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Patient Safety Learning

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  1. Patient Safety Learning
    Half of developers are not seeking ethical approval before they start producing new artificial intelligence systems for healthcare, according to a report by NHSX.
    The report, Artificial Intelligence: How to get it right, notes that the “complex governance framework” around AI tech could limit innovation and potentially compromise patient safety.
    It also revealed that there is “an almost 50/50 split” between developers who sought ethical approval before they started the development process for a new AI system and those who did not.
    Read full story (paywalled)
    Source: HSJ, 31 October 2019
  3. Patient Safety Learning
    Every NHS and social care worker in England will have to undergo mandatory training on autism and learning disability following the death of a teenager, the government has said.
    Eighteen-year-old Oliver McGowan, who had autism, died in November 2016 after being given anti-psychotic medication against his own and his parents’ wishes by staff at Bristol’s Southmead Hospital, part of the North Bristol NHS Trust. Oliver’s medical records showed he had an intolerance to anti-psychotic drugs and shortly after he was given the dose he developed severe brain swelling and died.
    His parents Paula and Tom McGowan have been campaigning for improved training for health and care staff and ministers have now backed their calls with new pilots and £1.4m of funding.
    The new training will be named after Oliver and will start next year, with the aim to improve care for people with autism and learning disabilities using case studies and ensuring all staff understand the needs of patients with learning disabilities and autism.
    Read full story
    Source: Independent, 5 November 2019
  4. Patient Safety Learning
    At last week’s meeting in Perth, Australia, the COAG Health Council discussed a number of national health issues, one of which was the Quality Use of Medicines.
    The Council’s resulting communique highlights that medicines are the most common intervention in healthcare and can contribute to significant health gains – but can also be associated with harm.
    “Half of all medication related harm is preventable and a coordinated national approach that identifies and promotes best practice models and measures progress towards reducing medication related harm has the potential to improve the health of Australians and create savings across the health care system,” it notes.
    At the meeting, the Health Ministers agreed to make the Quality Use of Medicines and Medicines Safety the 10th National Health Priority Area
    Read full story
    Source: Australian Journal of Pharmacy, 4 November 2019
  5. Patient Safety Learning
    A common hospital bed used by thousands of patients across New South Wales (NSW), Australia, poses a risk to heavier patients and nurses caring for them, healthcare staff have been warned.
    A safety alert has been issued throughout the state after NSW Health received five reports of Hill-Rom HR900 model beds tilting dangerously as nurses tried to manoeuvre patients. 
    The incidents are the latest pressure point for a healthcare system responsible for the rising overweight and obese patient population.
    No patients involved were harmed, but “there is a potential risk if the beds tip during an episode of patient care", the alert issued last month by the Clinical Excellence Commission reads.
    Read full story
    Source: The Sidney Morning Herald, 4 November 2019
  6. Patient Safety Learning
    The Professional Record Standards Body (PRSB) has published a standard for ambulance handover to ensure that information can be transferred digitally to emergency departments from any ambulance and improve patient care and safety.
    Emergency care needs fast, effective sharing of information. Once implemented, the standard for handover will improve continuity of care, as emergency care professionals will have the information they need available to them on a timely basis. It means that emergency care professionals will know what medications have been administered, diagnostic tests performed and whether the patient has any allergies as well as other important information.
    The standard is published as a draft while PRSB seeks endorsement from relevant members and other organisations.
    Read the Ambulance handover to emergency care standard
    Source: PRSB, 1 November 2019
  7. Patient Safety Learning
    A 7-year-old boy who has spent most of his life being branded naughty and disruptive has won a settlement of more than £30m after it was discovered that he had sustained a brain injury after negligent delays in his delivery at University College Hospital in London.
    The settlement is thought to be one of only a handful of NHS clinical negligence payouts to exceed £30m.
    Read full story (paywalled)
    Source: BMJ, 1 November 2019
  9. Patient Safety Learning
    Elderly patients are being “poisoned” with medication because too little is known about how different drugs interact with each other and correct dosages for older people, experts have said.
    Speaking at the House of Lords’ science and technology committee hearing on healthier living in old age, Sir Munir Pirmohamed, Professor of Molecular and Clinical Pharmacology at Liverpool University, said most of his patients are on more than 10 and often more than 20 drugs.
    “Those drugs are used at conventional doses and those doses have been tested in younger populations who had exclusion criteria for trials – so they have been tested in people who don’t have the multiple diseases,” he said. “So when we use a drug at a dose which is licensed at the moment, we are often ‘poisoning’ the elderly because of the dosing that we are using.”
    Read full story
    Source: Guardian, 29 October 2019
  10. Patient Safety Learning
    England’s top doctor has welcomed new polling showing that patients and the public support NHS proposals focussing on fast treatment for those who need it in A&E.
    A national survey commissioned by Healthwatch England found that an overwhelming majority of people placed a high priority on early initial assessment on arrival at A&E for everyone, allowing staff to prioritise those patients with the greatest need, and ensuring that patients with critical conditions get the right standard of care quickly.
    These priorities are mirrored in new standards now being trialled across the NHS, as part of a review led by NHS National Medical Director, Professor Stephen Powis, supported by leading staff and patient groups. They include a rapid assessment measure for all patients arriving at A&E, coupled with measuring how quickly life-saving treatment – or Critical Time Standards – is delivered for those with the most serious conditions, such as heart attacks, sepsis, stroke and severe asthma attacks.
    Experts believe updating the 15-year old target regime for emergency department teams with these new measures, combined with an average waiting time target to bring down long waits for all patients, may help NHS teams save more lives and prevent long term disability for thousands more people.
    Read full story
    Source: NHS England, 31 October 2019
  13. Patient Safety Learning
    Digital training should be “embedded” into clinical curricula rather than being “bolted on”, the Chief Executive of ORCHA has said. Liz Ashall-Payne said more needed to be done to ensure appropriate digital training for clinicians or risk a “knowledge gap” forming between current and future staff.
    Dr Sandeep Bansal, Chief Executive of Medic Creations and mentor on the Royal College of GPs innovation mentorship programme, echoed calls for digital training to be incorporated in the medical school curriculum. 
    “Your organisation is only as strong as lowest digitally mature staff member. It is all very well educating our tech-savvy junior doctors, but we must make sure those less au fait with digital advancements are not left behind. That is where patient safety could be put at risk. After all the main purpose of digital innovation is to enhance our ability to care for patients, by enabling more effective, efficient and precise clinical practice.”
    Clive Flashman, Patient Safety Learning's Chief Digital Officer, agreed with the need for clinicians to receive digital training but with a focus on how to quickly evaluate an apps. “What is essential is that all clinicians, not just GPs, have access to advice, tools and support to enable them to prescribe and monitor the effectiveness of apps and digital therapies,” he told Digital Health News.
    Read full story
    Source: Digital Health, 29 October 2019
     
  14. Patient Safety Learning
    The Health Products Regulatory Agency (HPRA) has revealed an increase in the number of adverse reaction reports to medicines as well as a rise in product recalls and quality defects in 2018. With more than 250 Irish patients dying last year while on treatment with medicines where an adverse reaction had been reported, should we be alarmed?
    The number of adverse reaction reports received by the authority last year more than doubled. It says the increase is largely accounted for by a new requirement to include non-serious reports of adverse reactions in addition to serious ones. Particular risk factors include age extremes, the prescribing of multiple drug types, co-morbidity and genetics. But in truth reporting of adverse drug reactions (ADRs) in the Republic has never been comprehensive. It is estimated that less than 5% of all ADRs are reported in practice. A 2018 Irish study found that 43% of hospital doctors and 35% of GPs had never reported a suspected ADR.
    Medication safety is an important patient safety issue. Working together, and with increased education, healthcare professionals and the public can do more to increase vigilance.
    Read full story
    Source: The Irish Times, 28 October 2019
  15. Patient Safety Learning
    Nearly 900 children in a Pakistani city have tested positive for HIV after a rogue paediatrician allegedly reused infected syringes.
    About 200 adults have also tested positive for the virus since the epidemic in Ratodero was confirmed in April. But health officials fear the true number affected could be far higher, with less a quarter of city’s 200,000 residents tested so far.
    The outbreak was initially blamed on Dr Muzaffar Ghanghro, a paediatrician who at 16p a visit was one of the cheapest in the small central city. He was arrested and charged with negligence and manslaughter after his patients accused him of frequently reusing syringes on their children.
    Despite an initial investigation by police and health officials concluding Dr Ganghro’s “negligence and carelessness” as the “prime” reason for the outbreak, officials believe he is unlikely to be the sole cause. Visiting health workers often see doctors in Ratodero reusing syringes, while dentists use unsterilised tools in roadside surgeries and barbers use the same razor on various customers, The New York Times reported.
    Read full story
    Source: The Independent, 27 October  2019
  16. Patient Safety Learning
    A coroner has criticised an NHS trust for “suboptimal care” and “missed opportunities” in the treatment of 10 patients with cancer at a urology department where relationships were “dysfunctional.”
    Coroner Penelope Schofield said that all 10 had died of natural causes but that missed opportunities, suboptimal care, and in three cases “neglect” had contributed to the deaths.
    The patients, who died from prostate or bladder cancer from 2006 to 2015, were under the care of Paul Miller, a consultant urologist at East Surrey Hospital in Redhill. 
    Read full story (paywalled)
    Source: BMJ, 25 October 2019
  18. Patient Safety Learning
    The public is being misled by scare stories about sepsis, say experts, warning that hype and misunderstandings about the so-called “hidden killer” have generated “an unhealthy climate of fear and retribution” in the UK and the US.
    Prof Mervyn Singer and colleagues from the Bloomsbury Institute of Intensive Care Medicine at University College London argue that the numbers are not that high and sepsis is not always preventable. “Many other non-contextualised or fictitious claims regularly fill media pages and airwaves,” they say in their letter to the Lancet, calling for a rethink of the approach to sepsis risk.
    The truth, they say, is that sepsis kills a very small proportion of patients – and those who die are overwhelmingly very elderly or frail. Their deaths are not always preventable because their chances of surviving their illness were not high to begin with. And the drive to ensure all patients suspected of sepsis get antibiotics within an hour is unhelpful and leading to unjust criticism of doctors and litigation against hospitals.
    A Department of Health and Social Care spokesperson said: “Sepsis can be life-threatening and it is absolutely right the NHS has focused on improving awareness, diagnosis and treatment of this syndrome. While the number of people identified as at risk of sepsis has increased, mortality rates are falling.”
    Read full story
    Source: The Guardian, 25 October 2019
  19. Patient Safety Learning
    A national survey, published by the Care Quality Commission (CQC), shows most people experience good urgent and emergency care, but waiting times are still a problem.
    More than 50,000 people, who received urgent and emergency care, took part in a CQC survey covering 132 NHS trusts across England. Findings show that the majority of their experiences were positive relating to their care and treatment but a significant number reported long waits, particularly in A&E.
    The survey, which ran between Oct and Mar 2019, reveals responses from patients who experienced either a major consultant-led A&E department (Type 1) or an urgent care or minor injury unit (Type 3) run directly by an acute hospital trust. 75% of people who attended a Type 1 department reported ‘definitely’ having enough time to discuss their condition with the doctor or nurse. This has risen from 73% who said the same in 2016, the last time the survey was carried out. A similar number (76%) said that they ‘definitely’ had confidence and trust in the staff treating them, up from 76% in 2016.
    Another improvement showed that 79% of participants were treated with respect and dignity ‘all of the time’, up from 78% in 2016.
    Professor Ted Baker, CQC’s chief inspector of hospitals, said:
    “I’m pleased to see that the majority of people surveyed continue to report positively about their experience. This is despite the pressures that urgent and emergency care services are under and is a testament to the dedication and hard work of hospital staff across the country.
    “However, it is disappointing that in some areas people’s experience continues to fall short. We cannot ignore the increasing impact of lengthy waiting times particularly for those patients attending A&E departments. Patients who are seriously ill and need urgent care should be consistently identified in a timely way, so it is concerning that such a low proportion say they waited 15 minutes or less for an assessment.
    Read full CQC report
    Source: CQC, 23 October 2019
  20. Patient Safety Learning
    Western Sussex Hospitals Foundation Trust has become the first non-specialist trust to be rated “outstanding” in all five Care Quality Commission (CQC) domains.
    The latest CQC report means the trust has not only retained its overall “outstanding” rating from its December 2015 inspection, but also improved its rating in the safe domain from “good” and in the responsiveness domain from “requires improvement”. The trust was also rated “outstanding” for critical care, improving from “requires improvement”. It was also rated outstanding for use of resources.
    Read CQC report
    Read full story (paywalled)
    Source: HSJ, 22 October 2019
  21. Patient Safety Learning
    Mike Stylianou, an operating department practioner, discusses how personal experiences led himself and a colleague to set up a debrief team for the operating theatres at Great Ormond Street hospital.
    "Healthcare professionals aren’t robots. When something goes tragically wrong, our debriefing programme supports them."
    Read full story
    Source: The Guardian, 24 October 2019
  22. Patient Safety Learning
    Poorly implemented electronic prescribing and medicines administration systems can result in potentially fatal medication errors, Healthcare and Safety Investigation Branch (HSIB) warns today.
    The report comes after HSIB looked at the case of 75-year old Ann Midson, who was left taking two powerful blood thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer.
    Ann sadly died from her cancer 18 days after being discharged and the error with her medication was only picked up three days before. This led to our investigation to question why this happened, even when the hospital had an ePMA system in place.
    Read report
    Read full story
    Source: HSIB, 24 October 2019
  23. Patient Safety Learning
    A hospital showed "poor behaviour" towards junior staff and "a culture of bullying behaviour", health inspectors have said.
    The Care Quality Commission (CQC) has downgraded Northampton General Hospital from "good" to "requires improvement".
    Inspectors also found the hospital's maternity and medical care "requires improvement".
    Dr Sonia Swart, chief executive, said staff should be treated "the way we care for patients".
    The CQC, which visited in June and July this year, also found that the hospital "requires improvement" in safety and leadership.
    Read full story
    Source: BBC News, 24 October 2019
  24. Patient Safety Learning
    The number of hospitals falling short of their planned nurse staffing by 10% or more has almost tripled in five years. An analysis of unpublished workforce data by HSJ reveals the gap between the number of nurses hospitals think they need, and what they are able to staff it with, has grown since 2014.
    The number of hospital trusts reporting a shortfall of 10% or more on their day shifts increased from 20 in June 2014 to 55 in June 2019 – nearly triple. 
    Experts said the data showed the NHS was “drifting into massive skill mix change” as hospitals overstaff with support workers, while having to run shortfalls of nurses, despite evidence this has a “detrimental impact on patient outcomes including survival”.
    Alison Leary, Professor of Healthcare and Workforce Modelling at London’s Southbank University, told HSJ: “It’s concerning but understandable that trusts are filling that gap with unregistered support staff because we know from the evidence that skill dilution has a detrimental impact on patient outcomes including survival." Professor Leary said NHS trusts needed to do more on retaining nurses and recognising their value.
    Read full story
    Source: HSJ, 24 October 2019
  25. Patient Safety Learning
    The Nursing and Midwifery Council (NMC) misled former health secretary Jeremy Hunt over its handling of fitness to practise cases linked to the Morecambe Bay maternity scandal, an independent report has said.
    In a letter to Mr Hunt, the nursing regulator’s former chief executive Jackie Smith said a document relied on by the family of one baby who died at the hospital had been considered by its lawyers ahead of a fitness to practise panel.
    Now a new report by consultancy Verita said the regulator had in fact lost the document and it was not considered ahead of the fitness to practise hearing. It said the misleading letter was “obviously concerning” and criticised the regulator for its poor practice in not checking documents.
    Verita’s report, commissioned by the NMC and published today, has also laid bare how the nursing regulator badly treated the parents of Joshua Titcombe, who died in October 2008 after poor care at Furness General Hospital. It concluded they were “unfairly attacked” in the press.
    Joshua’s father James Titcombe provided the NMC in 2010 with a chronology of what happened after his son’s death (written in 2008) in which it was mentioned that both he and his wife had been unwell before Joshua’s birth. This document was lost and not shared with a fitness to practise panel in 2016 with lawyers claiming the couple were unreliable witnesses.
    The report claims the errors were the result of “mainly accidental factors, combined with poor communication and management” at the regulator.
    It found the chronology document was never included in the original case file for the NMC, which was not noticed by NMC staff.
    Mr Titcombe, whose campaign about maternity safety at the Cumbria hospital led to the Kirkup inquiry being published in 2016, told HSJ: “Verita seem to have gone about this in a way that their objective was to provide an innocent explanation. The investigation doesn’t seem very logical and the report has changed significantly from earlier versions with significant criticisms removed.
    “If you wanted to design a process that tortured bereaved parents you couldn’t do much better than the process the NMC came up with. We were made to relive what happened again and again and when the hearing eventually took place, attempts were made to discredit our evidence with no one from the NMC challenging statements that were plainly untrue.”
    He said the actions of the NMC after he raised concerns made the situation worse: “I knew that the excuses given at the time made no sense, but the fact that it took an external investigation before we were told the truth, is something that still shocks me.”
    A report by the Professional Standards Authority last year found the NMC had put the public at risk of poor care and was guilty of “frequently incompetent” complaint handling.
    The former chief executive Jackie Smith resigned last year. Former chair Dame Janet Finch was replaced by Philip Graf in May 2018.
    Andrea Sutcliffe, new chief executive of the NMC, said: “Throughout these fitness to practise cases the way we treated Mr Titcombe and his family was unacceptable. Our actions made an awful situation much worse and I am very sorry for that. I am also very sorry that our communications with Mr Titcombe, the PSA and the secretary of state for health and social care contained incorrect and misleading information about our handling of this evidence.
    “Together with NMC Chair Philip Graf, I am writing to Mr Titcombe, the chief executive of the PSA and the current and former secretary of state to apologise for these errors which should not have occurred.”
    She said the investigation highlighted a number of failings for the regulator which “reflected a culture at the NMC at that time that prioritised process over people. When concerns were raised with us about our approach, we acted defensively and dismissed those concerns. That is frankly unacceptable.”
    The regulator has since made changes, she argued, including better record keeping, a new public support service and better training for panel members to appreciate the needs of witnesses.
    She added: “While I am clear that, if faced with the same situation again, we would do things differently, I am also very aware that for many of those going through our fitness to practise process, it remains a very difficult experience. That is why we are carrying out further work, to understand how we can better ensure that witnesses, particularly those in vulnerable circumstances, are able to give evidence in a way that causes as little distress as possible. This includes learning from other organisations and jurisdictions, such as the courts.
    “I know that this investigation does not address all of Mr Titcombe’s concerns and I am sorry for that. However, I am grateful for his continued engagement and support as we change and improve. I would like to pay tribute to him for the passion and determination he has shown to ensure women, babies and their families have the safest, best care possible – an objective shared by all of us at the NMC. I am absolutely committed to learning the lessons of the past, taking forward the recommendations of this investigation and building on recent improvements as we look to develop a just, learning culture, both within the NMC and the wider health and care system.”
    Read Verita report
    Read full story (paywalled)
    Source: HSJ, 23 October 2019

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