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Patient Safety Learning

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  1. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) will stop carrying out external maternity incident investigations by 2021, handing them back to the NHS, HSJ has learned.
    Powers to allow HSIB to continue investigating more than 1,000 serious incidents in maternity units each year were left out of legislation which was presented to the House of Lords this week, sparking criticism from former health secretary Jeremy Hunt.
    The new bill gives HSIB statutory independence from the NHS alongside a range of powers, including the power to enter and seize documents and equipment that could be evidence. It also grants HSIB the power to keep information in a so-called safe space that cannot be shared, except in exceptional circumstances, with bodies like the General Medical Council.
    Read full story (paywalled)
    Source: HSJ, 18 October 219
  2. Patient Safety Learning
    Cancer patients are suffering side-effects of treatment in silence because they are afraid of bothering overworked NHS staff, a new survey reveals.
    More than two thirds of newly diagnosed cancer patients questioned by Macmillan Cancer Support said they are not getting all the help they need - estimated to be about 300,000 people across the UK.
    About a fifth of the 6,905 people in the survey said the healthcare professionals caring for them seemed to have "unmanageable" workloads.
    These patients were a third more likely to have physical and emotional needs that were not being addressed, such as depression, anxiety, pain and trouble sleeping, the charity said.
    Read full story
    Source: The Telegraph, 22 October 2019
  3. Patient Safety Learning
    NHS bosses knew that a low roof at a Swindon mental health unit was a safety risk before a patient slipped off it 11 hours after scaling the building.
    The woman, who suffered paranoia, needed emergency surgery after breaking her jaw, hip, pelvis and nose in the fall from the roof. 
    Avon and Wiltshire Mental Health Partnership (AWP) NHS Trust has since apologised for the incident. In August, the trust was fined £80,000 by magistrates after bosses admitted failing to provide safe care at Sandalwood Court psychiatric hospital.
    Now, an internal report on the incident has been published demonstrating AWP bosses knew the low roof was a risk. But it was agreed to manage that risk clinically, with ward staff assessing whether a patient was likely to abscond. The authors of the report, released by AWP following a freedom of information request, said there was a systematic fault.
    “The risk was on the health and safety register, it was highlighted annually and escalated trust-wide,” they wrote.
    Read full story
    Source: Swindon Advertiser, 18 October 2019
  4. Patient Safety Learning
    Diabetes teams in some NHS trusts are blocking patients’ access to new technologies that could improve their care, clinical leaders have said.
    A Westminster Health Forum session on diabetes and technology on 16 October heard that there was unwarranted variation across the country in access to insulin pumps and other clinically effective devices. Poorer access often stemmed from a lack of understanding among individual consultants and departments and a reluctance to offer new devices to patients, the experts said.
    Read full story (paywalled)
    Source: BMJ, 17 October 2019
  5. Patient Safety Learning
    The Medicines and Healthcare products Regulatory Agency (MHRA) has found around 2,000 products available to buy online since last October.
    The fake test devices for HIV and other diseases can show negative results when the person is positive, resulting in an individual believing they are infection-free and unknowingly spreading an infection to others.
    An MHRA spokesman said: “Medical devices that do not display the CE mark and four-digit number cannot be guaranteed to meet quality and safety standards and could lead to false negative results, potentially leading to STIs or blood-borne viruses to be spread further. Always purchase medical devices from a registered pharmacy or reputable retail outlet. If you have any concerns about your health, speak to a doctor or healthcare professional.”
    The MHRA is running a #FakeMeds public health campaign to reduce the harm caused by purchasing fake, unlicensed or counterfeit medical products online. It comes after research found that more than half of all medical products bought online are either substandard or counterfeit.
    Read full story
    Source: The Guardian, 20 October 2019
  6. Patient Safety Learning
    A manager has won his employment tribunal against a patient transport company he alleged had misled clients over staffing.
    Richard Mott won a claim for unfair dismissal after being made redundant one day after raising concerns about Secure Care UK, a firm that transports mental health patients, who have often been detained under the Mental Health Act.

    The tribunal heard the organisation had significant staffing difficulties, both for drivers and for manning the operations room.
    The judgment issued this month said: “The claimant says and I accept that [chief executive] Femi Sanusi had instructed him to inform a client that they had staff available to cover an assignment when they did not."

    “He told Mr Sanusi that ‘I do not work like this’. He went on to say that the [company] was in breach of CQC [Care Quality Commission] regulations, health and safety law and working time regulations. He said that the health and safety of patients and staff was in danger. He threatened to contact the CQC and the Information Commissioner.”
    Read full story (paywalled)
    Source: HSJ, 21 October 2019
  7. Patient Safety Learning
    The "most likely cause" of a bacterial outbreak that has seen 15 people die was district nursing teams, a document obtained by the BBC has revealed. 
    At least 33 people in Essex have been infected by the strain of invasive Group A Streptococcus (iGAS) bacterium. Of 32 cases initially found in the area 29 had previously been visited by Provide nurses, files obtained showed. Mid Essex Clinical Commissioning Group (CCG) said an investigation into the cause was continuing.
    Provide said it had "robust infection prevention policies" and that the cause of the infection may never be known.
    The BBC submitted a request under the Freedom of Information Act to Public Health England (PHE) and the CCG, which oversaw health spending in the area, for documents relating to the outbreak.
    A PHE briefing note received through the request said: "The most likely hypothesis as to cause of the outbreak is contact with, and spread via, district nursing services in the area."
    Read full story
    Source: BBC News, 19 October 2019
  8. Patient Safety Learning
    Patients caught up in a massive neurology recall have received letters of apology from the head of the Belfast trust – more than a year after the scandal broke.
    This is the first time trust Chief Executive Martin Dillon has corresponded with those affected, many of whom were misdiagnosed or received the wrong drug treatment while under the care of consultant neurologist Dr Michael Watt.
    The letter, seen by The Irish News, contains three separate apologies from Mr Dillon and gives "assurances" on the trust's co-operation with separate health service reviews.
    Mr Dillon announced his resignation this morning. He is retiring after almost three years in the trust's top post. During his tenure the trust has found itself at the centre of the biggest PSNI safeguarding investigation of its kind following allegations of patient abuse at Muckamore Abbey Hospital and is also dealing with the largest patient recall in Northern Ireland following the Dr Watt scandal.
    In his statement he singled out the “very serious allegations” of mistreatment at Muckamore and the neurology recall as two “major issues” he has dealt with as chief executive. He stresses that as “accountable officer” he has been “resolute” in trying to “put things right” and is confident care at Muckamore is now safe. 
    Read full story
    Source: The Irish News, 17 October 2019
  9. Patient Safety Learning
    On the first-ever World Patient Safety Day on 17 September 2019, WHO recognised the efforts of healthcare workers in the north-western Syrian Arab Republic, which has been affected by intense conflict for over 8 years.
    In support of improving the quality of healthcare delivery, WHO launched a pilot infection prevention and control project in 30 Syrian health facilities in 2019. Initial assessment highlighted that 28 out of the 30 facilities were inadequately implementing the core components of infection prevention and control programmes according to WHO guidelines for acute health facilities. This emphasised the need to improve patient safety.
    Globally, it is estimated that as many as 4 out of 10 patients are harmed in primary and ambulatory care settings; up to 80% of harm in these settings can be avoided. By investing in patient safety in health facilities, no matter how challenging the environment, WHO can save lives and improve the quality of care.
    Read full article
    Source: WHO, 16 October 2019
  11. Patient Safety Learning
    Thousands of lives a year could be saved by providing cancer screening in supermarkets and other convenient locations so people can go in their lunch breaks, a report has suggested.
    Sir Mike Richards, the NHS’s first cancer director, was asked to review national screening programmes and suggest how to improve early detection rates. The Report of The Independent Review of Adult Screening Programme in England, released yesterday, recommends that people “should be able to choose appointments at doctors’ surgeries, health centres or locations close to their work during lunchtime or other breaks rather than having to attend their GP practice”.
    It adds: “Local screening services should put on extra evening and weekend appointments for breast, cervical and other cancer checks. And as people lead increasingly busy lives, local NHS areas should look at ways that they can provide appointments at locations that are easier to access.”
    Sir Mike said that screening programmes save 10,000 lives per year but added: “Yet we know that they are far from realising their full potential. We need to make it as easy and convenient as possible for people to attend these important appointments.”
    Read full story (paywalled)
    Source: The Times, 16 October 2019
  12. Patient Safety Learning
    A GP has been struck off the UK medical register after a tribunal found that she dishonestly recorded patients’ temperature, pulse, and other key variables without ever actually measuring them or carrying out a proper examination.
    Kathleen Bilton was an out-of-hours GP at Royal Glamorgan Hospital in south Wales in early 2018 when two complaints arose from patients she had sent home with antibiotic prescriptions. Both were admitted to hospital soon after and diagnosed with sepsis.
    Their medical records showed that Bilton had entered specific figures for their pulse, temperature, respiration, and other variables, but both complainants denied that she had taken such measurements.
    Read full story (paywalled)
    Source: BMJ, 15 October 2019
  14. Patient Safety Learning
    Encouraging diversity in the NHS isn’t simply a matter of inclusion, it’s a matter of patient safety, delegates at the Healthcare Excellence Through Technology (HETT) conference have heard.
    Speaking on 2 October, Heather Caudle and Ijeoma Azodo, both members of the Shuri Network, stressed the importance of diversity when developing new technologies like artificial intelligence (AI). Without a diverse and inclusive team, “unconscious bias” can be built into technology, ultimately putting patients at risk.
    The next step in ensuring inclusive digital health solutions is including technology teams throughout the whole process, Heather Caudle, Chief Nursing Officer at Surrey and Borders Partnership NHS Foundation Trust said. “In health what we have done really well is developed multidisciplinary teams when looking at the patient,” she told the audience at ExCel London.
    “I think our technology colleagues are the next member of our multidisciplinary teams. If you think about AI and these new ways of doing things, how are we including the creators and the developers when thinking about patient care?
    “We will have unintended consequences of artificial intelligence that hard-wires things like unconscious biases, that we are only going to treat people that are this age, this weight, this colour, because that’s how we think.
    “Having that diversity on the team will help.”
    Read full story
    Source: Digital Health, 2 October 2019
     
  15. Patient Safety Learning
    Royal Papworth Hospital in Cambridge, a leading heart hospital, has become the first NHS hospital trust to earn "outstanding" ratings across the board by inspectors.
    The hospital earned the top rating across all five tested areas – safety, effectiveness, care, responsiveness and leadership.
    The Care Quality Commission (CQC) inspectors said: "A caring culture ran through the trust."
    The CQC's Chief Inspector of Hospitals, Prof Ted Baker, said he was "very impressed by the high-quality care and treatment offered".
    "Patients received exemplary care from committed and qualified staff," the report concluded.
    Read full story
    Source: BBC News, 16 October 2019
  16. Patient Safety Learning
    The husband of a woman who died after repeated failures to diagnose her cervical cancer says he is "convinced there are other victims out there".
    Julie O'Connor was given the all-clear by doctors at Southmead Hospital in Bristol more than three years before a private doctor diagnosed her cancer. Mrs O'Connor and her husband Kevin later sued the hospital for its failings.
    An independent report concluded there were "serious errors" and a failing by the trust to act urgently when it was discovered Mrs O'Connor did have advanced cervical cancer.
    But Mr O'Connor criticised the report and said it did not cover the full length of his wife's cancer care. "It doesn't go back to 2014, it doesn't cover the smears, the biopsies and the missed clinical observations," he said. "We need to consider other victims, look further back, look back to 2014, and make sure we've got a safe and effective screening."
    Prof Tim Whittlestone, North Bristol NHS Trust's acting deputy medical director, said: "We are determined to learn from this and have made significant changes to the way we examine and test for cervical cancer, which I am confident will detect and prevent more cases in future."
    Read full story
    Source: BBC News, 16 October 2019
  17. Patient Safety Learning
    Women are half as likely as men to receive treatment for a heart attack – even after it has been diagnosed, research shows.
    Experts warned that "unconscious bias" means doctors are far less likely to think that female patients are suitable for interventions which can save lives. It follows evidence that 8,000 women have died needlessly from heart attacks in the last decade because they have not received the same standards of care as men.
    Some of the death toll was blamed on a failure to diagnose cases in women, with medics too often assuming symptoms signified a less serious ailment. But the new study by Edinburgh University found that even when women received a diagnosis, they were half as likely as men to be put on any of the main treatments available. 
    Read full story
    Source: The Telegraph, 14 October 2019
  18. Patient Safety Learning
    Today is Global Handwashing Day, a global advocacy day dedicated to increasing awareness and understanding about the importance of handwashing with soap as an effective and affordable way to prevent diseases and save lives.
    hub content on handwashing:
    WHO: Guidance on engaging patients and patient organisations in hand hygiene initiatives
    Safety and Health Practitioner: Tips for hand hygiene 
    Hand washing dance - this is how we do it
    What initiatives are in your hospital to ensure "clean hands for all"? Share your tips on the hub.
  19. Patient Safety Learning
    A new report reveals alarming shortage of country doctors. Just 15% of consultants take jobs in hospitals serving rural or coastal areas.
    Hospitals in rural and coastal Britain are struggling to recruit senior medical staff, leaving many worryingly “under-doctored”, a major new report seen exclusively by the Observer reveals. Some hospitals in those areas appointed no consultants last year, raising fears that the NHS may become a two-tier service across the UK with care dependent on where people live.
    Disclosure of the stark urban-rural split emerged in a census of consultant posts across the UK undertaken by the Royal College of Physicians (RCP), whose president, Andrew Goddard, has warned that patients’ lives may be at risk because some hospitals do not have enough senior doctors.
    Read full story
    Source: The Guardian, 13 October 2019
     
  20. Patient Safety Learning
    Doctor shortages are jeopardising patient safety and rota gaps are pushing the NHS to “breaking point”, Scottish physicians have warned.
    A lack of doctors in NHS Scotland due to unfilled vacancies, sick leave and a shortage of staff is often putting patients’ welfare at risk, a survey of consultants has found. More than a third of Scottish doctors (34%) reported, in the Royal Colleges’ annual census, that trainee rota gaps occurred at least daily, while 16% warned they are causing “significant patient safety problems”.
    A further 78% of those who responded said rota gaps potentially cause patient safety problems, but that there are solutions in place.
    Read full story
    Source: The Scotsman, 14 October 2019
  21. Patient Safety Learning
    A shortage of skilled staff, coupled with rising demand, has created a “perfect storm” for patients using mental health and learning disability services, England’s healthcare regulator has warned.
    In its annual State of Care report for 2018-19, the Care Quality Commission said that although quality ratings across health and social care, including community mental health services, had been maintained overall, this masked “a real deterioration” in some specialist inpatient services over the past 12 months.
    Read full story (paywalled)
    Source: BMJ, 14 October 2019
  22. Patient Safety Learning
    More than half of A&E units are providing substandard care because they are understaffed and cannot cope with an ongoing surge in patients, the NHS watchdog has said.
    The Care Quality Commission (CQC) said 44% of emergency departments in England required improvement and another 8% were inadequate, its lowest rating. Last year 48% of A&Es fell into the two ratings brackets combined.
    Prof Ted Baker, the CQC’s chief inspector of hospitals, said A&Es were getting overloaded because too few NHS services existed outside hospitals, meaning patients’ health could worsen. He said: “There needs to be a system-wide change: people need to get the care they need in the community… so they do not need to attend A&E unnecessarily,.."
    Dr Katherine Henderson, the president of the Royal College of Emergency Medicine, said: “As well as more patients coming to emergency departments due to a lack of accessible alternatives, there are fewer and fewer staffed beds in hospitals to admit sick patients to, which results in long waits for patients and overcrowded emergency departments. It is little wonder just over half of urgent and emergency services are rated as needing to improve.”
    Read full story
    Source: The Guardian, 15 October 2019
  23. Patient Safety Learning
    Only 15% of healthcare apps meet minimum safety standards, highlighting a “desperate need” for a proper review process, new research has concluded.
    Health app evaluation organisation ORCHA evaluated more than 5,000 apps against 260 performance and compliance factors and found that majority do not meet the minimum safety requirements.
    Liz Ashall-Payne, ORCHA’s Chief Executive, said: “We believe that digital health apps are one of the most important tools available to help tackle health issues in an ageing population that’s facing more complex, long-term problems. The fact that only 15% of apps that we review meet the minimum standards show there is a desperate need to regularly and properly assess the apps available to ensure that people are protected against the serious risks associated with downloading ineffective or even harmful apps.”
    Helen Hughes, Chief Executive of Patient Safety Learning, which is working with ORCHA to improve the safety of apps, said the research reiterated the need for consistent regulatory standards and accreditation frameworks to be applied to healthcare apps.
    “One of the areas we are beginning to explore with ORCHA is whether or not we can consider what patient safety would be in part of the review process,” she said. “Essentially what we want is patient safety embedded in all of the review processes so that we can inform and guide clinicians and inform and guide patients."
    “And that there is appropriate research on their use and their impact so that information can feed the improvement of standards.”
    Read full story
    Source: Digital Health. 9 October 2019
     
  24. Patient Safety Learning
    A Bill to fully establish the Healthcare Safety Investigation Branch (HSIB) as an arm’s-length body has been one of 26 proposed bills announced in the Queen’s speech at the State Opening of Parliament.
    The Queen announced: “New laws will be taken forward to help implement the National Health Service’s long-term plan in England and to establish an independent body to investigate serious healthcare incidents.”
    Keith Conradi, HSIB Chief Investigator, said: “This announcement marks the start of a significant change to our organisation that will result in us becoming an independent statutory body with significant legal powers.
    The legislation will prohibit the disclosure of information held by the investigations body, except in limited circumstances. This will allow participants to be candid in the information they provide and ensure thorough investigations.
    The Bill will also improve the quality and effectiveness of local investigations by developing standards and providing advice, guidance and training to organisations.
    There will also be a pledge to update the Mental Health Act to reduce the number of detentions made under the act.
    Read Queen's speech in full
    Read HSIB's response
  25. Patient Safety Learning
    Prisoners are at risk of being transferred without crucial medication, according to the latest Healthcare Safety Investigation Branch (HSIB) report.
    The report reveals errors and delays in the prison healthcare system. The investigation looks into the case study of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison.
    Each day around 120 prisoners with ongoing medication needs are moved between jails. Martin’s case is just one example of a serious outcome when medication was missed. Prisoners may also need to be treated in the community at local hospitals, with prison security staff being taken away from planned duties to accompany them.
    Dr Lesley Kay, Deputy Medical Director at HSIB and a Consultant Rheumatologist, has experience of working with prisoners that have long-term conditions: “I have seen first-hand the impact that the lack of medication management can have on patients, particularly when they have long-term conditions. This also places additional pressure on an already stretched NHS and prison service.
    “With over 2,400 transfers a month where medication is needed, we recognise how busy prison healthcare staff are and how challenging it is to get medication to the right place at the right time. We know that the system needs to be better and the recommendations we have made are aimed at making the whole process smoother and safer for everyone.”
    Read story and full report
    Source: HSIB, 10 October 2019

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