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Patient Safety Learning

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  1. Patient Safety Learning
    A deceased NHS consultant could have been charged with manslaughter over the deaths of haemophiliac patients given blood infected with HIV and hepatitis C, a lawyer for families has claimed. Des Collins said the reputation of Prof Arthur Bloom "cannot remain intact". The role of Prof Bloom has been mentioned by families of a number of victims giving evidence to the ongoing contaminated blood inquiry in Cardiff. 
    Cardiff and Vale University Health Board said it was co-operating fully with the inquiry. It added: "We cannot comment on historical allegations at this stage and will await the findings of the inquiry and then take any necessary steps. "We are committed to an open and transparent approach and have been working with Haemophilia Wales to support patients and families who are likely to be involved in the inquiry."
    Read full story
    Source: BBC News, 26 July 2019
  2. Patient Safety Learning
    Unlike many research lab, the Surgical Simulation Research Lab (SSRL) at the University of Alberta in Canada  is focusing on healthcare providers; specifically, they aim to know capacities and limitations of physicians and surgeons, and design a system to support them. 
    "Our goal is to create a simulation system for young physicians and surgeons to practice surgical skills without harming the patient..." said Bin Zheng, Associate Professor and the Director of SSRL. "This includes a better simulation programme for their skills training. We do everything to create a simulation model to replace patients being used as a training model".
    Read full story
    Source: Xinhua News, 21 July 2019
  3. Patient Safety Learning
    A type of anaesthetic machine that has been used in NHS hospitals can be hacked and controlled from afar if left accessible on a hospital computer network, says CyberMDX, a cyber-security company. For example, a successful attacker would be able to change the amount of anaesthetic delivered to a patient or alarms designed to alert anaesthetists to any danger could be silenced.
    GE Healthcare, which makes the machines, said there was no "direct patient risk". But CyberMDX's research suggested the Aespire and Aestiva 7100 and 7900 devices could be targeted by hackers if left accessible on hospital computer networks.
    Read full story
    Source: BBC News, 10 July 2019
  4. Patient Safety Learning
    Hundreds of patients, including children, dependent on intravenous nutrition to keep them alive are experiencing delays in vital deliveries, because of restrictions placed on the manufacturer by the MHRA. Clinicians warn patients may need to be admitted to hospital, rather than stay at home, if delays continue.
    Read full story (paywalled)
    Source: HSJ, 23 July 2019
  5. Patient Safety Learning
    GPs’ receptionists will divert patients to see pharmacists in a bid to relieve pressure on family doctors. The NHS plan aims to prevent 20 million GP appointments, with many of those telephoning for help instead offered a "same day” slot at a local chemist. Health officials said the moves would mean more accessible and convenient access to services. But patients’ groups said the measures were “worrying”, with fears that critical decisions could end up being taken by those with little training in how to assess patients. 
    From October, those calling 111 will be offered appointments at their local pharmacists if call handlers believe they are suffering from a minor ailment. Meanwhile, the NHS will pilot the same system for patients trying to make a GP appointment - with hopes to introduce the system nationally within nine months. 
    Health Secretary Matt Hancock said the moves were similar to “the French model” where pharmacists have a stronger role providing healthcare. Officials said the plans may be extended still further, to divert patients attempting to seek help from Accident & Emergency departments. 
    The changes are part of a five-year contract with pharmacists. 
    Read full story
    Source: The Telegraph, 22 July 2019
  6. Patient Safety Learning
    UK babies are missing out on checks for rare but serious health conditions, putting lives at risk, according to a report from the charity Genetic Alliance UK. The NHS offers newborns a blood test to screen for up to nine conditions, whereas many other European countries look for 20 or more illnesses and the US screens for more than 50, the charity says. 
    The UK National Screening Committee says its recommendations are based on evidence and are regularly reviewed. It is up to the governments in England, Scotland, Wales and Northern Ireland to decide which tests to provide. Genetic Alliance UK says affordable ways to expand the screening exist, but are not being used.
    Read full story
    Source: BBC News, 23 July 2019
  7. Patient Safety Learning
    Hospital admissions for sepsis in England have more than doubled in three years, according to new figures that shows a rise in recorded admissions among all age groups, including the very young.
    The NHS Digital data shows there were 350,344 recorded hospital admissions with a first or second diagnosis of sepsis in 2017/18, up from 169,125 three years earlier. This includes 38,401 admissions among those aged four years and under, up from 30,981 in 2015/16. For all children and young people aged 24 years and under, there were 48,647 admissions in 2017/18.
    Dr Ron Daniels, Chief Executive of the UK Sepsis Trust, and Patient Safety Learning topic leader, said the scale of the problem in children looks “alarming”, adding: “What this means is that parents need to continue to be aware of meningitis, but to arguably be even more aware of sepsis as it affects far more children and can be equally deadly.” He said: “These potentially alarming data show that the number of recorded episodes of sepsis has more than doubled in just three years, a period coinciding with the recent focus on sepsis by the NHS in England."
    Read full story
    Source: Mirror, 22 July 2019
  10. Patient Safety Learning
    NHS England together with Ipsos MORI, have published the latest Official Statistics from the GP Patient Survey. The survey provides information on patients’ overall experience of primary care services and their overall experience of accessing these services.
    Read results of the survey
  11. Patient Safety Learning
    The Professional Records Standard Body (PRSB) has published a new standard for shared care records that determines the vital information about a person that should be shared between health and care systems so care is safer, timely and more effective. Working with NHS England, the PRSB has asked citizens and health and care professionals to help produce a ‘core information standard’ that defines exactly what information should be shared in a person’s care record throughout their life. 
    Read full story
    Source: PRSB, 17 July 2019
  12. Patient Safety Learning
    Public Health Minister, Seema Kennedy, has confirmed that Professor Dame Sally Davies will take on the role of UK Special Envoy on antimicrobial resistance (AMR) later this year. Dame Sally will be working across all sectors to deliver a ‘One Health’ response to AMR, which includes health, agriculture and the environment.
    The appointment of Dame Sally follows the government’s 20-year vision and 5-year national action plan published earlier this year, setting out how the UK will contribute to containing and controlling AMR by 2040.
    Professor Dame Sally Davies said: “AMR is a complex challenge which needs local, national and global action. The UK should be proud of its world-leading work on AMR. We have made tangible progress but it is essential we maintain momentum. I am honoured to have been asked to continue this vital work on behalf of the UK government.”
    Last year the government committed £32 million funding to accelerate the UK’s work in the global fight against AMR. The awarded funding will support the development of a state-of-the-art, virtual ‘open access’ centre that will link health outcomes and prescribing data. This technology, led by Public Health England (PHE), will gather real-time patient data on resistant infections, helping clinicians to make more targeted choices about when to use antibiotics and cutting unnecessary prescriptions.
    PHE will use £5 million in funding to develop a fully functional model ward, the first of its kind in the UK, to better understand how hospital facilities can be designed to improve infection control and reduce the transmission of antibiotic-resistant infections.
    Other successful funds include £4.4 million to Manchester University to test ‘individualised’ approaches to antibiotic prescribing by bringing together patient care and clinical research, and £3.5 million to the University of Liverpool to apply innovative genome sequencing to enable more personalised antibiotic prescribing.
    Public Health Minister Seema Kennedy said: “Antibiotic resistance poses an enormous risk to our NHS – we are already seeing the harmful effect resistant bugs can have on patient safety in our hospitals. It is vital that we retain the irreplaceable expertise of Professor Dame Sally Davies – an international expert in AMR – and continue to invest in research.”
  13. Patient Safety Learning
    The parents of Claire Roberts said those responsible for their daughter's care should "hang their heads in shame". Alan and Jennifer Roberts were speaking after an inquest found that the nine-year-old's death in October 1996 was caused by the treatment she received in hospital. Outside Laganside courthouse, Mr and Mrs Roberts welcomed the coroner's findings but said the public can have "no confidence in patient safety" in Northern Ireland. 
    Mr Roberts said that after a two decade wait the inquest had finally delivered the truth about how their daughter died. "We would like to thank the coroner for reaching a verdict after 22 years of cover-up that finally identifies the truth. The coroner has confirmed an unnatural cause of death. We have known as a family since 2004 the true cause of death - this has not been news to us but the coroner reaffirming what we have always known."
    Mr Roberts also issued a demand to health officials for accountability, saying those responsible for failings in his daughter's care should "hang your heads in shame."
    Source: Belfast Telegraph
  14. Patient Safety Learning
    NHS bosses have been accused of “burying” a damning report into child cancer services commissioned following complaints that patients were “dying in agony”. Completed in 2015, the document highlights failings at the Royal Marsden NHS Foundation Trust, one of the UK’s flagship cancer organisations. It found that, despite being supposedly a centre of excellence, children admitted for cancer treatment were routinely transferred between hospitals to get the care they needed.
    Compiled by Professor Mike Stephens, the report was commissioned after a coroner found “astonishing” failures in the care of a two-year-old girl, Alice Mason, leading to her suffering irreversible brain damage and dying in 2011. It recommended a radical shake-up of the Marsden’s services. The document was never made public, however, and former NHS medical director for London, Dr Andy Mitchell, accused the head of NHS England, Simon Stevens, and Cally Palmer, England’s National Cancer Director and Chief Executive of the Royal Marsden, of suppressing its publication.
    Dr Mitchell told the Health Service Journal (HJS): “I can’t imagine any other individuals having the power and influence to be able to stop this report moving forward.”
    NHS England has denied that its then Medical Director, Sir Bruce Keogh, was improperly leaned on and said the report remained unpublished because it made “implausible suggestions” which would have forced children with cancer to travel further for care. But Gareth Mason, Alice’s father, said: “To write a report, shelve it and not debate it, that is a cover-up [and] it has left children since Alice and danger, and the Marsden won’t acknowledge that.”
    The controversy surrounds the performance of a so-called “shared care system”, with the Marsden’s Sutton site forming part of a network for South London, Surrey, Sussex and Kent.
    Critics say the format meant children were transferred between sites more regularly than they should have been and were put in danger because information was not properly shared.
    Read full story
    Source: The Telegraph, 19 June 2019  
  15. Patient Safety Learning
    Nearly half of care workers in care homes have been both physically and verbally abused by the residents they are supporting, according to new research.
    A poll of 2,803 staff working in care homes revealed 17% have received verbal abuse from residents and 11% have been subject to physical abuse.
    A spokesperson for carehome.co.uk, said: “All over the UK, care workers are doing physically and emotionally demanding jobs on often low pay and long hours. Yet at the same time, the rewards of working in a care home can be huge, as you can build strong relationships with the people you care for and make deep, emotional connections."
    “Lashing out at staff is often a sign of frustration and it is vital care homes give staff dementia training so they can find the reasons behind this challenging behaviour. Care workers do such an important job and with around three-quarters of people in care homes having dementia, it is vital care workers are given adequate support and specialist training to care for them.”
    Read full story
    Source: Carehome.co.uk, 10 May 2019
  16. Patient Safety Learning
    Regina Stepherson needed surgery for rectocele, a prolapse of the wall between the rectum and the vagina. Her surgeons said that her bladder also needed to be lifted and did so with vaginal mesh, a surgical mesh used to reinforce the bladder.
    Following the surgery in 2010, Stepherson, then 48. said she suffered debilitating symptoms for two years. An active woman who rode horses, Stepherson said she had constant pain, trouble walking, fevers off and on, weight loss, nausea and lethargy after the surgery. She spent days sitting on the couch, she said.
    In August 2012, Stepherson and her daughter saw an ad relating to vaginal mesh that mentioned 10 symptoms and said that if you had them, to call a lawyer.
    Vaginal mesh, used to repair and improve weakened pelvic tissues, is implanted in the vaginal wall. It was initially — in 1998 — thought to be a safe and easy solution for women suffering from stress urinary incontinence.
    But over time, complications were reported, including chronic inflammation, and mesh that shrinks and becomes encased in scar tissue causing pain, infection and protrusion through the vaginal wall.
    More than 100,000 lawsuits have been filed against makers of mesh, according to ConsumerSafety.org, making it “one of the largest mass torts in history.”
    Read full story
    Source: Washington Post, 20 January 2019
  17. Patient Safety Learning
    An unfortunate series of events involving a magnetic resonance imaging (MRI) machine led to the death of a man at a hospital in India.
    Rajesh Maruti Maru, a 32-year-old, was thrust into the MRI machine  while he was visiting an elderly relative at the BYL Nair Charitable Hospital in Mumbai, India. As the Hindustan Times reports, the man was apparently told by a junior member of staff to carry a metal cylinder of liquid oxygen into a room containing an MRI machine.
    Unbeknownst to everyone, the MRI machine was turned on. This caused Maru to be suddenly jolted pulled towards the machine, causing the oxygen tank to rupture and leak. The man later died after inhaling large amounts of oxygen. His body also bled heavily as a result of the accident.
    "When we [the hospital staff] told him that metallic things aren't allowed inside an MRI room, he said 'sab chalta hai, hamara roz ka kaam hai' [it's fine, we do it every day]. He also said that the machine was switched off. The doctor, as well as the technician, didn't say anything,” Harish Solanki, Maru's relative, told NDTV.
    "It's because of their carelessness that Rajesh died," Solanki added.
    Police are currently examining the CCTV footage of the incident and have arrested at least two members of hospital staff for the negligence. The local government has also awarded the man's family 500,000 rupees ($7,855) in compensation.
    Read full story
    Source: IFL Science, 29 January 2018
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