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Patient Safety Learning

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  1. Patient Safety Learning
    Peter Marshall was delighted when he finally got an appointment after calling his GP surgery for several days.
    On the day, he saw a young medic who said his excruciating stomach pain was caused by irritable bowel syndrome (IBS) and suggested over-the-counter peppermint tablets to ease the discomfort.
    And off the 69-year-old retired IT specialist went, happy to have a diagnosis and treatment.
    In fact, Peter hadn't had an appointment with a GP — he had been seen by a physician associate (PA).
    This is a type of healthcare worker whose numbers are about to soar in the NHS in order to reduce the pressure on doctors so that they can concentrate on the most complex and seriously ill patients.
    It all sounds like a great idea. Indeed, PAs are now being employed across areas that are particularly stretched, with around a third of PAs working in GP surgeries and 10% in A&E departments, according to the latest census by the Royal College of Physicians. But they are actually spread across 46 NHS specialties, from urology and surgery to cardiology and mental health.
    In this role, they are permitted to carry out a range of medical tasks, from performing physical examinations, diagnosing patients and analysing test results to running clinics and performing minor procedures — as well as doing home visits — all under the supervision of a doctor.
    However, in the case of Peter Marshall, although he was reassured by his diagnosis, his symptoms were, in fact, a sign of bowel cancer — and he died nine months later, in January this year.
    His sister, who has told Good Health his story, says: 'My brother had no idea that he had seen a PA and not a qualified doctor — he didn't know the word physician associate even existed, no one does.'
    The family, from London, later received an apology from the PA. 'Patients are so desperate to get an appointment with their GP, you are grateful to see anyone and whatever they say, you accept,' she says.
    Read full story
    Source: Daily Mail, 9 October 2023
     
  2. Patient Safety Learning
    Inspectors have demanded action over patients facing long waits on trolleys at Wrexham Maelor Hospital's A&E unit.
    Healthcare Inspectorate Wales (HIW) said officials found some people waiting eight hours during an unannounced visit in August. It wants Betsi Cadwaladr University Health Board (BCUHB) to make rapid improvements.
    In a statement, it said some of HIW's recommendations had already been addressed.
    In its report, HIW acknowledged efforts made by emergency department staff to look after those in need, the Local Democracy Reporting Service reported.
    "It was identified that patients who were waiting on trolleys in the corridor were not receiving appropriate and timely care," said HIW. "We had to alert the nurse responsible for the patients in the emergency department corridor to a patient who was experiencing increased chest pain."
    "During the inspection, we found that there were no pressure relieving mattresses available for any patients who were waiting on trolleys within the emergency department."
    "We considered the above practices to be unsafe and increased the risk of harm to patients."
    Read full story
    Source: BBC News, 9 November 2019
  3. Patient Safety Learning
    Health trackers worn on the wrist could be used to spot Covid-19 days before any symptoms appear, according to researchers.
    Growing numbers of people worldwide use the devices to monitor changes in skin temperature, heart and breathing rates. Now a new study shows that this data could be combined with artificial intelligence (AI) to diagnose Covid-19 even before the first tell-tale signs of the disease appear.
    “Wearable sensor technology can enable Covid-19 detection during the presymptomatic period,” the researchers concluded. The findings were published in the journal BMJ Open.
    The discovery could lead to health trackers being adapted with AI to detect Covid-19 early, simply by spotting basic physiological changes. This could help provide an early warning system to users that they may be infected, which may in turn help to prevent the spread of the disease more widely.
    Read full story
    Source: The Guardian, 21 June 2022
  4. Patient Safety Learning
    “Human error” resulted in a man having the wrong leg amputated at a major Austrian hospital.  The error occurred when a healthcare employee marked the wrong leg for amputation during pre-surgical procedures.
    The mistake was not noticed anytime during the surgery, or even during the immediate postoperative period.  It was recognised during a routine wound dressing change, about 48 hours postoperatively.
    “A disastrous combination of circumstances led to the patient’s right leg being amputated instead of his left,” the hospital’s statement said.  “We would also like to affirm that we will be doing everything to unravel the case, to investigate all internal processes and critically analyze them. Any necessary steps will immediately be taken.”
    Read full story
    Source: Lansing Injury Law News, 24 May 2021
  5. Patient Safety Learning
    A new mum was confused for another patient and mistakenly fitted with a contraceptive coil after a C-section.
    Another patient in north Wales almost had the wrong toe removed during surgery to amputate two others.
    A third incident happened when a patient, unable to swallow oral medication, had it crushed, mixed with water and administered with a syringe.
    These so-called "never events" happened at hospitals in the Betsi Cadwaladr health board area in February.
    In a report into the three incidents in February, Betsi Cadwaladr health board outlined how a patient had a coil - an intrauterine device which prevents pregnancy - inserted after undergoing a Caesarean section.
    Described in the report as "wrong procedure", it had been planned for a different patient but a mistake had been made after the "list order was changed due to the increase in category for this patient".
    Another incident, described in the report as "wrong site surgery", described a patient who was due to have their second and third toes amputated. However, an incision was made in their fourth toe by accident.
    Luckily, the error was spotted and the correct toes were amputated.
    In the third never event, described as "wrong route", the report details the case of a patient who was unable to swallow oral medication.
    To administer it, a member of staff crushed it, mixed it with water and "inadvertently" gave it intravenously, according to the report.
    Read full story
    Source: BBC News, 28 March 2024
  6. Patient Safety Learning
    A woman who had her ovaries removed by mistake was one victim of the hundreds of “never events” that occurred in the NHS over the past year.
    Between April 2021 and March 2022 more than 400 patients in England’s hospitals suffered errors so serious that they should never have happened according to data released by NHS England. They include the wrong hips, legs, eyes and knees being operated on, and diabetic patients being given too much insulin.
    Foreign objects were left inside 98 patients after operations, including gauzes, swabs, drill guides, scalpel blades and needles. Vaginal swabs were left in patients 32 times and surgical swabs were left 21 times. Other objects left inside patients included part of a pair of wire cutters, part of a scalpel blade, and the bolt from surgical forceps. On three separate occasions part of a drill bit was left in a patient.
    “Wrong-site surgery” was carried out on 171 patients and six patients had injections to the wrong eye. The wrong hip implant was put in 12 times, a wrong knee implant was performed 11 times, and patients were connected to air instead of oxygen 13 times. Seven patients were given the wrong type of blood during a transfusion.
    Some patients were given doses of drugs that were far too high, including the immunosuppressant methotrexate, which is used for severe arthritis, psoriasis and leukaemia. There were 11 overdoses of insulin.
    Read full story (paywalled)
    Source: The Times, 19 May 2022
     
  7. Patient Safety Learning
    A hospital for adults with eating disorders has been rated inadequate after inspectors found the provision of food was "unsafe and unacceptable".
    A Care Quality Commission (CQC) report of the Schoen Clinic in York said some patients were given mouldy bread and one was served food containing plastic.
    Concerns were also raised around lack of staff and patient safety, though wards were clean and well-equipped.
    Schoen Clinic Group said issues raised in the report "were quickly addressed".
    Following the inspection in January the hospital has been placed in special measures and will be visited again in six months.
    Brian Cranna, CQC's head of hospital inspection, said: "The standards of care we found at Schoen Clinic York were putting patients at risk and so we have taken urgent enforcement action, which means the service must improve if it's to retain its registration."
    According to the report patients were put at risk of "physical and psychological harm due to unsafe and unacceptable food provision".
    Read full story
    Source: BBC News, 21 April 2022
  8. Patient Safety Learning
    An ambulance trust has apologised after a man having a heart attack said he was advised to get a lift to hospital or face a long wait.
    Graham Reagan said he was on the verge of collapsing when he finally got to York hospital after a lift from his son.
    Mr Reagan said he was concerned about the impact on patients with potentially life-threatening conditions.
    Speaking to BBC Yorkshire and Lincolnshire's Politics North programme, Mr Reagan described his experience as "scary".
    "I'd had indigestion, or so I thought, for a couple of days, and then on 17 December I went to bed early feeling rough," he said.
    In the early hours, Mr Reagan said the pains in his chest grew worse and he asked his wife to call for an ambulance. "I couldn't take it any more," he said.
    Mr Reagan, from Malton in North Yorkshire, said his wife was asked "can you get to hospital" as the nearest ambulance was about 20 to 30 miles away.
    "My wife doesn't drive, but fortunately my son was with us and he drove me to York hospital."
    On arrival Mr Reagan said they found the entrance to A&E had also been re-routed.
    "So, we then had to walk out of the hospital grounds and back in - by which time I'm collapsing," he added.
    He said staff at the hospital were "absolutely brilliant" and arranged for him to be transferred to Hull for treatment after a heart attack was confirmed. However, he said he was faced with a further 35-minute delay while he waited for an ambulance to take him.
    Mr Reagan said he wanted to share his experience to raise awareness.
    Read full story
    Source: BBC News, 16 January 2022
  9. Patient Safety Learning
    Dozens of young autistic people have died after serious failings in their care despite repeated warnings from coroners, BBC News has found.
    Their investigation found issues that were flagged a decade ago are still being warned about now.
    Two bereaved mothers said lessons had not been learned by their local health authority after the deaths of their teenage sons, two years apart.
    The coroner who oversaw both cases, noted a repeated failure in care.
    After the first death, the coroner criticised NHS Kent and Medway for "inadequate support" and said a similar incident may happen if this continued.
    Two years later, the second autistic teenager died under the care of the same authority. The same coroner found that had the victim received the recommended level of care, he might have got the therapy he needed.
    In the first piece of research of its kind, the BBC combed through more than 4,000 Prevention of Future Death (PFD) notices delivered in England and Wales over the past 10 years.
    Read full story
    Source: BBC News, 7 September 2023
  10. Patient Safety Learning
    A safety investigation has warned that young people with complex mental health needs are being put at significant risk, by being placed on general children's wards in England.
    The findings come from the Healthcare Safety Investigation Branch (HSIB).
    BBC News recently highlighted the plight of a 16-year-old autistic girl, who spent several months in a children's ward.
    Other families have since contacted the BBC describing similar situations.
    The majority had faced similar difficulties getting appropriate support.
    HSIB says that paediatric wards are designed to care for patients who only have physical health needs and not for those with mental health needs.
    It describes the situation in 18 hospitals it visited as "challenging", and 13 were described as "not safe" for children who were suicidal or at risk of harming themselves to be on their paediatric wards.
    Read full story
    Source: BBC News, 25 May 2023
  11. Patient Safety Learning
    A young mother lost both her feet and all 10 fingers to sepsis after a significant delay in treatment, an investigation has found.
    Sadie Kemp has been left permanently disabled from the “dangerous condition”, whilst an NHS hospital probe found a 3.5 hour delay in starting her care.
    Sadie is now calling for lessons to be learned after the internal report found numerous concerns in her treatment that ultimately led to her needing multiple amputations.
    The 35-year-old mother-of-two first attended A&E with agonising back pain caused by a kidney stone on Christmas night 2021.
    She was given pain relief at Hinchingbrooke Hospital, Cambridgeshire, and sent home to return the following morning for a kidney scan.
    She returned the same night at 4am as her pain endured.
    An assessment at 5.40am found she may have also been suffering from sepsis, but the step-by-step guide to chart and treat the illness was not found in her notes as being done at the time.
    The investigation found not only should the sepsis have been discovered and treated sooner, but the “lack of effective treatment” of the sepsis prior to the surgery meant she needed prolonged critical care.
    Read full story
    Source: The Independent, 22 November 2022
  12. Patient Safety Learning
    Younger adults are particularly affected by the rare blood clotting disorder linked to the Oxford-AstraZeneca vaccine, the UK's medicines regulator has said.
    The Medicines and Healthcare products Regulatory Agency (MHRA) said there were 209 cases in the UK of the rare combination of blood clots with low platelet counts following being vaccinated the Oxford-AstraZeneca jab, with 41 deaths, up to 21 April.
    This is up from 168 cases and 32 deaths the previous week.
    The new data also shows 24 cases of clots in people aged 18 to 29, 28 in those in their thirties, 30 in people in their forties, 59 in people in their fifties and 57 in those aged 60 and above, with the age not known in the remaining cases.
    The numbers appear to rise with age but that is because more older people have been vaccinated. Fewer than one in five clots was fatal.
    The latest NHS England data show that 5.5 million people under 45 had received a first dose by 25 April, while 22.6 million of those 45 and over had done so.
    MHRA chief executive June Raine said no medicine or vaccine was without risk, but that blood clots were extremely rare.
    She added: “The benefits of the vaccine continue to outweigh the risks for most people. It is still vitally important that people come forward for their vaccination when invited to do so."
    Read full story
    Source: The Independent, 3 May 2021
  13. Patient Safety Learning
    More than 70 children and young people have been put at risk by long delays in treatment by mental health services in Kent and Medway, HSJ has learned.
    According to a response to a Freedom of Information request submitted by HSJ, 205 harm reviews have been carried out for patients waiting for treatment following a referral to the North East London Foundation Trust, which runs the child and adolescent mental health services in Kent and Medway.
    Of those, 76 patients, who had all waited longer than the 18 week target time for treatment, were found to be at risk of harm. One patient had to be seen immediately as they were judged to be at “severe” risk. Seven were found to be at “moderate” risk and 68 at “low” risk. 
    The trust said “risk” meant a risk of harm to themselves or others. But it said none of the 76 patients had come to actual harm. 
    Read full story (paywalled)
    Source: HSJ, 25 February 2020
  14. Patient Safety Learning
    Younger adults and those living in poorer neighbourhoods and black people have the highest levels of vaccine hesitancy, new survey data from the Office for National Statistics has shown.
    The vast majority of Britons back the COVID-19 vaccines and are keen to be inoculated, with more than 9 out 10 people being positive about the jab. But the ONS said data from a survey between 13 January and 7 February revealed reluctance among less than 10% of the population.
    It found more than 4 in 10 of black or black British adults reported vaccine hesitancy, the highest of all ethnic groups, while adults aged 16-29 were most likely to report hesitancy, at around 1 in 6 or 17%.
    Adults living in the most deprived areas of England were more likely to report vaccine hesitancy at 16%, compared with 7% of adults in the least deprived areas of England.
    This has been evident in the take up of the vaccine among some deprived areas of the country which have struggled to vaccinate everyone in priority groups. Even among NHS and social care staff there has been reported hesitancy over vaccines, particularly among BAME staff.
    Read full story
    Source: The Independent, 9 March 2021
  15. Patient Safety Learning
    YouTube has launched a verification system for healthcare workers in the UK as it battles disinformation online.
    In 2022, health videos were viewed more than three billion times in the UK alone on the video-sharing platform.
    Doctors, nurses and psychologists have been applying for the scheme since June and must meet rigorous criteria set by the tech giant to be eligible.
    Successful applicants will have a badge under their name identifying them as a genuine, licensed healthcare worker.
    But YouTubers have warned the system is only meant for education purposes, not to replace medical advice from your GP.
    Vishaal Virani, who leads health content for YouTube, said it was important simply due to the sheer number of people accessing healthcare information on the video-sharing platform.
    "Whether we like it or not, whether we want it or not, whether the health industry is pushing for it or not, people are accessing health information online," he told the BBC.
    "We need to do as good a job as possible to bring rigour to the content that they are subsequently consuming when they do start their care journey online."
    Read full story
    Source: BBC News, 8 September 2023
  16. Patient Safety Learning
    People would rather go to England if they had a stroke than use the A&E at a north Wales hospital, a health watchdog has said.
    Inspectors said there was a "clear and significant risk to patient safety" after inspections at the department in Ysbyty Glan Clwyd, Denbighshire.
    North Wales Community Health Council's Geoff Ryall-Harvey said it was the "worst situation" they had seen.
    The report said inspectors found staff who were "working above and beyond in challenging conditions" during a period of "unrelenting demand". Many staff told them they were unhappy and struggling to cope. They said they did not feel supported by senior managers.
    However inspectors said that the health board was not fully compliant with many of the health and care standards, and highlighted significant areas of concern, which could present an immediate risk to the safety of patients, including:
    Doctors were left to "come across" high-risk patients instead of being alerted to them. Patients were not monitored enough - including a suspected stroke patient and one considered a suicide risk. Children were at serious risk of harm as the public could enter the paediatric area unchallenged. Inspectors found evidence of children leaving unseen or being discharged against medical advice. Betsi Cadwaladr health board said it was committed to improvements.
    Read full story
    Source: BBC News, 8 August 2022
     
  17. Patient Safety Learning
    Copperbelt province Clinical Care Specialist Morgan Mweene has warned people against buying medicines from undesignated places such as buses or on the street as the trend is risky to their health.
    And stakeholders on the Copperbelt have come together to advocate for reduced deaths or disability related cases resulting from wrong administering of medicine to patients in health facilities.
    Speaking at the inaugural World Patient Safety Day, commemorated in Ndola under the theme, “Medication Safety”, Dr Mweene emphasised the need for people to avoid buying medicines from undesignated places such as buses and on the streets.
    He further urged patients to take keen interest in medication given at hospitals.
    “As health workers, we also need to take interest in patients. As health workers let us not tire as we the custodian of health. It is our duty that we take keen interest of whatever we administer to our patients,” he said.
    Read full story
    Source: Mwebantu, 30 September 2022
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