apologised over the death of a 27-year-old events manager after a locum gynaecologist mistook aggressive cervical cancer for a hormonal or bowel problem. The family of Porsche McGregor-Sims, who died a day after being admitted to Queen Alexandra hospital in Portsmouth, told her inquest that she had felt she was not listened to and that the misdiagnosis had robbed them of a chance to say goodbye. The area coroner Rosamund Rhodes-Kemp said the case was one of the most “shocking and traumatic” she had dealt with and she would write to Portsmouth hospitals university NHS trust expressing her concern. In December 2019, McGregor-Sims’ GP referred her to a consultant after she complained of abdominal pain and vaginal bleeding. She saw Dr Peter Schlesinger, an agency locum at the Queen Alexandra hospital, at the end of January 2020. He did not physically examine her and believed her symptoms were linked to changing hormones or irritable bowel syndrome (IBS). After the UK went into lockdown two months later, McGregor-Sims continued to report symptoms but was prescribed antibiotics over the phone and was seen in person only after a GP thought she might have Covid because she had shortness of breath. McGregor-Sims was finally diagnosed with an aggressive form of cervical cancer and on 13 April was taken to hospital, where she died a day later. During the inquest, her family accused Schlesinger of having denied them their chance to say goodbye. Her mother, Fiona Hawke, told him: “You robbed us of the opportunity to prepare for her death and say goodbye to her.” Schlesinger insisted McGregor-Sims’ symptoms – including bleeding after sex – did not lead him to think she had a serious illness. Dr Claire Burton, a consultant gynaecologist, said Schlesinger should have physically examined McGregor-Sims, and apologised for the care she received at the trust. Read full story Source: The Guardian, 24 March 2022
  11. Content Article
    Nigeria is projected to become one of the most populous countries in the world, and is rightly taking its place on the world stage. The Lancet Nigeria Commission tells the story of the country through a health lens, and details recommendations that will enable the country and its people to fulfil their potential, and seize the opportunity ahead. It has been led by Nigerians for Nigerians. The Commissioners call for the creation of a new social contract that redefines the relationship between citizen and state. They argue that health has, to date, been neglected by successive governments and consequently the citizens of Nigeria, and must be recentred as a vital investment in the population – one that will reap political and economic benefits. Nigeria is poised to define the future of West Africa, the African continent, and the whole world. This Commission lays out how best to realise that ambition.
  12. Content Article
    This guide from the Patient Safety Movement Foundation gives actions and resources for creating and sustaining safe practices for reducing medication errors. In it, you’ll find: Executive summary checklist What we know about medication errors Leadership plan Action plan Technology plan Measuring outcomes Conflicts of interest disclosure. Workgroup References.
  13. Content Article
    CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments.
  14. News Article
    A senior medic has won a whistleblowing case after judges ruled she was dismissed after raising concerns about a new procedure her department was using. An employment tribunal found consultant nephrologist Jasna Macanovic was fired from Portsmouth Hospitals University Trust in March 2018 after telling bosses a dialysis technique called “buttonholing”, which had been “championed” there, was potentially dangerous. The trust’s case was that the way she had gone about raising concerns had made for an untenable working environment in the Wessex Kidney Centre. The process saw a Care Quality Commission complaint, an independent investigation and multiple referrals to the General Medical Council. Employment Judge Fowell said: “The plain fact is that after over twenty years of excellent service in the NHS, Dr Macanovic was dismissed from her post shortly after raising a series of protected disclosures about this one issue. It is no answer to a claim of whistleblowing to say that feelings ran so high that working relationships broke down completely, and so the whistleblower had to be dismissed.” Dr Macanovic resigned from the regional renal transplant team in July 2016 when she discovered two incidents had occurred that “had not been reported by either surgeon” and felt that one of the surgeons had misled the medical director over the issue, the tribunal heard. In an email sent after the resignation meeting, Dr Macanovic said the practice was considered inappropriate by the vast majority of experts in the field and that no other renal unit in England was using it. The case exposes some worrying governance, both within the trust and between it and the Care Quality Commission, with which the issues were raised in 2016. When the CQC asked the trust for more information the unit’s clinical director responded that in his view that the deaths and infections were not due to the buttonholing. The CQC made no further enquiries and wrote back saying “they were satisfied that there were no safety concerns and that appropriate governance had been followed”. Read full story Source: HSJ, 24 March 2022
  15. News Article
    A regulator that sets standards on staff wellbeing and holds the NHS to account should be established to help protect doctors from burnout, a champion of physicians’ wellbeing has said. The proposal was one of several put forward by Clare Gerada, president of the Royal College of General Practitioners, who recently stepped down as medical director of the confidential mental health support service NHS Practitioner Health. She was speaking on 22 March to MPs on the House of Commons health and social care committee about how the Covid-19 pandemic had increased the number of doctors struggling with mental health problems, particularly in general practice. Read full story (paywalled) Source: BMJ, 24 March 2022
  16. News Article
    The government has doubled the annual efficiency expectation on the NHS, he has said, as systems and trusts grapple with large gaps in their financial plans for 2022-23. The Treasury told the media over the weekend the Chancellor was doubling the NHS’s annual savings target to 2.2% from 1.1%. Reports said this would deliver an annual saving of £4.75bn. It is unclear whether the move represents a change to the underlying efficiency expectation in NHS planning — which would require all systems and trusts to revise their plans for 2022-23 — or is simply a re-statement or recognition that the effective efficiency requirement was already well above the 1.1 per cent envisaged under the pre-covid NHS long-term plan. Rishi Sunak told the Mail on Sunday the move was linked to the “health and social care levy” which will see a rise in National Insurance next month. He also said he would chair a new cabinet committee to reduce waste in the public sector. Speaking ahead of his Spring Statement on Wednesday, he said: “Your readers should be reassured that unlike any other tax that they pay, every penny of this levy goes specifically to the thing that they care most about… So we are setting up a new Cabinet committee, that I am chairing, to focus on efficiency, value for money, waste and reform. Working with the health secretary we are doubling the efficiency target for the NHS. Every pound from this levy is going to go incredibly far.” In NHS England’s annual report, published last month, its chief executive Amanda Pritchard said: ”The certainty we have recently received on both capital and revenue budgets for the years ahead provide a welcome basis on which the NHS nationally and locally can now plan. We should however be under no illusions that the challenges ahead – for financial balance and operational performance – are anything other than unprecedented.” Read full story (paywalled) Source: HSJ, 20 March 2022
  17. News Article
    Covid hospitalisations will continue to rise for at least two weeks, England’s government’s chief medical officer warned on Wednesday as Britain’s daily cases breached 100,000 for the second time this month. Professor Sir Chris Whitty said the country’s Covid crisis “is not over” and that new variants of the disease could arise at any time. He pointed to the latest data showing that the number of people with Covid in hospitals has been rising, and said this would likely continue for at least two weeks. The current rise in cases is “currently being driven by Omicron rather than new variants”, he told an audience at a Local Government Association conference, but added: “We need to keep a very close eye on this, because at any point new variants could emerge anywhere in the world, including the UK, obviously, as what happened with the Alpha variant.” Another 194 Covid deaths were reported on Wednesday, up 27% on last week. Prof Whitty said that death rates were fortunately still low but that hospitalisations meant there was still pressure on the NHS. Asked about the end of free testing for the public on 1 April, Sir Chris said it was a “trade-off between disparities, because the effects of free testing are probably going to be differential across society, and [there are] very substantial sums that are going into it, which otherwise would be going into other public health issues." However, he said that testing for staff within health and social care was “slightly different” as the risks are greater, and those who are in hospital or care homes are more vulnerable. His comments come on the second anniversary of the day the UK announced a national lockdown. Read full story Source: The Independent, 23 March 2022
  18. News Article
    The chief nursing officer for England has spoken about the ongoing shortages of nurses across the country and how the government’s previous pledge for 50,000 more nurses is now “not enough”. At one of her first in-person speeches since the start of the pandemic, Ruth May also revealed that she thought the removal of the student nurse bursary in England was “fundamentally the wrong decision”. Ms May was speaking at an event organised by the League of St Bartholomew’s Nurses in honour of pioneering nurse Pam Hibbs, who died following a Covid-19 infection last year. During her keynote address, Ms May said workforce remained a “big focus” for her team due to the “shortage” of nursing staff nationally. She said work to address the gaps was centred on the three areas of international recruitment, domestic training, and retention. She said numbers of nurses being recruited from overseas annually had risen from around 5,000 to 6,000 before the pandemic, to an expected 20,000 in this financial year. “I’m very, very glad that the NHS has had a diverse workforce from its very inception. We have welcomed colleagues from across all countries of the world, and we will continue to do that,” Ms May said. Read full story (paywalled) Source: The Nursing Times, 22 March 2022
  19. Content Article
    This Joint Committee on Human Rights inquiry will look at human rights concerns in care settings in England, highlighting areas in which the human rights of patients, older people and others living with long-term disabilities, including learning disabilities and autism, are currently undermined or at risk.
  20. Content Article
    All big experiences in our lives have two realities. There is what really happened. And there is the narrative, the story we tell ourselves and each other about what happened. Of the two, psychologists say it’s the narrative that matters most. Creating coherent stories about events allows us to make sense of them. It is the narrative that determines our reactions, and what we do next. Two years after the World Health Organization (WHO) finally used the word “pandemic” in its own story about the deadly new virus from Wuhan, narratives have multiplied and changed around the big questions. How bad is it? What should we do about it? When will it be over? The stories we embraced have sometimes been correct, but others have sown division, even caused needless deaths. Those stories aren’t finished – and neither is the pandemic. As we navigate what could be – if we are lucky – Covid’s transition to a present but manageable disease, it is these narratives we most need to understand and reconcile. What has really happened since 2020? And how does it still affect us now?
  21. News Article
    Four years ago, inside the most prestigious hospital in Tennessee, nurse RaDonda Vaught withdrew a vial from an electronic medication cabinet, administered the drug to a patient, and somehow overlooked signs of a terrible and deadly mistake. The patient was supposed to get Versed, a sedative intended to calm her before being scanned in a large, MRI-like machine. But Vaught accidentally grabbed vecuronium, a powerful paralyser, which stopped the patient’s breathing and left her brain-dead before the error was discovered. Vaught, 38, admitted her mistake at a Tennessee Board of Nursing hearing last year, saying she became “complacent” in her job and “distracted” by a trainee while operating the computerized medication cabinet. She did not shirk responsibility for the error, but she said the blame was not hers alone. “I know the reason this patient is no longer here is because of me,” Vaught said, starting to cry. “There won’t ever be a day that goes by that I don’t think about what I did.” If Vaught’s story followed the path of most medical errors, it would have been over hours later, when the Board of Nursing revoked her RN license and almost certainly ended her nursing career. But Vaught’s case is different: This week she goes on trial in Nashville on criminal charges of reckless homicide and felony abuse of an impaired adult for the killing of Charlene Murphey, a 75-year-old patient who died at Vanderbilt University Medical Center on the 27 December 2017. Prosecutors do not allege in their court filings that Vaught intended to hurt Murphey or was impaired by any substance when she made the mistake, so her prosecution is a rare example of a health care worker facing years in prison for a medical error. Fatal errors are generally handled by licensing boards and civil courts. And experts say prosecutions like Vaught’s loom large for a profession terrified of the criminalization of such mistakes — especially because her case hinges on an automated system for dispensing drugs that many nurses use every day. Read full story Source: Kaiser Health News, 22 March 2022
  22. Content Article
    Wearable devices are a modern marvel. They teach users exactly how many calories you can burn by running up a flight of stairs, record sleep patterns down to the minute a neighbour’s safety light wakes you up, monitor your heart rate and alert you if anything gets out of whack, and even control your music during a workout. And that’s not even touching on the medical wearables that patients use to manage chronic conditions. We’re living in a time when so much information is available on our wrists or in our palms, and these devices are improving the lives and health of users all over the world. And yet, they’re not perfect. Software Advice surveyed over 450 US patients who currently use medically-prescribed wearable devices to better understand their experiences.
  23. Content Article
    Patient safety is typically assessed by the frequency of adverse events or incidents, which means we seek to determine safety by its absence rather than its presence. The Safety-II perspective aspires to overcome this paradox by bringing into focus situations where safety is actually present, that is, in everyday work that usually goes well. Central to Safety-II is the notion that, in complex systems such as healthcare, safety is a consequence of collective efforts to adapt to dynamic conditions and uncertainty, rather than the natural state of a system where nothing untoward happens. This type of thinking has been met with significant interest and enthusiasm in healthcare, because it feeds increased appreciation for the fact that healthcare workers continuously ensure that most patients receive safe and high-quality care in challenging circumstances. However, despite its appeal and potential, significant challenges remain for the fruitful interpretation and application of the Safety-II perspective in healthcare, which could give rise to misinterpretations, misuse and a missed opportunity for the potential enrichment of quality and safety practices in healthcare.
  24. News Article
    Judges’ notes are regarded as the official record and are made available to employment appeal tribunals, but they are seen as private documents and are not available to the parties. If the judgment that follows a hearing omits substantial elements of oral evidence that support the claimant’s case, the prospects of a successful appeal are hampered without a court record. 'This imbalance irretrievably denies parties the right to prepare adequately an appeal and it is manifestly unfair,' the letter states. Reference to the full record 'is the only way to determine whether the decision made was fair and proper'. Signatories include Sir Adam Ridley, a former senior civil servant at 10 Downing Street and the pioneering cardiologist Jane Somerville of Imperial College, London. A spokesperson for the judiciary said: 'The letter has been received and is being reviewed.' Barrister Sophie Walker, founder of the company Just Transcription, told the Gazette: 'Providing litigants and their legal teams recordings and automated transcripts of the hearing would be a major leap forward for open justice and access to justice.' Read full story Source: The Law Society Gazette, 22 March 2022
  25. News Article
    A man who experiences regular mental health crises says an NHS scheme designed to offer support during emergency episodes has become broken. The trust running the service says a crisis team offers immediate support in an emergency, and a 24-hour helpline. But when Mark Doody, who has bipolar disorder, cried "down the phone, begging the team for help", he was told to call an ambulance, his wife said. The trust said a 999 call could sometimes be the appropriate action. Trish Doody cited a "dreadful" deterioration in mental healthcare where the couple lived in Redditch, Worcestershire. She said while her husband was able to get support if an emergency happened "between 9am and 5pm", assistance became difficult outside of those hours. Mr Doody said his condition meant he experienced a mental health crisis every three months. He has also made suicide attempts. Mental healthcare provision in the county had gone downhill over the last 20 years, Mrs Doody said, with her husband adding: "The system is just broken really." Healthwatch Worcestershire, which helps hold the NHS to account locally, said it was "exploring" whether there was a problem with the crisis helpline, and was also aware of delays for those seeking one-to-one counselling, which it said the trust was tackling. Read full story Source: BBC News, 22 March 2022
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