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Patient Safety Learning

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  1. Patient Safety Learning
    A new £700,000 computer system has been deployed in an intensive care unit at Aberdeen Royal Infirmary. The new Philips system will replace bedside charts, freeing up clinical time and improving patient safety at the NHS Grampian hospital.
    ICU clinical director Dr Iain MacLeod said: “At the heart of this change is patient safety. The system records physical measurements like blood pressure and heart rate as well as blood results and parameters from the various machines used in ICU, such as dialysis machines and ventilators."
    “It will also save on staff time. Currently medical staff members waste lots of time transcribing blood results from a computer onto sheets of paper. The new system allows this to happen automatically. That’s great from a timesaving point of view but more importantly there will be a reduction of errors that can happen when writing something down.”
    Read full story
    Source: FutureScot, 11 November 2019
  2. Patient Safety Learning
    Thousands of bowel cancer cases are being missed due to “unacceptable” testing failures, research in the BMJ shows. 
    The UK research found that some providers carrying out colonoscopies were three times as likely as others not to spot signs of disease. At the worst units, almost one in ten cases which turned out to be bowel cancer were not picked up during the tests, the study led by the University of Leeds found. 
    Researchers said that almost 4,000 more cases could have been prevented or treated sooner had there been better screening over a nine year period tracked. 
    Researcher Roland Valori, Consultant Gastroenterologist from Gloucestershire Hospitals NHS Foundation Trust, said: “We are seeing unacceptable variation in post colonoscopy bowel cancers between providers in the English NHS and this variation in quality needs to be addressed urgently.” 
    Read full story
    Source: The Telegraph, 2019
  3. Patient Safety Learning
    A privately run mental health unit has been banned from admitting new patients after inspectors found numerous safety failings, one of which led to a resident dying by hanging.
    The Care Quality Commission (CQC) has stopped the Cygnet Acer Clinic, in Chesterfield, Derbyshire, from accepting new inpatients. It declared that the facility was “not safe” for people to use.
    Inspectors found that clinic patients had opportunities to hang themselves, and the unit had soaring levels of patient self harm, and a huge shortage of trained staff.
    The CQC’s report is one of the most damning it has issued about poor and unsafe care affecting vulnerable and potentially suicidal patients in a mental health facility.
    Read full story
    Source: The Guardian, 13 November 2019
  4. Patient Safety Learning
    Fragmented patient data can lead to redundant and unnecessary care, potentially harming individuals. Thought leaders are calling for standardised methods to identify patients and minimise potential harm.
    At a recent US Food and Drug Administration conference for improved data standards, Shaun Grannis, Regenstrief Institute Vice President of Data and Analytics, advocated for standards that promote better patient matching.
    “Any time you lack complete information to make the best decision possible, there's an opportunity for error,” Grannis said. “Patient matching is a safety issue. Patient identification is paramount to making sure that patients receive appropriate, safe care.”
    Grannis noted that patient data is currently fragmented across healthcare systems. Patients often do not receive care at just one facility or in one health system.
    “They’re going to be identified differently across organizations. You might go to your primary care doctor or they refer you to a specialist who’s outside of your system, so your data is fragmented,” he continued.
    Disjointed data can make it difficult for providers to make decisions about patient care. Without a complete picture of the patient’s medical history, it is more challenging for clinicians to make care decisions.
    Read full story
    Source: EHR Intelligence, 12 November 2019
  5. Patient Safety Learning
    Dozens of doctors from across Greater Manchester have warned health bosses plans to reform cancer services in the city will put patients at risk and destabilise smaller hospitals.
    In a letter, seen by The Independent, to the head of the devolved NHS and social care system for the city, almost 40 urological consultants called on the NHS to abandon its plans.
    NHS leaders are aiming to centralise hundreds of bladder and kidney cancer operations a year at the University Hospital of South Manchester but the doctors warn this will make their roles in smaller district general hospitals harder to recruit to and leave patients who need input from urologists at a disadvantage. Ultimately they fear the reorganisation could put services at smaller hospitals such as emergency care, gynaecology, trauma and obstetrics at risk because of the role urologist play in their delivery.
    The letter added: “The inevitable consequences of centralisation of complex urological cancer services on a single site will result in an inability to provide a safe sustainable comprehensive service to large areas of the city, particularly those areas which are already under resourced with regard to access to care and which have the highest levels of social deprivation."
    Read full story
    Source: The Independent, 12 November 2019
     
  6. Patient Safety Learning
    Radiology failings at a teaching hospital led to eight patients coming to severe harm, with three dying, a hospital trust has admitted. 
    A report into issues at St George’s University Hospitals Foundation Trust identified multiple problems, including staff missing cancers, improperly reported results and diagnoses being sent to unmonitored inboxes.
    Read full story (paywalled)
    Source: HSJ, 11 November 2019
  8. Patient Safety Learning
    Family doctors are calling for an end to home visits - saying they are too busy to visit the frail and elderly.
    The radical proposal, to be put forward at a conference of the British Medical Association, would see the duties removed from the standard contract for GPs. Medics said house calls were too “time consuming” for family doctors, who were overloaded. 
    But patients’ groups said the threat to withdraw such services from GPs was “appalling” and would put the vulnerable at risk. 
    Doctors will vote later this month on a proposal to remove home visits from the core GP contract, requiring a separate service to be created for those in need of urgent visits. 
    Read full story
    Source: The Telegraph, 11 November 2019
  9. Patient Safety Learning
    A coroner questioned the regulation of online pharmacies after a woman died as a result of her addiction to the painkiller codeine.
    Debbie Headspeath, 41, collapsed at home in Ipswich in 2017. The inquest heard she had been prescribed the opiate for back pain by her GP in 2008 and had later bought more online without his knowledge. The inquest found Mrs Headspeath died from pneumonitis caused by acute pancreatitis which in turn was caused by chronic codeine use. An investigation by the coroner's office found she had been prescribed codeine from 16 online companies spending more than £10,000 - on top of her prescriptions from her local NHS surgery.
    The Suffolk Coroner, Nigel Parsley, said he would ask the government to look at closing "regulatory gaps" in the system. He said Mrs Headspeath had been able to "manipulate" the system and he delivered a narrative conclusion that she died as a result of the "uncoordinated availability of codeine from multiple suppliers". The coroner said he would prepare a full prevention of future deaths report for the family and Department of Health.
    Read full story
    Source: BBC News, 12 November 2019
  10. Patient Safety Learning
    Five-day-old Abel Cepeda died in Geisinger Medical Center’s neonatal intensive care unit in the US. Cepeda’s parents didn’t know it at the time, but their son was the eighth baby since the summer to get sick after exposure to the same bacteria in Geisinger Medical Center’s NICU. Two had died by the time Cepeda’s mother was admitted on 18 September, according to the family’s lawsuit. Geisinger staff have admitted noticing “unusual” illness weeks before the hospital went public with its problem.
    On Friday, Geisinger announced that its own equipment contaminated the donor breast milk that exposed premature infants to a bacteria called pseudomonas. The medical center in Danville, Pa., says it changed its equipment on 30 September, switching to single-use materials — the same day Cepeda died while his parents remained in the dark about the ongoing bacteria problem, the family’s lawsuit alleges.
    Matt Casey, a Philadelphia-based lawyer representing Cepeda’s parents, says findings that Geisinger’s breast milk measurement materials led to the infections have reinforced his belief that Geisinger — which runs sites around Pennsylvania — was negligent both in cleaning its equipment and in taking steps to save lives once red flags surfaced.
    Read full story
    Source: The Washington Post, 9 November 2019
  11. Patient Safety Learning
    Alder Hey is leading on a new study called DETECT (Dynamic Electronic Tracking and Escalation) to reduce critical care transfers and to record vital signs.
    The study has received £1.25m in funding from the National Institute for Health Research Invention for Innovation Programme (NIHR i4i) and involves The University of Liverpool, Edge Hill University, Lancaster University and System C.
    Healthcare professionals at Alder Hey are currently using electronic devices to record breathing rate, effort of breathing, oxygen saturation, oxygen requirement, heart rate, blood pressure, capillary refill time, temperature and nurse or parental concerns.
    The DETECT Study is the first research study of its kind in the UK as an early warning system for children.
    The recorded data will automatically calculate an age-specific paediatric early warning score (PEWS), which categorises the risk of developing serious illness into low, medium, high or critical. These scores and signs suggestive of sepsis are automatically flagged to staff to help them recognise the early signs of deterioration, with a view to reducing emergency admissions to critical care.
    Read full story
    Source: Health Tech Newspaper, 11 November 2019
  13. Patient Safety Learning
    Healthcare organisations including regulators, royal colleges and faculties have issued a set of principles to help protect patient safety and welfare when accessing potentially-harmful medication online or over the phone.
    The jointly-agreed High level principles for good practice in remote consultations and prescribing set out the good practice expected of healthcare professionals when prescribing medication online.
    The ten principles, underpinned by existing standards and guidance, include that healthcare professionals are expected to:
    Understand how to identify vulnerable patients and take appropriate steps to protect them Carry out clinical assessments and medical record checks to ensure medication is safe and appropriate Raise concerns when adequate patient safeguards aren’t in place. Charlie Massey, Chief Executive of the General Medical Council (GMC), said:
    ‘The flexibility of accessing healthcare online can benefit patients, but it is imperative these services do not impact on their safety, especially when doctors are prescribing high-risk medicines."
    Read full story
    Source: General Medical Council, 8 November 2019
  14. Patient Safety Learning
    Inspectors have demanded action over patients facing long waits on trolleys at Wrexham Maelor Hospital's A&E unit.
    Healthcare Inspectorate Wales (HIW) said officials found some people waiting eight hours during an unannounced visit in August. It wants Betsi Cadwaladr University Health Board (BCUHB) to make rapid improvements.
    In a statement, it said some of HIW's recommendations had already been addressed.
    In its report, HIW acknowledged efforts made by emergency department staff to look after those in need, the Local Democracy Reporting Service reported.
    "It was identified that patients who were waiting on trolleys in the corridor were not receiving appropriate and timely care," said HIW. "We had to alert the nurse responsible for the patients in the emergency department corridor to a patient who was experiencing increased chest pain."
    "During the inspection, we found that there were no pressure relieving mattresses available for any patients who were waiting on trolleys within the emergency department."
    "We considered the above practices to be unsafe and increased the risk of harm to patients."
    Read full story
    Source: BBC News, 9 November 2019
  15. Patient Safety Learning
    NHS staff are being told to report whether hospital mistakes have been caused by Brexit.
    Staff at a London trust must now record whether a safety incident was “caused or contributed to by leaving the European Union”. All patient-related mishaps – anything from a patient falling over, to a medicine being missed – must be recorded on a national database.
    But in the last few weeks, staff at Barts Health NHS Trust have been told they must stipulate whether or not Brexit was a contributing factor, according to documents seen by The Independent. The patient safety reporting system now poses the yes-or-no question: “Is there reason to believe it was caused or contributed to by the EU exit transition [Brexit]?”
    Read full story
    Source: The Independent, 9 November 2019
  16. Patient Safety Learning
    More than 550 objects have been unintentionally left in Canadian medical and surgery patients between 2016 and 2018, and the problem appears to be getting worse.
    A new report released by the Canadian Institute for Health Information says 553 foreign items – such as sponges and medical instruments – were left behind over that two-year period. That's a 14%  increase between the most recent data collected in 2017–2018 and statistics collected five years earlier.
    It's also more than two times the average rate of 12 reporting countries, including Sweden, the Netherlands and Norway, which had the next highest rates.
    The information was examined as part of a broad look at how Canada's health-care system compares to other member nations of the Organisation for Economic Co-operation and Development.
    Read full story
    Source: CTV News, 7 November 2019
  17. Patient Safety Learning
    Staff working at Blackpool hospitals raised 32 concerns with their bosses during the last three months as part of a national NHS whistle-blowing scheme.
    Figures presented to the Blackpool Victoria Hospital board show 16 of the complaints related to patient safety, while 14 were in connection with incidents of bullying and harrassment. The overall figure was in line with the average for the hospital trust since the scheme was introduced nationally by the government in 2015, and is down from 37 during the previous three months.
    But it was felt staff were still cautious about pointing the finger with anonymity requested in almost every case.
    Terri Vaselli, Freedom to Speak Up Guardian for the Trust, said: "Within the nursing teams there are fears they will be ostracised. "It doesn't matter how much I reassure them, the fear factor is still there."
    Read full story
    Source: Blackpool Gazette, 8 November 2019
  19. Patient Safety Learning
    The team of healthcare professionals at Doncaster and Bassetlaw Teaching Hospitals (DBTH) discuss their work ‘Sharing How We Care’ after being awarded the Shared Learning Award for their outstanding contributions to improving patient safety.
    The Trust ‘Sharing How We Care’ work was selected as the winners of the Shared Learning Award at the Patient Safety Learning Conference in London last month. The award recognised the work involved in setting up an annual conference as a forum to share examples of exemplary healthcare practice and a monthly newsletter which focuses on aspects of patient’s safety, including patient experience and articles about improvements in clinical areas.
    As a result of the work through Sharing How We Care, the Trust has seen a 40% decrease in the number of serious incidents reported.
    Cindy Storer, Acting Deputy Director of Nursing, Midwifery and Allied Health Professionals at Doncaster and Bassetlaw Teaching Hospitals, said: “We’re so pleased that the work through Sharing How We Care at the Trust has been recognised. We’ve seen real improvements in the quality of the care we provide as a direct result of this shared learning. These results reflect the commitment from all of our staff to support Doncaster and Bassetlaw Teaching Hospitals to become the safest Trust in England.”
    Read full story
    Source: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust website
  20. Patient Safety Learning
    The 23 winners of the 2019 HSJ Awards have been announced.
    The awards, now in their 39th year, are among the world’s most fiercely contested health service awards, attracting hundreds of entries from the NHS and its partners.
    The winner of the HSJ Patient Safety Award went to the Wessex Academic Health Science Network for their National Polypharmacy Prescribing Comparators.
    Read full list of winners
    Source: HSJ 7 November 2019
  21. Patient Safety Learning
    Tens of thousands of people have have had their operations cancelled because of staff shortages and faulty medical equipment, according to newly revealed NHS figures. 
    The number of procedures called off by hospitals for non-clinical reasons has increased by 32 per cent in the last two years, the statistics obtained via a freedom of information (FOI) request. Almost 4,000 more were scrapped in 2018 than in 2016.    
     They also show that of the 79,000 operations to be cancelled last year, 20 per cent were scrapped because of staffing issues and equipment failures.
    It comes as the staff vacancies continue to put the health service under strain, with the NHS reporting last year it was short of 100,000 staff including, 10,000 doctors and 35,000 nurses.
    Read full story
    Source: The Independent, 5 November 2019
  22. Patient Safety Learning
    Troubled teenagers seeking urgent help from NHS mental health services are being denied treatment or facing months of delays, GPs have said. Three in four family doctors do not believe under-18s they refer to child and adolescent mental health services will end up being treated, research shows.
    In a survey of 1,008 GPs across the UK, 76% said they did not usually feel confident a young person they referred to Child and Adolescent Mental Health Services (CAMHS) would receive treatment for their illness. Only 10% were confident that treatment would follow.
    Emma Thomas, Chief Executive of YoungMinds, said: “As these worrying results show, GPs are on the frontline when it comes to mental health. But too often they don’t believe that there is good enough early support in their community".  She added, "This means many young people either receive support from GPs who have the best of intentions but may not feel equipped to provide the right help, or face long waiting times for specialist services, which may then turn them away because of high thresholds for treatment.”
    Read full story
    Source: Guardian, 7 November 2019
  23. Patient Safety Learning
    A hospital trust has declared a "critical incident" because of the "exceptional" pressure on A&E.
    Nottingham University Hospitals Trust (NUH) runs the Queen's Medical Centre (QMC) and City Hospital and has been on OPEL 4 – previously known as black alert – since Monday morning. On Wednesday it raised the level further.
    Some routine operations have been cancelled as the trust prioritises those who need emergency care. Health bosses do not want to operate on patients who cannot be guaranteed a bed in which to recover.
    Lisa Kelly, NUH Chief Operating Officer, said: "This is following a number of days seeing exceptional pressure across the system, with high numbers of very poorly patients arriving at our emergency department."
    The trust has been on OPEL 4 at least once this year but this is the first time in 2019 the pressure in the emergency department has been escalated to a critical incident.
    Ms Kelly added: "This is not unique to Nottingham, and hospitals across the country are also experiencing similar pressures."
    In the East Midlands, University Hospitals of Leicester and Sherwood Forest Hospitals NHS Foundation Trust were both on OPEL 4 – which means patient safety could be compromised – earlier this week. They have since been scaled down to OPEL 3.
    Read full story
    Source: BBC News, 6 November 2019
  25. Patient Safety Learning
    More mental health hospital beds are needed in England to end the "distressing" sending of patients far from home, analysis suggests. Patients with conditions such as schizophrenia can be sent to hospitals miles away from their home if their nearby units do not have space. 
    The Department of Health aims to end inappropriate far-away placements by 2021. But the Royal College of Psychiatrists report suggested the push had stalled. The number of inappropriate out-of-area placements at any one time has been consistently between 700 and 800 patients in recent months, after dipping below 600 towards the end of 2018.
    Marjorie Wallace, Chief Executive of the charity Sane, said the drive to cut bed numbers had been "relentless" and caused "widespread distress and neglect".
    "Far too many people contacting us are being shunted around the country like unwanted parcels," she said. "We believe this has led to ever more patients left at risk of self-harm and suicide."
    Read full story
    Source: BBC News, 6 November 2019

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