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  1. 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
  2. Patient Safety Learning
    UK women face widespread barriers to essential healthcare services. 
    A survey of over 3,000 women in the UK shows many are struggling to access basic healthcare services including contraception, abortion care and menopause support . The Royal College of Obstetricians and Gynaecologists (RCOG) calls for one-stop women’s health clinics to provide healthcare needs for women in one location and at one time. The RCOG launched a landmark report “Better for Women” – to improve the health and wellbeing of girls and women across their life course –  in The House of Commons. The RCOG is calling for better joined up services, as part of its 'Better for Women' report. It emphasises the need for national strategies to meet the needs of girls and women across their life course – from adolescence, to the middle years and later life.
    Read full report
  3. Patient Safety Learning
    A hospital has made changes after two patients were accidentally given medical air instead of oxygen.
    The two incidents, which took place at the Norfolk and Norwich University Hospital (NNUH), were classed as "never events" meaning they were serious but preventable.
    They happened to patients in November who were being handed over to the hospital by the East of England Ambulance Service.
    The patients should have been given oxygen but were given medical air instead which only contains 20pc oxygen.
    The ambulance service said in a message to staff: "Severe harm or death can occur, if medical air is accidentally administered to patients instead of oxygen. As per NNUH's request, with immediate effect, when handing over at the NNUH, all medical equipment and oxygen should be swapped only by an emergency department doctor or registered nurse."
    Read full story
    Source: Eastern Daily Press, 2 December 2019
  4. Patient Safety Learning
    How many people die in California psychiatric facilities has been a difficult question to answer. No single agency keeps tabs on the number of deaths at psychiatric facilities in California, or elsewhere in the nation.
    In an effort to assess the scope of the problem, The Times submitted more than 100 public record requests to nearly 50 county and state agencies to obtain death certificates, coroner’s reports and hospital inspection records with information about these deaths.
    The Times review identified nearly 100 preventable deaths over the last decade at California psychiatric facilities. It marks the first public count of deaths at California’s mental health facilities and highlights breakdowns in care at these hospitals as well as the struggles of regulators to reduce the number of deaths.
    The total includes deaths for which state investigators determined that hospital negligence or malpractice was responsible, as well as all suicides and homicides, which experts say should not occur among patients on a psychiatric ward. It does not include people who died of natural causes or other health problems while admitted for a psychiatric illness.
    Read full story
    Source: Los Angeles Times, 1 December 2019
  5. Patient Safety Learning
    Royal Cornwall Hospital has deployed an artificial intelligence (AI) tool that allows clinicians to view case videos safely and securely.
    Touch Surgery Enterprise enables automatic processing and viewing of surgical videos for clinicians and their teams without compromising sensitive patient data. These videos can be accessed via mobile app or web shortly after the operation to encourage self-reflection, peer review and improve preoperative preparation.
    James Clark, consultant upper gastrointestinal and bariatric surgeon at the trust, said: “Having seamless access to my surgical videos has had an immense impact on my practice both in terms of promoting patient safety and for educating the next generation of surgeons."
    Read full story
    Source: Digital Health, 28 November 2019
  6. Patient Safety Learning
    All healthcare leaders, providers, patients and the public should wrestle with a fundamental question:  How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky?  
    Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?”
    “The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.”
    Read full story
    Source: Hospital News, 3 December 2019
  7. Patient Safety Learning
    Public and professional understanding of sepsis has increased greatly in recent years. This has led to campaigns to diagnose sepsis early in the clinical course of the illness and to start treatment with antibiotics and fluid replacement promptly. But could this pressure to improve sepsis management be counterproductive and lead to overdiagnosis of sepsis? This was the argument made by the authors of a recent letter to the Lancet.
    One problem arising from overdiagnosis of sepsis is the overuse of broad spectrum antibiotics, says Paul Morgan in an Editorial to the BMJ. Another concern is that the emphasis on the early treatment of sepsis detracts from the recognition, diagnosis, and treatment of other acute illnesses. 
    Read full story (paywalled)
    Source: BMJ, 28 November 2019
  8. Patient Safety Learning
    Industrial action by healthcare workers is intensifying as Northern Ireland's nurses take part in 24 hours of action. Health workers are staging industrial action in protest at pay and staffing levels which they claim are "unsafe".
    In an unprecedented joint statement, the five health trusts said the action was likely to result in "a significant risk to patient safety".
    Last week, the Royal College of Surgeons warned NI's healthcare system was "at the point of collapse". On Tuesday, members of the Royal College of Nursing (RCN) are refusing to do any work that is not directly related to patient care.
    Full details and advice on current health care services can be found on the Health and Social Care Board website.
    Read full story
    Source: BBC News, 3 December 2019
  9. Patient Safety Learning
    It is a requirement that patient cards detailing information on the risks are issued every time valproate is dispensed, under Medicines and Healthcare products Regulatory Agency (MHRA) guidance.
    Only 40% of pharmacists are meeting a patient safety requirement when dispensing valproate to women, an audit carried out by the Company Chemists’ Association (CCA) has found.
    The drug can cause birth defects in women who take it when pregnant.
    In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) stated that valproate must not be used by women and girls of childbearing age unless a pregnancy prevention programme (PPP) is in place.
    Duncan Rudkin, Chief Executive of the General Pharmaceutical Council (GPhC), said pharmacies must do more to ensure the safe dispensing of valproate.
    Read full story
    Source: The Pharmaceutical Journal
  10. Patient Safety Learning
    The Care Quality Commission (CQC) has rated six mental health hospitals “inadequate”, just months after describing them as either “good” or “outstanding”, since the Whorlton Hall scandal was revealed.
    HSJ analysis shows that of the 13 mental health hospitals admitting people with learning disabilities or autism which have been rated “inadequate” by the CQC since May this year, six of them dropped at least two ratings in a short space of time. The six hospitals which dropped at least two ratings include Whorlton Hall — the County Durham hospital closed following a BBC Panorama report in May showing residents being mistreated — which the CQC rated as “good” in December 2017 before revising this to “inadequate” in May.
    The BBC investigation prompted the CQC to investigate all similar mental health hospitals run by Cygnet, which took over the running of Whorlton Hall in January 2019. 
    Cygnet Newbus Grange in Darlington — which was rated “outstanding” in a report published in February 2019 – was judged “inadequate” by September, while Cygnet Acer Clinic in Chesterfield fell from “good” in November 2018 to “inadequate’ in a report published 12 months later.
    The other three hospitals were the Breightmet Centre for Autism in Bolton, Kneesworth House in Hertfordshire and The Woodhouse Independent Hospital in Staffordshire.
    It comes as the CQC prepares to publish independent reports on its role in relation to the Whorlton Hall scandal. NHS England — one of the commissioners, along with local authorities and clinical commissioning groups, of learning disability inpatient care — also last month initiated a “taskforce” on the issue.
    The CQC has acknowledged it needed to “strengthen” its assessments of this type of care and said it had begun to do so, and was reviewing them further “from a human rights perspective”.
    Read full story (paywalled)
    Source: HSJ, 2 December 2019
  11. Patient Safety Learning
    Patients are facing a week of disruption, with more than 10,000 outpatient appointments and surgeries cancelled in Belfast.
    Some people referred by their GPs on suspicion of cancer could have their diagnosis delayed, the head of the Belfast Trust has said. The trust apologised, blaming industrial action on pay and staffing.
    Martin Dillon said outpatient cancellations "could potentially lead to a delay in treatment" for cancer.
    The Department of Health said the serious disruption to services was "extremely distressing".
    Read full story
    Source: BBC News, 2 Decmeber 2019
  12. Patient Safety Learning
    Georgina Day works as an A&E nurse in a London hospital. Every shift, her team of just over 20 starts four nurses short because there are posts it cannot fill.
    "It can be worse - if people are sick or agency staff don't turn up. It makes providing good patient care difficult."
    She says the demands are huge - her department sees more than 400 patients a day. But the shortages mean patients face delays or have to be given care, such as intravenous antibiotics, in corridors instead of in cubicles.
    She says that can make patients angry, recounting the experience of one father shouting at her and saying she didn't care about his sick son.
    "I care massively," she says. "When patients are angry it makes me really sad. I want more for them."
    Georgina's experience is not unique. A survey by the Royal College of Nursing found six in 10 nurses felt they could not provide the level of care they wanted to.
    Read full story
    Source: BBC News, 2 December 2019
  13. Patient Safety Learning
    Australia needs to “get real on medicine safety”, Federal Parliament heard this week.
    Speaking in the House of Representatives, Julian Hill (ALP, Vic) said “too many Australians are being seriously injured, sometimes with lifelong impacts or dying, because of the weakness in our pharmacovigilance system”.
    Mr Hill, Deputy Chair of the Parliamentary Joint Committee of Public Accounts and Audit, referred to a recent study by the Pharmaceutical Society of Australia which “estimated the extent of the problem at 250,000 annual hospital admissions as a result of medication related problems and 400,000 additional presentations to emergency departments, likely because of medicine related problems.
    There’s an annual cost of $1.4 billion, and yet 50 per cent of this harm is estimated to be preventable,” he said.
    “I have spoken before about my concerns in this area, and so have many other advocates, but the  government is still not taking these issues seriously. Every day of inaction means Australians are at risk of death or serious harm from medicines when it could be avoided”.
    Read full story
    Source: AJP.com.au, 28 November 2019
  14. Patient Safety Learning
    More than 2.8 million antibiotic-resistant infections occur in the U.S. every year, and more than 35,000 people die as a result of those infections, according to a newly released Centers for Disease Control and Prevention (CDC) report.

    The updated Antibiotic Resistance Threats in the United States (AR Threats Report) also estimates when antibiotic-resistant bacterium Clostridium difficile (or C. diff) is included, that number exceeds 3 million infections and 48,000 deaths. The report, which used data sources such as electronic health records not previously available, shows that there were nearly twice as many annual deaths from antibiotic-resistant infections as the CDC originally reported in 2013.
    CDC officials called the numbers in this report "more precise, though still conservative, estimates of the human costs of antibiotic resistance.
    Read full story
    Source: FierceHealthcare, 13 November 2019
  15. Patient Safety Learning
    A 99-war-old war veteran was left in agony on an A&E trolley in a hospital for almost 10 hours.
    Brian Fish, a former captain in the Royal Engineers, was left “crying out in pain” as he endured the long wait at Margate’s Queen Elizabeth Queen Mother Hospital, his daughter said. Mr Fish had been urgently admitted to hospital with gall bladder problems.
    Details of his ordeal emerged as figures showed the queues at NHS emergency departments are now the longest on record, with one in four patients at major A&Es waiting longer than four hours to be seen or treated in October.
    His daughter Hilary Casement, who witnessed her father’s hospital ordeal, said: “It was traumatic for him. He lay for hours crying out in pain on a hard trolley. Eventually, with much pleading from me, he was transferred, actually tipped, on to a slightly more comfortable hospital bed and eventually seen by the kind, but overworked, medical team".
    Read full story
    Source: The Independent, 19 November 2019
  16. Patient Safety Learning
    The NHS is relying on less qualified staff to plug workforce gaps because of a huge shortage of nurses, according to a new report.
    Support staff, such as healthcare assistants and nursing associates, have been used to shore up staffing numbers, said the Health Foundation charity.
    The NHS has relied upon overseas recruitment, but a lack of EU nurses because of Brexit means it is now taking more nurses from countries such as India and the Philippines.
    At present, there are almost 44,000 nursing vacancies across the NHS (12% of the nursing workforce), but this could hit 100,000 in a decade, the report said.
    The report said most changes to the skill mix – meaning the ratio of fully qualified to less qualified staff – are implemented well and led by evidence, but added: “It is important that quality and safety are at the forefront of any skill mix change.”
    Read full story
    Source: The Guardian, 28 November 2019
  17. Patient Safety Learning
    Hospitals are so short of doctors and nurses that patients’ safety and quality of care are under threat, senior NHS leaders have warned in a dramatic intervention in the general election campaign
    Nine out of 10 hospital bosses in England fear understaffing across the service has become so severe that patients’ health could be damaged. In addition, almost six in 10 (58%) believe this winter will be the toughest yet for the service.
    The 131 chief executives, chairs and directors of NHS trusts in England expressed their serious concern about the deteriorating state of the service in a survey conducted by the NHS Confederation. The findings came days after the latest official figures showed that hospitals’ performance against key waiting times for A&E care, cancer treatment and planned operations had fallen to its worst ever level. However, many service chiefs told the confederation that delays will get even longer when the cold weather creates extra demand for care.
    “There is real concern among NHS leaders as winter approaches and this year looks particularly challenging,” said Niall Dickson, the chief executive of the confederation, which represents most NHS bodies, including hospital trusts, in England."
     “Health leaders are deeply concerned about its ability to cope with demand, despite frontline staff treating more patients than ever."
    Read full story
    Source: 19 November 2019
  18. Patient Safety Learning
    A health board criticised for severe maternity failings put too much emphasis on targets instead of patient safety, according to a new review of quality governance arrangements at Cwm Taf Morgannwg University.
    It found wider failings in Cwm Taf Morgannwg health board's governance. Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) also found a high level of risk to patient safety was accepted as the norm in some departments. The health board said work was under way to address the issues raised.
    The report was not an assessment of frontline care, but spoke to staff about procedures for reporting and learning from problems.
    It found Cwm Taf Morgannwg health board had not given enough attention to the safety of its services, in contrast to a strong focus on targets and financial controls.
    Read full story
    Source: BBC News, 19 November 2019
  19. Patient Safety Learning
    Babies and mothers died amid a "toxic" culture at a hospital trust stretching back 40 years, a report has said. The catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust are contained in a report leaked to The Independent.
    It reveals that some children were left disabled, staff got the names of some dead babies wrong and, in one case, referred to a child as "it".
    The trust apologised and said "a lot" had been done to address concerns.
    In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement.
    Its initial scope was to examine 23 cases but this has now grown to more than 270 , covering the period from 1979 to the present day. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.
    The interim report said the number of cases it is now being asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort".
    Read full story
    Source: BBC News, 20 November 2019
  20. Patient Safety Learning
    The avoidable deaths of babies and mothers in Shrewsbury and Telford Hospital Trust’s maternity services are heartbreaking. What makes them a scandal, however, is that the problems have been known about for so long, and yet the instinct of managers was to deflect and minimise. 
    The Healthcare Commission, a forerunner to the Care Quality Commission, was concerned about injuries to babies in the trust’s maternity units as long ago as 2007. It was not until Rhiannon Davies and Richard Stanton insisted on answers about the death of their baby Kate in 2009 that the Parliamentary and Health Service Ombudsman concluded in 2013 that it had been the result of serious failings in care. 
    Trusts need to ensure lessons stemming from failings are being implemented while patients and their families are being treated with respect and as a valuable source of feedback.
    Read full editorial (paywalled)
    Source: The Independent, 20 November 2019
  21. Patient Safety Learning
    Hundreds of women left in debilitating pain by faulty transvaginal mesh devices have won a landmark case against multinational giant Johnson & Johnson.
    The Australian class action against companies owned by Johnson & Johnson was won on behalf of 1,350 women who had mesh and tape products implanted to treat pelvic prolapse or stress urinary incontinence, both common complications of childbirth.
    The devices all but ruined the lives of many. Women have been left in severe, debilitating and chronic pain, and often unable to have intercourse. The vast majority also suffered a significant psychological toll. The mesh eroded internally in many cases, has caused infections, multiple complications, and is near impossible to completely remove, Australia’s federal court has heard.
    The devices were not properly tested for safety before being allowed on to the Australian market, though Johnson & Johnson and the associated companies clearly knew the potential for serious complications. 
    The companies were accused of launching a “tidal wave” of aggressive promotion at doctors, marketing the devices as cheap, simple to insert, and a relatively risk-free way to boost profits. All the while, their potential dangers were minimised, downplayed or ignored, both in communications to doctors and patients, the plaintiffs alleged. When patients complained of pain, they were frequently disbelieved.
    Read full story
    Source: The Guardian, 21 November 2019
  22. Patient Safety Learning
    The Care Quality Commission (CQC) issued a warning notice to the West Suffolk Hospital in Bury St Edmunds, which must improve by 31 January.
    It has not released details but the hospital said inspectors flagged up how it recorded observations and monitored women in its care.
    A hospital spokeswoman said: "We have taken this feedback seriously and are acting accordingly."
    She added: "Concerns have been raised about how we record patient observations after we have taken them, which are currently not in line with national guidance". "The CQC also identified that we should make changes to the way we monitor women in our care, again to bring us in line with national guidance".
    "We are making the necessary changes and the CQC is satisfied with the plans we have in place to make the improvements required."
    Read full story
    Source: BBC News, 21 November 2019
  23. Patient Safety Learning
    As many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. 
    Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself.
    Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women."
    Read full story
    Source: The Independent, 20 November 2019
  24. Patient Safety Learning
    A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations.
    The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants.
    The incident took place in 2015 but only came to light when one of the sick patients attended a hospital in Wales. It had involved a surgeon from Oxford University NHS Foundation Trust.
    Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs. The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients.
    The patient, who did not want to be named, said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest. It was only when people who received the organs became unwell that the truth was told."
    Read full story
    Source: BBC News, 21 November 2019
  25. Patient Safety Learning
    In March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua.
    The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. 
    The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale.
    James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families."
    Read full story
    Source: The Independent, 21 November 2019
     
     

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