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  1. Patient Safety Learning
    Stakeholders from across various sectors in Australia attended a medicine safety forum convened in Canberra on Monday.
    Held by the Consumers Health Forum of Australia (CHF), Pharmaceutical Society of Australia (PSA), the Society of Hospital Pharmacists of Australia (SHPA), NPS MedicineWise and academic partners Monash University and University of Sydney, the forum challenged participants to ‘think differently’ on the safe use of medicines in Australia.
    This included brainstorming on what success in improving medicine safety would look like in 10 years.
    “Medicine safety is a priority for us all and we each have a role to play,” PSA National President Associate Professor Chris Freeman said. “It was inspiring to see the sector work together today to proactively identify those measures we can cooperatively pursue to make a real difference and protect patients.”
    Read full story
    Source: AJP.com.au
  2. Patient Safety Learning
    A nationwide effort in the US to improve and coordinate patient safety measures will strive to make a connection between workplace and patient safety.
    The Institute for Healthcare Improvement (IHI) gave an update during its National Forum this week on the creation of a national patient safety plan intended to encourage better coordination of safety efforts. A key goal of the plan, expected to be released next year, was to emphasise the role of improving workforce safety.
    “In our view, too many systems have a separation between workforce safety and patient safety and yet we know the two are connected,” said Derek Feeley, President and CEO of IHI, in a briefing with reporters Monday before the start of the forum in Orlando, Florida. “Patient safety incidents are much less likely to occur when workers feel safe.”
    The steering committee developing the plan includes 27 organizations that range from patient advocates and professional societies to provider organizations and government representatives. The committee's plan hopes to target healthcare leaders and policymakers.
    Read full story
    Source: Fierce Healthcare, 10 December 2019
  3. Patient Safety Learning
    An NHS hospital has admitted it failed to properly anaesthetise a patient who was operated on while conscious – leaving her with post-traumatic stress disorder (PTSD) and recurring nightmares.
    The woman, who has chosen to remain anonymous, said she screamed out as the gynaecological surgery at Yeovil District Hospital began to operate, but could not be heard through her oxygen mask as the surgeon cut into her belly button.
    Medical negligence lawyers said she was given a spinal rather than general anaesthetic during the procedure at the hospital in Somerset last year. She remained conscious while a laparoscope – a long camera tube – was placed inside her, and her abdomen was filled with gas. Her law firm Irwin Mitchell said that an increase in blood pressure had alerted staff to her discomfort, but that the procedure was continued.
    The woman, who is in her 30s, said: “While nothing will change what has happened to me, I just hope that lessons can be learned so no one else faces similar problems in the future."
    A spokeswoman for Yeovil Hospital said the incident was the result of “a breakdown of communication” which “led to the use of a different anaesthetic to that normally required for such an operation”.
    Read full story
    Source: The Independent, 10 December 2019
  4. Patient Safety Learning
    Manish Shah preyed on cancer concerns to carry out invasive intimate examinations for his own sexual gratification, the Old Bailey heard.
    He convinced his victims to have unnecessary checks between May 2009 and June 2013. He was convicted of 25 counts of sexual assault and assault by penetration. Jurors acquitted 50-year-old Shah, of Romford, of five other charges.
    They were told afterwards he had already been found guilty of similar allegations relating to 17 other women, bringing the total number of victims to 23.
    Prosecutor Kate Bex QC told the trial: "He took advantage of his position to persuade women to have invasive vaginal examinations, breast examinations and rectal examinations when there was absolutely no medical need for them to be conducted."
    The NHS in London said it "extended sympathies" to the victims and added: "As soon as the allegations came to light, swift action was taken and we have supported the police throughout their investigation."
    Read full story
    Source: BBC News, 11 December 2019
  5. Patient Safety Learning
    More deaths could occur unless action is taken to keep people safe when obtaining medications from online health providers, says a UK coroner.
    Nigel Parsley has written to Health Secretary Matt Hancock highlighting the case of a woman who died after obtaining opiate painkillers online.
    Debbie Headspeath, 41, got the medication, dispensed by UK pharmacies, after website consultations. Her own GP was unaware of what she had requested from doctors on the internet.
    The Suffolk coroner has now written to the Department of Health asking for urgent action to be taken.
    The General Pharmaceutical Council – the independent regulator for pharmacies – said it was responding to the coroner's report and would continue to take necessary action to make sure medicines are always supplied safely online.
    Read full story
    Source: BBC News, 9 December 2019
  6. Patient Safety Learning
    A hospital in Greater Manchester has declared a "black alert" due to "heightened pressure," the Bolton NHS Foundation Trust has said.
    The Royal Bolton Hospital triggered the alert on Monday, which is the highest level of escalation in the NHS for measuring demand against capacity.
    NHS chief Rae Wheatcroft said patient safety remained a "top priority".
    "We have been busier than we would have expected across the hospital," the deputy chief operating officer added. "We are working hard to ensure that everyone who needs a bed is admitted and treated as quickly as possible."
    Read full story
    Source: BBC News, 9 December 2019
  7. Patient Safety Learning
    European clinical guidelines on how to treat a major form of heart disease are under review following a BBC Newsnight investigation.
    Europe's professional body for heart surgeons has withdrawn support for the guidelines, saying it was "a matter of serious concern" that some patients may have had the wrong advice. Guidelines recommended both stents and heart surgery for low-risk patients, but trial data leaked to Newsnight raises doubts about this conclusion.
    Thousands of people in the UK and hundreds of thousands worldwide will be treated for left main coronary artery disease each year. This is a narrowing of one of the main arteries in the heart.
    The guidelines on how to treat it were largely based on a three-year trial to compare whether heart surgery or stents – a tiny tube inserted into a blocked blood vessel to keep it open – was more effective. The trial called Excel started in 2010 and was sponsored by big US stent maker, Abbott. Led by US doctor Gregg Stone, the study and aimed to recruit 2,000 patients. Half were given stents and the other half open heart surgery. Success of the treatments was measured by adding together the number of patients that had heart attacks, strokes, or had died.
    The research team used an unusual definition of a heart attack, but had said that they would also publish data for the more common "Universal" definition of a heart attack alongside it. There is debate around which is a better measure and the investigators stand by their choice.
    In 2016, the results of the trial for patients three years after their treatments were published in the New England Journal of Medicine. The article concluded stents and heart surgery were equally effective for people with left main coronary artery disease. But researchers had failed to publish data for the common, "Universal" definition of a heart attack.
    Newsnight has seen that unpublished data and it shows that under the universal definition, patients in the trial that had received stents had 80% more heart attacks than those who had open heart surgery.
    The lead researchers on the trial have told Newsnight that this is "fake information". But Newsnight has spoken to experts who say they believe the data is credible.
    Read full story
    Source: BBC News, 9 December 2019
  8. Patient Safety Learning
    Safety incidents at hospital, mental health and ambulance trusts were linked to more than 4,600 patient deaths in the last year, data shows.
    The types of patient safety issues recorded by the National Reporting & Learning System (NRLS), which compiles NHS data, include problems with medication, the type of care given, staffing and infection control.
    In total 4,668 deaths were linked to patient safety incidents, of which 530 deaths specifically linked to mental health trusts and 73 to ambulance trusts.
    Guidance accompanying the data from the NRLS, which was set up in 2003, states deaths are not always “clear-cut” and cannot always be attributed to patient safety incidents. However, under the “degree of harm” section recorded on the system, there were 4,688 cases listed as death. In total, 4,356,277 reports of patient safety incidents were reported between November 2018 and October 2019. They are described as issues where unintended or unexpected incidents which could have – or did – lead to harm of a patient under the care of the NHS.
    Other safety incidents had links to consent, paperwork, facilities, and in some cases patient abuse by staff or a third party.
    Read full story
    Source: The Guardian, 9 December 2019
  9. Patient Safety Learning
    Half of the unexpected deaths in Belgian hospitals are due to a shortage of nurses, according to a study by the University of Antwerp.
    Researchers from the University of Antwerp show the link between the number of nurses in hospitals and the death of the patients they care for, based on data from 34,567 patients’ medical records in four Flemish, one Walloon and two Brussels hospitals. The records showed that, on average, three out of every thousand patients in the hospital died ‘unexpectedly’. A death is considered as unexpected when a patient suddenly dies during active treatment, with no care plan for the end of their life having been started.
    “We know from previous research that part of these unexpected deaths can be avoided, which is always heartbreaking for the family as well as the staff,” said Filip Haegdorens, a researcher at the university. “As a sector, we must do everything we can to prevent this,” he added.
    The average nurse in Belgium is responsible for 9.7 patients at a time. For 89% of all departments, the number of nurses per hospital department was too low to be able to ensure good quality care. “Compared to, for example, Australian hospitals, where legal minimums exist, our Belgian figures could be improved,” said Haegdorens.
    The study also shows a link between the training level of nurses and the number of unexpected deaths in the hospital. “In some hospital services, we found that more nurses with a high level of education would reduce the risk of unexpected deaths,” Haegdorens added.
    Read research paper
    Read full story
    Source: The Brussels Times, 4 December 2019
  10. Patient Safety Learning
    One of the main brands of adrenaline auto-injector pen, which can save lives during serious allergy attacks, is being recalled in the UK after the death of a teenager whose family say the product failed.
    Shante Turay-Thomas, 18, died in September last year after it is claimed that her adrenaline pen did not work although she tried it twice. She told her mother, “I’m going to die,” as she succumbed to an allergic reaction to hazelnuts. Her death was the subject of an inquest hearing last month, which resumes this week.
    The Medicines and Healthcare products Regulatory Agency (MHRA) confirmed this weekend that all batches of Emerade auto-injector had been recalled from pharmacies after an error was identified that can cause some pens to fail to activate. Between July and November, the agency said it had been made aware of 16 suspected activation failures. The agency said it was aware of two fatalities of patients reported to have used the pens but the fault had not been confirmed as a contributor to the deaths.
    Read full story
    Source: The Times, 8 December 2019
  11. Patient Safety Learning
    The first publication of data from the Royal College of Emergency Medicine’s 2019-20 Winter Flow Project shows that existing data does not reflect the true scale of the problem of 12 hour stays in A&E.

    RCEM data shows that in the first week of December over 5,000 patients waited for longer than 12 hours in the Emergency Departments of 50 Trusts and Boards across the UK. The sample of trusts and boards from across the UK is the equivalent to a third of the acute bed base in England. 

    From the beginning of October 2019 over 38,000 patients have waited longer than 12 hours for a bed at the sampled sites across the UK – yet data from NHS England reports that in England alone a total of only 13,025 patients experienced waits over 12 hours since 2011-12. 

    President of the Royal College of Emergency Medicine, Dr Katherine Henderson said: “In a nine-week period, at only a third of trusts across the UK, we’ve seen nearly three times the number of 12 hour waits than has been officially reported in eight years in England. This must be fixed."
    Read full story
    Source: Royal College of Emergency Medicine, 9 December 2019
     
  12. Patient Safety Learning
    A "life-changing" mental health service at three hospitals in north Wales is to be expanded to GP surgeries.
    More than 2,500 people have used 'I Can' centres at Glan Clwyd, Gwynedd and Wrexham Maelor hospitals since the trial was launched earlier this year. The centres offer support to patients at A&E departments who may not require medical treatment or a bed. They employ both volunteers and paid staff, many of whom have experienced mental health issues themselves.
    Betsi Cadwaladr University Health Board said the service allowed people to talk about mental health issues away from wards.
    It hopes extending the scheme to GP surgeries and community hubs will allow people to get support close to home if they do not need medical treatment.
    Read full story
    Source: 9 December 2019
  13. Patient Safety Learning
    Hospitals across England are using 21 separate electronic systems to record patient health care – risking patient safety, researchers suggest.
    A team at Imperial College say the systems cannot "talk" to each other, making cross-referencing difficult and potentially leading to "errors". Of 121 million patient interactions, there were 11 million where information from a previous visit was inaccessible.
    The team from London's Imperial College's Institute of Global Health Innovation (IGHI) looked at data from 152 acute hospital trusts in England, focusing on the use of electronic medical records on the ward.
    Around a quarter were still using paper records. Half of trusts using electronic medical records were using one of three systems: researchers say at least these three should be able to share information. 10% were using multiple systems within the same hospital.
    Writing in the journal BMJ Open, the researchers say: "We have shown that millions of patients transition between different acute NHS hospitals each year. These hospitals use several different health record systems and there is minimal coordination of health record systems between the hospitals that most commonly share the care of patients."
    Lord Ara Darzi, lead author and co-director of the IGHI, said: "It is vital that policy-makers act with urgency to unify fragmented systems and promote better data-sharing in areas where it is needed most – or risk the safety of patients."
    A spokesperson for NHSX, which looks after digital services in the NHS, said: "NHSX is setting standards, so hospital and general practioner IT systems talk to each other and quickly share information, like X-ray results, to improve patient care."
    Read research article
    Read full story
    Souce: BBC News, 5 December 2019
  14. Patient Safety Learning
    Greater Manchester community pharmacies have signed up to a new national scheme, which will see patient consultations booked via NHS 111 for the very first time.
    The scheme launched on the 29 October is part of major plans to boost the role of pharmacists in patient care, outlined in the national NHS Long Term Plan. People who call the free NHS 111 phone service can now be offered same day consultation with their local community pharmacist, if they need an urgent supply of a prescription medicine or advice on minor illnesses.
    The aim of the scheme is to leverage pressure on GP practices and A&E departments, which come under increasing strain when the winter hits.
    Early stages of the initiative in other parts of the country found that an estimated 6% of all GP consultations could be handled by a community pharmacist, freeing up around 20 million GP appointments each year nationally.
    Sarah Price, Executive Lead for Population Health and Commissioning at Greater Manchester Health and Social Care Partnership said: “Our health services are facing unprecedented challenges and that means finding new ways to deliver the standard of care that patients expect, whilst ensuring that services are sustainable and fit for the future. Doing things the way we’ve always done, is no longer an option. Greater Manchester pharmacists are rising to the challenge and becoming more closely involved in patient care, often in close partnership with other health and care professionals." 
    Read full story
    Source: National Health Executive, 4 December 2019
  15. Patient Safety Learning
    Today marks the seventh annual Patient Solidarity Day, where people and organisations across the world rally around one of the key issues facing patients and help to raise awareness of this. The theme this year is ‘Acceleration for Safe Patient-Centred Universal Health Coverage’ with a call to hold leaders accountable for the commitments they have made to ensure safe and patient-centred universal health coverage for all.
    In a bog released today, Patient Safety Learning's Helen Hughes discusses why patient engagement is essential for a patient-safe future and how we are currently working with Joanne Hughes, founder of Mother’s Instinct, to take action to help patients engage for patient safety. 
    Read blog
  16. Patient Safety Learning
    Maternity services at Shrewsbury and Telford Hospitals Trust were 50 midwives short of what was safe, hospital inspectors have said.
    A new report by the Care Quality Commission, published today, revealed the trust, which is at the centre of the largest maternity scandal in the history of the NHS, had a 26% vacancy of midwives in April this year.
    An independent investigation has been examining poor maternity care at the hospital since 2017 and the trust was put into special measures and rated inadequate by the CQC in 2018.
    Read full story
    Source: The Independent, 6 December 2019
  17. Patient Safety Learning
    Nearly 70,000 patients are injured while receiving care in Ontario's hospitals each year, the province's auditor general said Wednesday, calling for immediate government action to help reduce that number.
    In her 2019 annual report, Bonnie Lysyk said her team's audits of acute-care centres found that six in every 100 patients treated and discharged from provincial hospitals were harmed during care.
    "Each year, Ontario hospitals discharge one million people," Lysyk said. "Of those, about 67,000 people were harmed during their hospital stay."
    The audit found that hospitals are currently not required to report to the Ministry of Health so-called "never-events" — a medical error that should never happen, such as leaving a foreign object inside a patient.
    Lysyk said her team visited six of the 13 hospitals that track "never-events," and found that 214 such incidents had occurred since 2015.
    Ontario's rates of patient harm are the second-highest in Canada, after Nova Scotia.
    Read full story
    Source: Niagara Falls Review, 5 December 2019
  18. Patient Safety Learning
    An outbreak of norovirus on hospital wards across the NHS has forced the closure of more than 1,100 beds in the last week.
    The news comes amid record numbers of patients turning up to emergency departments at some hospitals and higher than expected cases of flu.
    There are fears the dire situation could herald the start of a winter crisis for the NHS which is starting earlier than in previous years.
    Miriam Deakin, Director of Policy and Strategy at NHS Providers, which represents hospitals said: “We are going into what is traditionally the NHS’s busiest time with a health and care system already under severe demand pressure."
    “Patient safety is the top priority for trusts, but alongside high levels of staff vacancies, an outbreak of flu or norovirus could have a serious effect on the delivery of services.”
    Read full story
    Source: The Independent, 5 December 2019
  19. Patient Safety Learning
    Two patients have died as a result of NHS hospitals failing to heed warnings about the use of super-absorbent gel granules, which patients mistakenly eat thinking they are sweets or salt packets.
    A national patient safety alert has been issued by NHS bosses to all hospitals, ambulance trusts and care homes instructing them to stop using the granules unless in exceptional circumstances.
    An earlier alert in 2017 warned the granules, which are used to prevent liquid being spilled, had caused the death of one patient who choked to death after eating a sachet left in an empty urine bottle in their room. The 2017 alert warned hospitals there had been a total of 15 similar incidents over a six-year period between 2011 and 2017.
    The latest warning from NHS England says most hospitals concentrated on “raising awareness” rather than stopping the use of gel granules.
    Read alert
    Read full story
    Source: The Independent, 4 December 2019
  20. Patient Safety Learning
    The family of a father-to-be have criticised hospital staff who left him "screaming out in pain" in the final hours of his life.
    Adam Hurst, 31, died from a rare type of hernia a few hours after arriving at Hinchingbrooke Hospital in Cambridgeshire, last December.
    The hospital found Mr Hurst's pain management and the communication with him and his relatives was "inadequate".
    The Medical Director of North West Anglia NHS Foundation Trust, Dr Kanchan Rege, said: "Our staff strive to provide high quality care at all times and this was not the case in this instance."
    At the inquest into his death, the coroner concluded it was "not possible to say whether on the balance of probabilities earlier surgery would have resulted in a different outcome due to the rare and complex nature of the surgery". But the hospital's serious incident report, seen by the BBC, found Mr Hurst's pain "should have been more aggressively managed, from the outset".
    It also found the frequency of his observations was "inadequate" and stated the documentation in the emergency department "was generally very poor from the nursing staff that cared for the patient".
    The report also said "clear explanations to the patient and relatives are essential to allay fears and reduce anxiety".
    Read full story
    Source: BBC News, 5 December 2019
  21. Patient Safety Learning
    Patients with mental health problems are being left in limbo on "hidden" waiting lists by England's NHS talking therapy service, the BBC can reveal.
    The service, Improving Access to Psychological Therapies, provides therapy, such as counselling, to adults with conditions like depression, post-traumatic stress disorder and anxiety.
    It starts seeing nine in 10 patients within the target time of six weeks, but that masks the fact many then face long waits for regular treatment. Half of patients waited over 28 days, and one in six longer than 90 days, between their first and second sessions in the past year.
    Charities said the headline target was giving a false impression of what was happening, warning that patients were facing "hidden waits" that were putting their health at risk.
    NHS England acknowledged the pressure on the system was causing delays, but pointed out that despite the delays, half of patients given treatment still recovered.
    Read full story
    Source: BBC News, 5 December 2019
  22. Patient Safety Learning
    Two patients at a hospital in West Lancashire came to “avoidable harm” after medical staff failed to act on concerns raised by nurses, according to a health watchdog.
    The issue was highlighted by the Care Quality Commission (CQC) following an inspection of children and young people’s services at Ormskirk Hospital in July and August.
    In there report CQC stated: “In children and young people’s services we found evidence that there had been occasions when medical staff had not responded to nursing concerns, which led to avoidable harm occurring to two patients.”
    The document added that the two serious incidents, which had both been reported by staff, were "relating to babies".
    Read full story
    Source: The Nursing Times, 3 December 2019
  23. Patient Safety Learning
    NHS bosses have been accused of using a 2013 report to “maintain a false narrative” about maternity services in Shropshire, which meant poor practices and conditions went unchallenged for years.
    The Independent has obtained a 2013 report, commissioned by NHS managers in Shropshire, which concluded maternity services at the Shrewsbury and Telford Hospital Trust were “safe”, of “good quality”, and “delivered in a learning organisation”.
    The report, written by rheumatologist Dr Josh Dixey (now high sheriff of Shropshire), delivered a glowing assessment of the care given to women and babies and appeared to gloss over hints of deeper problems within the service.
    Sources within the Shropshire and Telford clinical commissioning groups (CCGs), which paid £60,000 for the report, said since it was written it had been “proven to be wrong, inaccurate and to have come to the wrong conclusions and recommendations”, but also stressed it was based on the information received from the trust at the time.
    A leaked report last month revealed dozens of mothers and babies had died at the Shrewsbury and Telford Hospital Trust, with incidents of poor care stretching over four decades, due to repeated failures to learn from mistakes.
    Read full story
    Source: The Independent, 4 December 2019
  24. Patient Safety Learning
    A “critical” shortage of lung specialists may leave the NHS struggling to cope with a spike in hospital admissions related to complications of pneumonia and flu this winter, the British Thoracic Society (BTS) has warned.
    At its winter meeting this week (taking place 4-6 December), the society presented results from a survey it conducted of almost 250 UK NHS respiratory specialists. Some 83% of respondents (199) thought respiratory healthcare staff shortages would impair the ability of the NHS to cope with the increase in lung disease hospital admissions this winter.
    Read full story (paywalled)
    Source: BMJ, 4 December 2019
  25. Patient Safety Learning
    Women are having their appendixes removed wrongly in nearly a third of cases, British research suggests.
    Researchers said too many female patients were being put under the knife when they should have undergone investigations for period pain, ovarian cysts or urinary tract infections. They said the study, which compared practices in 154 UK hospitals with those of 120 in Europe, suggests that Britain may have the highest rate of needless appendectomies in the world. 
    Surgeons said they were particularly concerned by the high rates among women, with 28% of operations found to be unnecessary. 
    They said the NHS was too quick to book patients in for surgery, when further scans and investigations should have been ordered. 
    Researchers warned that such operations put patients at risk of complications, as well as fuelling NHS costs.
    Read full story
    Source: The Telegraph, 4 December 2019

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