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  1. Patient Safety Learning
    Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service.
    Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining away signs of danger.
    Across the NHS there are passionate clinicians and managers dedicated to building a culture that delivers consistently high quality care. But they are undermined by a pervasive willingness to tolerate and excuse poor care and silence dissent. Until that changes, the scandals will keep coming.
    Read full story
    Source: The Guardian, 2 November 2019
  2. Patient Safety Learning
    England’s most senior nurse has called on the NHS’ million-plus frontline workers to protect themselves and their patients this year by taking up their free flu jab.
    Ruth May, the Chief Nursing Officer for England, is spearheading this year’s drive to ensure that as many NHS staff as possible get vaccinated against seasonal flu – meaning they are both less likely to need time off over the busy winter period, and less likely to pass on the virus to vulnerable patients.
    Since September, hospitals and other healthcare settings across the country have been laying on special activities designed to highlight the importance of the flu vaccine, and celebrate those staff who choose to protect themselves and their patients. A record 70% of doctors, nurses, midwives and other NHS staff who have direct contact with patients took up the vaccine through their employer last year, with most local NHS employers achieving 75% or higher.
    Ruth has been joined in writing an open letter to NHS staff by other heads of professions like the NHS National Medical Director, Professor Stephen Powis, Chief Allied Health Professions Officer, Suzanne Rastrick, Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent, and Chief Pharmaceutical Officer, Dr Keith Ridge. In it they urge every member of the NHS’ growing frontline workforce to work together to achieve even higher level of coverage this year.
    Read full story
    Source: NHS England, 25 November 2019
  3. Patient Safety Learning
    When Kea Turner’s 74-year-old grandmother checked into Virginia’s Sentara Virginia Beach General Hospital in the US, with advanced lung cancer, she landed in the oncology unit where every patient was monitored by a bed alarm.
    “Even if she would slightly roll over, it would go off,” Turner said. Small movements — such as reaching for a tissue — would set off the alarm, as well. The beeping would go on for up to 10 minutes, Turner said, until a nurse arrived to shut it off.
    Tens of thousands of alarms shriek, beep and buzz every day in every US hospital. All sound urgent, but few require immediate attention or get it. Intended to keep patients safe by alerting nurses to potential problems, they also create a riot of disturbances for patients trying to heal and get some rest.
    Alarms have ranked as one of the top 10 health technological hazards every year since 2007, according to the research firm ECRI Institute. That could mean staffs were too swamped with alarms to notice a patient in distress, or that the alarms were misconfigured. The Joint Commission, which accredits hospitals, warned the nation about the “frequent and persistent” problem of alarm safety in 2013. It now requires hospitals to create formal processes to tackle alarm system safety, but there is no national data on whether progress has been made in reducing the prevalence of false and unnecessary alarms.
    The commission has estimated that of the thousands of alarms going off throughout a hospital every day, an estimated 85-99% do not require clinical intervention. Staff, facing widespread “alarm fatigue,” can miss critical alerts, leading to patient deaths. Patients may get anxious about fluctuations in heart rate or blood pressure that are perfectly normal, the commission said.
    Read full story
    Source: The Washington Post, 24 November 2019
  4. Patient Safety Learning
    A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months.
    Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black.
    But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour.
    Read full story (paywalled)
    Source: BMJ, 25 November 2019
  5. Patient Safety Learning
    Doctors and nurses must adapt their routines and improvise their actions to ensure continued patient safety, and for their roles to be effective and to matter as new technology disrupts their working practices.
    Research from Lancaster University Management School, published in the Journal of Information Technology, found electronic patient records brought in to streamline and improve work caused changes in the division of labour and the expected roles of both physicians and nursing staff.
    These changes saw disrupted working practices, professional boundaries and professional identities, often requiring complex renegotiations to re-establish these, in order to deliver safe patient care. Managers implementing these systems are often quite unaware of the unintended consequences in their drive for efficiency.
    Read full story
    Source: EurekAlert, 25 November 2019
  6. Patient Safety Learning
    A mobile app designed by a patient is helping people with breast cancer prepare for the start of radiotherapy.
    The treatment requires them to raise their arm above their head, but patients often find that difficult or painful after breast surgery. Exercises are important but Karen Bonham said leaflets giving details did not help her enough.
    So she helped create the app to offer exercise videos and medics say it is helping more women be ready on time. Staff at Velindre Cancer Centre in Cardiff say they have noticed fewer patients needing urgent referral for physiotherapy ahead of the treatment since the "Breast Axilla Postoperative Support app", or BAPS App, was launched in February.
    Kate Baker, clinical lead physiotherapist at Velindre, who helped devise the app, said: "Previously, we've always handed out information on exercises in a leaflet, that patients would be given by a physiotherapist and taken home. But often these pieces of paper get lost and they're not followed through.
    "What we wanted to do was provide exercises, physical activity advice and further information in an app format, which would allow individuals to have it with them at all times."
    Donna Egbeare, breast surgeon at Cardiff and Vale University Health Board, who was also involved in developing the bilingual app, said the impact of being able to start radiotherapy on schedule was significant.
    Read full story
    Source: BBC News, 27 November 2019
     
  7. Patient Safety Learning
    More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire.
    Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg.
    Dr Bill Kirkup says it suggests failure might be more widespread in the NHS.
    The surge in new cases follows the leak of an interim report last week.
    Read full story
    Source: BBC News, 27 November 2019
  8. Patient Safety Learning
    More than a third of maternity doctors are “burnt out,” and at risk of lacking empathy for the women in their care, researchers have warned.
    The study of more than 3,000 obstetricians and gynaecologists found high levels of long-term stress and overwork, especially among trainee medics. 
    Researchers said the findings – from the largest UK study on the topic – were “very worrying,” with serious implications for patients. 
    Overall, 36% of those surveyed met the criteria for “burnout,” which is associated with emotional exhaustion, lack of empathy and connection with others, researchers said. 
    Medics who met the criteria for burnout were three times as likely to report anxiety, irritability and anger. They were also four times more likely than colleagues to practice “defensively”- meaning they tried to avoid difficult cases, or else carried out more interventions than necessary, for fear of error. 
    Read full story
    Source: The Telegraph, 26 November 2019
     
  9. Patient Safety Learning
    It’s been 20 years since the Institute of Medicine — known now as the National Academy of Medicine — published the groundbreaking report, To Err is Human. And in that time, the healthcare industry has seen vast changes, bringing patient safety and healthcare quality to the forefront.
    The notion that patient safety issues are not only common, but they are preventable, challenge previously held industry beliefs, Craig Clapper, a partner in strategic consulting at Press Ganey, said during a recent interview with PatientEngagementHIT.com. 
    In this article he discusses the progress that has been made and what still needs to be done.
    Looking into the future, Clapper sees an industry that integrates patient safety as a key element of everything it does. While clinicians focus on boosting patient satisfaction, delivering good clinical outcomes, and fulfilling other obligations, they should feel and see the connection with patient safety.
    “We should talk less about safety culture in isolation and more about how to make it about the entire patient experience,” Clapper concluded. “That'll be our biggest single advantage in the next decade. Instead of having a subculture for every outcome, we must have one seamless performance culture that can emphasize the safety, quality, and experience of care.”
    Read full story
    Source: PatientEngagementHIT, 26 November 2019
  10. Patient Safety Learning
    Large numbers of previously missed abnormalities have been uncovered in the biggest review of smear tests undertaken since cervical cancer screening began in Ireland.
    The review led by the Royal College of Obstetricians and Gynaecologists in the UK has found hundreds of “discordant” results after re-examining the slides of over 1,000 women who had been tested for the disease under CervicalCheck, were given the all-clear and later developed cancer, according to an informed source.
    Discordant means the re-examination of the smear test by Royal College reviewers has produced a result that is different from the original finding by CervicalCheck.
    The extent of the individual divergences from the initial results is not yet known, but the review has found some cancers could have been prevented, it is understood.
    The college is due to submit an aggregate report on its findings to Minister for Health Simon Harris shortly.
    Read full story
    Source: The Irish Times
  11. Patient Safety Learning
    Hospitals will face penalties if staff do not notify patients of serious adverse incidents under proposed new legislation.
    Due to be brought to Cabinet by the Minister for Health Simon Harris in early December, it will provide for mandatory open disclosure of patient safety issues. It is understood that the new Bill would mean that where a hospital or health service provider was satisfied that a notifiable patient safety incident had occurred, information in its possession on the issue should be disclosed. A doctor or practitioner would be obliged to inform the patient and hospital of the incident.
    Under the proposals, failure to comply with this requirement on disclosure would mean the health service provider would be penalised. The nature or extent of the proposed penalties is unknown.
    The department is preparing a list of notifiable patient safety incidents for the mandatory open disclosure proposals.
    Read full story
    Source: The Irish Times, 25 November 2019
  12. Patient Safety Learning
    Health Secretary Matt Hancock has ruled out scrapping home visits by GPs, describing the idea as “a complete non-starter”.
    Doctors argued that they were no longer able to provide home visits as part of their core work and voted at a conference on Friday to remove them from their NHS contract. Under the proposals GPs would negotiate a separate service for urgent visits to patients. However, the health secretary said he was strongly opposed to the plans and insisted that they would not come to fruition.
    “The idea that people shouldn’t be able, when they need it, to have a home visit from a GP is a complete non-starter and it won’t succeed in their negotiations,” he told BBC Radio 4’s Today programme.
    He admitted that most home visits were done by nurses but said that on some occasions a GP was needed.
    Read full story
    Source: The Independent, 24 November 2019
  13. Patient Safety Learning
    Back in 2009, healthcare experts, including mainly members of the American Medical Informatics Association, envisioned creating a national databank to track reports of deaths, injuries and near misses linked to issues with the move to have computerised medical records.
    The experts at that September 2009 meeting agreed that safety should be a top priority as federal officials poured more than $30 billion into subsidies to wire up medical offices and hospitals nationwide. However, it never happened. Instead, plans for putting patient safety first — and for building a comprehensive injury reporting and reviewing system — have stalled for nearly a decade, because manufacturers of electronic health records (EHRs), health care providers, federal health care policy wonks, academics and Congress have either blocked the effort or fought over how to do it properly, an ongoing investigation by Fortune and Kaiser Health News (KHN) shows.
    Meanwhile, patients remain at risk of harm. In March, Fortune and KHN revealed that thousands of injuries, deaths or near misses tied to software glitches, user errors, interoperability problems and other flaws have piled up in various government-sponsored and private repositories. One study uncovered more than 9,000 patient safety reports tied to EHR problems at three pediatric hospitals over a five-year period.
    Despite such incidents, experts believe EHRs have made medicine safer by eliminating errors due to illegible handwriting and in some cases speeding up access to vital patient files. But they also acknowledge they have no idea how much safer, or how much the systems could still be improved because no one — a decade after the federal government all but mandated their adoption — is assessing the technology’s overall safety record.
    Read full story
    Source: Kaiser Health News, 21 November 2019
  14. Patient Safety Learning
    At least 74,000 older people in England have died, or will die, waiting for care between the 2017 and 2019 general elections. A total of 81 older people are dying every day, equating to about three an hour, research by Age UK has found.
    In the 18 months between the last election and the forthcoming one, 1,725,000 unanswered calls for help for care and support will have been made by older people. This, said the charity, was the equivalent of 2,000 futile appeals a day, or 78 an hour.
    Age UK’s director, Caroline Abrahams, said: “This huge number of requests for help did not lead to any support actually being given for three main reasons: because the older people died or will die before services were provided, because of a decision that they did not meet the eligibility criteria as interpreted by their local authority, or because their local authority signposted them to some other kind of help than a care service.”
    Read full story
    Source: The Guardian, 22 November 2019
  15. Patient Safety Learning
    The General Medical Council (GMC) has asked the NHS to share concerns about any doctors involved in poor care at the Shrewsbury and Telford Hospital Trust.
    It comes as West Mercia Police said it was considering a range of criminal charges against the hospital including corporate manslaughter.
    Anthony Omo, Director of Fitness to Practice for the GMC, said the reports of poor maternity care at the trust were “shocking” and his thoughts were with the families. He added: “We are in contact with the trust and have asked NHS England and NHS Improvement for details of any concerns about individual doctors." 
    “All doctors have a responsibility to take action if they are aware that patient safety may be put at risk.”
    Meanwhile, the Royal College of Obstetricians and Gynaecologists has said it will make changes to the way it inspects hospitals after criticism of the way it allowed a report into the Shrewsbury trust in 2017 to be used.
    Read full story
    Source: The Independent, 22 November 2019
  16. Patient Safety Learning
    Progress on treating cancer has stalled in Scotland because of staff shortages and a lack of funding, according to a parliamentary report.
    The Scottish Parliament's Cross-Party Group on Cancer found that 18% of cancer patients in June were not seen within the six-week target. Their report, which will be published later, has been described as "deeply concerning" by Cancer Research UK.
    The Scottish government said its £100m strategy would improve survival rates.
    Cancer Research UK Chief Executive Michelle Mitchell said the Scottish government must "publish a long-term cancer workforce plan" to enable the NHS to prepare for rising demand in the future. She said: "The findings of this inquiry are deeply concerning".
    "Diagnosing cancer early can make all the difference, but there are major shortages in the staff trained to carry out the tests that diagnose cancer. Cancer services in Scotland are already struggling. Without urgent action, this will only worsen as demand increases."
    Read full story
    Source: BBC News, 18 November 2019
  17. Patient Safety Learning
    Patients are being left in pain and having operations delayed or denied because insurers are overruling consultants’ decisions on treatment.
    Policy holders with breast cancer, heart conditions, arthritis and knee problems are among those who have been unfairly denied procedures, The Times has found.
    Analysis of Financial Ombudsman Service reports shows that complaints about private medical insurers have risen sharply.
    Richard Packard, chairman of the Federation of Independent Practitioner Organisations, estimates that hundreds of patients a year are denied recommended treatments. “Consultants have reported that their expert decisions for the benefit of the patient are being overturned,” he said. “This is being done by insurance administrators at the end of a telephone. Some would seem to lack medical knowledge and [make] decisions based on computer algorithms, which can result in delayed treatment and patients suffering pain for longer than necessary.”
    Read full story (paywalled)
    Source: The Times, 18 November 2019
  18. Patient Safety Learning
    The World Health Organization's (WHO) World Antibiotic Awareness Week (WAAW) aims to increase awareness of antibiotic resistance as a global problem, and to promote best practices among the general public, health workers and policy-makers to avoid the further emergence and spread of antibiotic resistance.
    Since their discovery, antibiotics have served as the cornerstone of modern medicine. However, the persistent overuse and misuse of antibiotics in human and animal health have encouraged the emergence and spread of antibiotic resistance, which occurs when microbes, such as bacteria, become resistant to the drugs used to treat them.
    As part of preparations for the 2019 Awareness Week this November, a group of senior leaders from across the health system, including NHS England and Improvement, have co-signed a letter, coordinated by Public Health England, that reminds commissioners and providers alike of their responsibility to contribute to this important agenda. The letter also reminds colleagues that this year’s WAAW campaign is the first of a new five-year UK National Action Plan for antimicrobial resistance, which contains stretching ambitions for reducing inappropriate prescriptions; as well as controlling and preventing infections.
  19. Patient Safety Learning
    At a launch event last week, Bradford Teaching Hospitals NHS Foundation Trust has officially opened its new Command Centre.
    The Command Centre, using technology from GE Healthcare Partners, went live earlier this year and was recently awarded Tech Project of the Year in the innovative Health Tech Awards 2019.
    The Trust said it helps staff to optimise patient flow and allow real-time co-ordination of care for each and every patient. Using advanced analytics and machine learning, the new system provides staff with real-time information to help them make speedy and informed decisions on managing patient flow across the Trust’s hospitals.
    Sandra Shannon, Chief Operating Officer and Deputy Chief Executive at the Trust “Demand for services is growing at Bradford Teaching Hospitals every year, with up to 400 patients coming through our A&E every day, and we have to get smarter at how we manage the needs of patients with the resources we have.”
    “The Command Centre is a major investment in how we, as a very busy acute Trust, can improve our performance, maintain and improve patients’ experience of coming into hospital and support our staff to do their jobs more efficiently, so they can concentrate on delivering excellent patient care.”
    Read full story
    Source: Health Tech Newspaper, 12 November 2019
  20. Patient Safety Learning
    A&E waiting times are at their worst on record as the NHS comes under intense pressure before what doctors and hospital bosses fear will be a very tough winter for the service.
    Less than three-quarters (74.5%) of people who sought care at A&E unit in England in October were treated and then discharged, admitted or transferred within four hours – the smallest proportion since the target was introduced in 2004.
    That is far below the 95% of patients that ministers and NHS chiefs say should be dealt with by A&E staff within four hours.
    “As political parties vie to prove their NHS credentials, today’s figures highlight that the NHS is desperately struggling to stay afloat,” said Dr Rebecca Fisher, a GP and senior policy fellow at the Health Foundation.
    Read full story
    Source: The Guardian, 14 November 2019
  22. Patient Safety Learning
    Having spent 5 months in a hospital bed, Jame Hale, a disabled poet and essayist, urges us as we go into this election not to forget the damage that’s been done to the NHS – and the individual, human casualties that have resulted. 
    "High-quality staff are not enough if we put them in environments where they cannot do their best", Jame says to the Guardian newspaper. 
    "An NHS in this state is a stain on the country, and an ongoing risk to patient safety. It’s come about because of nine years of persistent underfunding and austerity, which has come on top of PFI hospital-building initiatives that have loaded hospital trusts with unsustainable repayments."
    Read full story
    Source: The Guardian, 7 November 2019
     
  23. Patient Safety Learning
    A whistleblower claimed a cancer patient died as a result of contaminated water at Scotland's largest hospital. The whistleblower raised concerns about the findings of a review into infections in child cancer patients.
    Jeane Freeman, the health secretary, says she knew in September a child had died after contracting an infection possibly linked to water at the Queen Elizabeth University Hospital, but did not make it public. She told BBC Scotland she acted on the information but chose to maintain patient confidentiality.
    Ms Freeman said she felt for the child's parents. She said: "I deeply regret not only the death of their child. In any circumstance that has to cause a pain that I can't possibly imagine, but I also deeply regret that they feel they haven't been given the information that they have a perfect right to receive and are entitled to. They have my commitment to act to ensure that situation does not happen to parents in the future".
    "I don't regret honouring patient confidentiality. But upholding patient confidentiality does not mean I don't act on the information I am given."
    Labour MSP Anas Sarwar had raised the issue - which was brought to light by an NHS whistleblower - during First Minister's Questions on Thursday. He  described the situation as a "cover-up".
    The MSP said he had seen information which showed that senior managers were repeatedly alerted to the fact a previous review failed to include cases of infection related to the water supply in 2017. He said the parents of the child had never been told the true cause of their child's death.
    Greater Glasgow Health Board say a link between the infection and the hospital cannot be proven because regulations at the time did not require water testing.
    Read full story
    Source: BBC News, 14 November 2019
  24. Patient Safety Learning
    Reports that medical errors are the third leading cause of death in the US have led the Institute of Medicine and several state legislatures to suggest that data from patient safety event reporting systems could help health care providers better understand safety hazards and, ultimately, improve patient care.
    "Tens of thousands of these safety report databases provide a free text field that does not constrain the reporter to fixed, predefined categories," said Srijan Sengupta, Assistant Professor of Statistics in the College of Science and a faculty member at the Discovery Analytics Center.
    Sengupta has received an $815,218 Research Project Grant (R01) from the National Institutes of Health (NIH) to develop novel statistical methods to analyze such unstructured data in safety reports.
    "Detailed information that spans multiple categories can be more valuable than identifying an event by just checking off a category," he said.
    Read full story
    Source: EurekAlert, 13 November 2019
  25. Patient Safety Learning
    Existing claims that locum GPs present a greater risk of harming patients are unfounded, according to new research published in the Journal of the Royal Society of Medicine. It found that there is little evidence that locum doctors, including GPs, have a 'detrimental' impact on patient care delivery.
    Researchers from the University of Manchester looked at 42 international papers, including 24 from the UK, on the impact of locum doctors working in various healthcare settings to determine whether this group is more likely to harm patients than permanent doctors. 
    Previous reports highlight longstanding and growing concerns about the quality, safety and cost of locum doctors among a range of stakeholders such as policymakers, employers, regulators and professional bodies. These include locum GPs being less aware of local policies and less familiar with the patient's healthcare history and lacking commitment. 
    However, the researchers found there is 'very limited evidence' to support claims that these healthcare professionals deliver lower quality of care than their permanent counterparts. 
    Read full story (registration required)
    Source: Pulse, 12 November 2019

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