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  1. Patient Safety Learning
    Critically ill children are being rushed from one part of England to another because NHS hospitals are running short of intensive care beds in which to treat them, the Guardian has revealed.
    An increase in severe breathing problems in children driven by winter viruses and infections, including flu, means some are having to be transferred sometimes many miles from their home area because there are not enough paediatric intensive care (PICU) beds locally.
    Specialist doctors who staff the units say the situation is “dangerous and rotten for the families” involved and that staff are firefighting to handle the number of children needing sometimes life-saving care, many of whom are on a ventilator to help them breathe.
    In the past few weeks, young patients have been sent from the Midlands to Sheffield, from London to Cambridge, and from one side of the Pennines to the other in order to get them a place in a PICU.
    One doctor at a PICU in the Midlands said: “PICU beds are always in high demand. But since winter hit this year, around six weeks ago, the situation feels like we are simply firefighting. Many days I come on shift to find there are no beds in [our] region and the patients referred to us end up in Southampton, Sheffield, Oxford and other centres far away."
    “The PICU network is overstretched. There aren’t enough beds, nurses or skilled doctors.”
    Read full story
    Source: The Guardian, 29 December 2019
  2. Patient Safety Learning
    Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed.
    Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved.
    Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospitals ignoring the deadlines.
    National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes.
    NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt.
    Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.”
    He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.”
    Read full story
    Source: The Independent, 30 December 2019
  3. Patient Safety Learning
    Cancer patients are being pushed to “breaking point” because of a lack of support from overstretched nurses and carers, a leading charity has warned.
    Almost half of specialist cancer nurses have told the Macmillan Cancer Support charity that their high workload was having a negative impact on patient care, while one in five people diagnosed with the disease say the staff responsible for their care have unmanageable demands.
    Now the charity says this is affecting patients, with thousands calling its specialist support helpline in distress and worried because they feel they can’t get answers from their health workers.
    Read full story
    Source: The Independent, 31 December 2019
  4. Patient Safety Learning
    Hospitals will be required to employ patient safety specialists from next April as part of efforts by the health service to reduce thousands of avoidable errors every year.
    NHS trusts will be told to identify staff who will be designated as the safety specialist for each organisation. These workers, who will get specific training and work as part of a network across the country, will help to tackle a fragmentation in the way safety issues are dealt with in the NHS and ensure nationwide action on key safety risks is coordinated.
    The proposals are part of a national patient safety strategy which is aiming to save 928 lives and £98.5m across the NHS, as well as reducing negligence claims by £750m by 2025.
    The specialists will be identified from existing staff, with part of the role focused on embedding a so-called “just culture” approach to safety. This means reducing blame, supporting staff who make honest errors and tackling systemic causes of mistakes.
    Read full story
    Source: The Independent, 26 December 2019
    What do you think? Join the conversation on the hub.
  5. Patient Safety Learning
    MedAware, a developer of AI-based patient safety solutions, has announced the publication of a study by The Joint Commission Journal on Quality and Patient Safety, validating both the significant clinical impact and anticipated ROI of MedAware's machine learning-enabled clinical decision support platform designed to prevent medication-related errors and risks.
    The study analysed MedAware's clinical relevance and accuracy and estimated the platform's direct cost savings for adverse events potentially prevented in Massachusetts General and Brigham and Women's Hospitals' outpatient clinics. If the system had been operational, the estimated direct cost savings of the avoidable adverse events would have been more than $1.3 million when extrapolating the study's findings to the full patient population.  
    Dr David Bates, study co-author, Professor at Harvard Medical School, and Director of the Center for Patient Safety Research & Practice at Brigham and Women's Hospital, said: "Because it is not rule-based, MedAware represents a paradigm shift in medication-related risk mitigation and an innovative approach to improving patient safety."
    Read full story
    Source: CISION PR Newswire, 16 December 2019
  6. Patient Safety Learning
    Cultivation of kindness is a valuable part of the business of healthcare, discusses Klaber and Bailey in an Editorial in the BMJ. 
    "When we reflect on the past decade, it feels as if we have made a big mistake in healthcare. We have allowed the dominant narrative to be around money, taking the focus, energy, and leadership away from our core purpose of delivering the best care possible. Balancing the books is important, especially in a tax funded system, and we have a duty to drive value for every pound we spend — but money is not the most important thing."
    Read full Editorial
    Source: BMJ, 16 December 2019
  7. Patient Safety Learning
    Nurses in Northern Ireland have announced their plans for further strike action in the new year.
    Earlier this month, more than 15,000 nurses took to the picket lines over pay and staffing levels. It was the first time in the 103-year history of the Royal College of Nursing (RCN) that its members had taken such action.
    It has announced nurses will strike on 8 January and 10 January 2020, unless a resolution is reached.
    Read full story
    Source: BBC News, 24 December 2019
  8. Patient Safety Learning
    Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal.
    Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage.
    At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died.
    City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed.
    An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world."
    “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.”
    Read full story
    Source: Chronicle Live, 22 December 2019
  9. Patient Safety Learning
    Only 14% of pharmacy professionals are worried about criminal prosecution when reporting a patient safety incident, compared with 40% in 2016, survey results have showed.
    The results of the 2019 ‘Patient safety culture survey’ of 917 pharmacy professionals, carried out by the Community Pharmacy Patient Safety Group (PSG) in April and May 2019 came after the introduction of a legal defence for dispensing errors in 2018.
    The survey also showed that 22% of pharmacy professionals would not report a patient safety incident inside their organisation owing to fears of criminal prosecution. This is compared with 40% of 623 respondents saying in 2016 that they would not report a patient safety incident because of the possibility of criminal prosecution.
    Janice Perkins, chair of the PSG, said the results “demonstrate that there have been significant positive improvements since 2016”.
    “Nurturing an open and honest safety culture in community pharmacies is vital. It requires everyone to feel confident in openly sharing when things go wrong to learn from errors and prevent them occurring again,” she added.
    Read full story
    Source: The Pharmaceutical Journal. 19 December 2019
  10. Patient Safety Learning
    An NHS hospital has been so overwhelmed that it told senior doctors to make “the least unsafe decision” when treating patients.
    Medical groups have voiced concern that Norfolk and Norwich hospital trust’s instruction to its consultants this week showed it was struggling so much to cope with the number of people needing care that patient safety was being put at risk.
    At the time the hospital had no spare beds, a full accident and emergency department, 35 patients waiting on trolleys to be admitted, and had declared a major internal incident.
    In its message, seen by the Guardian, it said: “We would like you to know that the trust will support you in making difficult decisions that may be the least unsafe decision, and we would appreciate your cooperation over the coming days with this.”
    The circular from the Norwich hospital added: “We are facing our most challenging situation with our trust today,” because it was so overcrowded and unable to find a bed for the 35 patients doctors had decided needed to be admitted as emergencies.
    Read full story
    Source: The Guardian, 20 December 2019
  11. Patient Safety Learning
    The Healthcare and Safety Investigation Branch (HSIB) started a new national investigation looking into a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient hospital stay.
    If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.
    The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.
    Read full story
    Source: HSIB, 20 December 2019
  12. Patient Safety Learning
    A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed.
    Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder.
    Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital.
    He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria.
    Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS.
    Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.”
    Read full story
    Source: The Telegraph, 21 December 2019
  13. Patient Safety Learning
    Hospital wards across the country are having to look after an unsafe number of patients, with hundreds of beds closed due to an outbreak of norovirus.
    NHS England has said that on average almost 900 beds were closed each day during the week to Sunday 15 December.
    Hospitals have reported fewer empty beds with bed-occupancy rates reaching as high as 95 per cent, 10 per cent higher than the recommended safe level.
    Read full story
    Source: The Independent, 20 December 2019
  14. Patient Safety Learning
    A Dublin mental health centre has failed to comply with the code of practice on physical restraint for four consecutive years, an inspection report has found.
    The 39-bed Elm Mount Unit at St Vincent’s University Hospital said the issue was now high risk. 
    Two episodes were recorded by the Mental Health Commission (MHC) where the staff member responsible for leading the physical restraint did not monitor the person’s head or airway, and that this went undocumented. In another case, inspectors noted, the physical restraint was not reviewed by members of the multidisciplinary team and recorded correctly.
    There was also concern regarding the administration of medicine, specifically deficits in the prescription and administration record “which could potentially lead to medication errors”.
    Read full story
    Source: The Irish Times, 17 December 2019
  16. Patient Safety Learning
    Experts have warned hundreds of “hidden” children who rely on machines to help them breathe at home are at significant risk of harm due to staff shortages, poor equipment and a lack of training.
    The number of children who rely on long-term ventilation is rising but new research has shown the dangers they face with more than 220 safety incidents reported to the NHS between 2013 and 2017.
    In more than 40% of incidents the child came to harm, with two needing CPR after their hearts stopped. Other children had to have emergency treatment or were rushed back to hospital.
    Many parents reported concerns with the skills of staff looking after their children or reported paid carers falling asleep while caring for their child. Families reported having to cover multiple night shifts due to staff shortages, while also having to care for their child during the day. Other patient safety incidents including broken or faulty equipment or information on packaging that did not match the item or incorrect equipment being delivered.
    Consultant Emily Harrop, who led the study, said it was “easy for the plight of individual complex children to slip down the agenda”.
    She warned: “This is a very hidden group of very vulnerable children who are at risk without investment in staffing, access to training and good communication."
    Read full story
    Source: The Independent, 18 December 2019
  17. Patient Safety Learning
    A hospital trust believes it is the first in the UK to introduce disposable sterile headscarves for staff to use in operating theatres.
    Junior doctor Farah Roslan, who is Muslim, had the idea during her training at the Royal Derby Hospital. She said it came following infection concerns related to her hijab that she had been wearing throughout the day.
    It is hoped the items can be introduced nationally but NHS England said it would be up to individual trusts.
    Ms Roslan looked to Malaysia, the country of her birth, for ideas before creating a design and testing fabrics. "I'm really happy and looking forward to seeing if we can endorse this nationally," she said.
    Consultant surgeon Gill Tierney, who mentored Ms Roslan, said the trust was the first to introduce the headscarves in the UK. "We know it's a quiet, silent, issue around theatres around the country and I don't think it has been formally addressed," she said.
    Read full story
    Source: BBC News, 19 December 2019
  18. Patient Safety Learning
    Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. That’s the safety risk the Healthcare Safety Investigation Branch highlight in their new report published yesterday.
    Vaginal swabs and surgical tampons (larger than tampons used by women during their menstrual cycle) are used to absorb bodily fluids in a number of procedures both in delivery suites and surgical theatres on maternity wards. They are intended to be removed once a procedure is complete.
    The report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital. Whilst being in immense pain throughout, Christine saw the community midwife and GP twice before going back to hospital where the swab was found.
    Sandy Lewis, HSIB’s Maternity Investigation Programme Director, said: “Although measures have been put in place to reduce the chance of swabs and tampons being left in, it continues to happen, leaving women in pain and distress when they may have already gone through a traumatic labour.
    “There are numerous physical effects; pain, bleeding and possible infection, but we can’t forget about the psychological impact as there was in Christine’s case – she had to seek private counselling and felt that what happened affected her ability to bond with her baby."
    Read full story
    Source: Healthcare Safety Investigation Branch, 18 December 2019
  19. Patient Safety Learning
    An 88-year-old woman with a broken neck died after being transferred three times between two hospitals in the space of just 48 hours, The Independent has reveal.
    The death of Jean Waghorn, who died after contracting pneumonia in hospital, sparked criticism from a coroner who said the NHS trust had ignored earlier warnings over moving patients between hospitals. Senior coroner Veronica Deeley had issued two official alerts to Brighton and Sussex Hospitals Trust last year after the deaths of frail elderly patients who were wrongly shuttled between hospitals.
    But despite this, in June this year Ms Waghorn, who broke her neck after falling at home, was repeatedly transferred between the Princess Royal Hospital in Sussex and Brighton’s Royal Sussex County Hospital. She caught pneumonia and died two days later.
    The hospital, which is rated good by the CQC, has now apologised and said it has learned lessons from the case. A spokesperson said it did take action following the previous warnings and added that work was ongoing to ensure the changes were consistently applied.
    Read full story
    Source: The Independent, 17 December 2019
  20. Patient Safety Learning
    A hospital A&E department has been rated "inadequate" after warnings over urgent and emergency care.
    The Care Quality Commission (CQC) reported a lack of support for staff and safety concerns in Weston General hospital's A&E department.
    Dr Nigel Acheson, deputy chief inspector of hospitals for the South NHS , said it was "disappointing". Weston Area Health NHS Trust "fully recognises that while improvements have been made... further work is required."
    Read full story
    Source: BBC News, 17 December 2019
  21. Patient Safety Learning
    A lot has been written about the workforce crisis in health and social care. 43,000 registered nurse vacancies, a 48% drop in district nurses in eight years and not enough GPs to meet demand.
    When we talk about workforce, the focus is always on numbers. There are campaigns for safe staffing ratios and government ministers like to tell us how many more nurses we have. But safety is not just about numbers. Recent workforce policy decisions have promoted a more-hands-for-less-money approach to staffing in healthcare. More lower-paid workers mean something in the equation has to give. In this case, it’s skill and expertise.
    In this article in The Independent, Patient Safety Learning's Trustee Alison Leary  discusses how healthcare has failed to keep frontline expertise in clinical areas due to archaic attitudes to the value of the experienced workforce.
    Read full story
    Source: The Independent, 15 December 2019
  22. Patient Safety Learning
    Paging systems used across B.C could be exposing sensitive health data of patients, and the privacy researcher who first discovered the data breach believes it’s likely happening across the country.
    “I wouldn’t be surprised to find this everywhere in Canada,” said privacy researcher Sarah Jamie Lewis, in an interview with CTVNews.ca in Vancouver. Lewis first discovered and reported the breach to Vancouver Coastal Health in November 2018. Now, internal emails released this month through a Freedom of Information request show that the vulnerability is not limited to Vancouver.
    Read full story
    Source: CTV News, 13 December 2019
  23. Patient Safety Learning
    How would you feel about a robot performing major surgery on you?
    2019 has seen a boom in the use of cutting edge robotic technology and there is more to come. Evidence suggests robotic surgery can be less invasive and improve recovery time for patients.
    That could be good news with ever growing demand on health services. But how do patients feel? BBC News speaks to a patient as he prepares to put his trust in robotic assisted surgery, hoping it would mean he could get back to work more quickly.
    Read full story
    Source: BBC News, 12 December 2019
  24. Patient Safety Learning
    A hospital has been fined £45,000 after the death of a leukaemia patient who was given five times the amount of drugs she needed.
    Royal Bournemouth Hospital Trust ignored repeated warnings from inspectors raising concerns about the unit where the 80-year-old patient, who was taking part in a clinical trial, was given the wrong dose on two separate occasions.
    The trust was fined at Bournemouth Crown Court on Monday after pleading guilty in August to supplying a medicinal product that was not of the nature or quality demanded.
    Investigations revealed that, while staff spotted the incorrect dosage, they were wrongly told it was fine, meaning the pensioner, who was terminally ill, was given five times the prescribed amount over four days rather than a lower dose over 10 days.
    An investigation by the Medicines and Healthcare products Regulatory Agency (MHRA) found staff were working “beyond capacity”.
    Inspections in 2012, 2013, 2015 and 2017 all found the unit was running over capacity and highlighted it as an issue that urgently needed addressing to prevent any mistakes being made.
    Read full story
    Source: The Independent, 12 December 2019
  25. Patient Safety Learning
    Patients are more likely to die on wards staffed by a high number of temporary nurses, a study has found.
    Researchers say the findings, published in the Journal of Nursing Scholarship, are a warning sign that the common practice by many hospitals of relying on agency nurses is not a risk-free option for patients.
    The University of Southampton study found that risk of death increased by 12 per cent for every day a patient experienced a high level of temporary staffing – defined as 1.5 hours of agency nursing a day per patient. For an average ward, this increased risk could apply when between a third and a half of the staff on each shift are temporary staff, according to Professor Peter Griffiths, one of the study’s authors.
    He told The Independent: “We know that patients are put at risk of harm when nurse staffing is lower than it should be.
    “One of the responses to that is to fill the gaps with temporary nursing staff, and that is an absolutely understandable thing to do, but when using a higher number of temporary staff there is an increased risk of harm.
    “It is not a solution to the problem.”
    Read full story
    Source: The Independent, 10 December 2019

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