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  1. Patient Safety Learning
    An orthopaedic surgeon falsified records and lied to a patient after he performed the wrong operation on her. 
    Alan Norrish admitted performing the wrong type of partial knee replacement on his patient in January 2018 at the Nuffield Hospital in Cambridge. Having realised his mistake the former Addenbrooke's consultant tried to cover it up by falsifying records and doing "revision" surgery six days later.
    Mr Norrish has been suspended for a year following a medical tribunal. He told the hearing of the Medical Practitioners Tribunal Service (MPTS) he was "shocked" and "upset" when he realised his mistake. It was found he had lied in a letter to a hospital matron about the reason for the second operation, which was carried out on 25 January 2018.
    Read full story
    Source: BBC News, 30 August 2019
  2. Patient Safety Learning
    Hospital patients’ safety is being put at risk by fires, floods and crumbling, overcrowded buildings caused by a £4 billion government squeeze on capital funding, NHS bosses are warning.
    Hospitals say they do not have the funding to replace outdated scanners, fix leaking roofs and boilers, or remove ligature points that suicidal patients may attempt to use to try to end their lives.
    Four out of five (82%) chief executives and chief finance officers at NHS trusts in England fear the lack of capital funding poses a medium or high risk to patient safety.
    Read full story
    Source: Guardian, 30 August 2019
  3. Patient Safety Learning
    A small number of babies at a Belfast hospital have been found to have pseudomonas on their skin. The infants involved were being treated in the neonatal unit of the Royal Jubilee Maternity Service. Although the bacteria was found on their skin, it does not mean the babies were infected. Staff have put in place infection prevention measures and carried out a deep clean of the unit.
    A spokesperson for the Belfast Health Trust said while the issue was unfortunate it wanted to reassure patients, their families and the public that the situation was being managed appropriately.
    Read full story
    Source: BBC News, 29 August 2019
  4. Patient Safety Learning
    An NHS children’s mental health unit has been closed down by the Care Quality Commission after being rated “inadequate” last week.
    A child and adolescent mental health ward run by Tees, Esk and Wear Valley’s Foundation Trust has been closed after the CQC took enforcement action to protect the safety of patients.
    In a statement today, a CQC spokesman said: ”[We have] taken urgent enforcement action at Tees, Esk and Wear Valley’s Foundation Trust which will lead to the closure of the child and adolescent mental health service units at West Lane Hospital. The Holly unit at West Park Hospital and Baysdale Unit at Roseberry Park are unaffected. The action follows continued concerns identified at earlier inspections in June and August, and the recent inspection on 20 and 21 August 2019."
    Read full story (paywalled)
    Source: HSJ, 23 August 2019
  5. Patient Safety Learning
    A cardiologist has been struck off the UK medical register after he failed to check a patient’s medical notes before surgery, implanted the wrong type of pacemaker, and then destroyed the notes specifying the correct type.
    Amer Chit, a locum consultant cardiologist at Royal Cornwall Hospitals NHS Trust, admitted to a trust investigation that, before implanting the pacemaker, he had looked at the operating list but not at the patient’s medical notes.
    Read full story (paywalled)
    Source: BMJ, 23 August 2019
  7. Patient Safety Learning
    A mental health unit for young people where two girls died in two months is not safe. The Care Quality Commission (CQC) rated West Lane Hospital in Middlesbrough inadequate and said patients were at high risk of "avoidable harm". It found staff did not store medicines safely, out-of-date medicines were still in use, and staff used non-approved restraint techniques.
    Tees, Esk and Wear Valleys NHS Trust said it was taking "urgent action".
    The inspection in June uncovered a catalogue of failings, including "substantial and frequent staff shortages" and employees not always "adequately assessing, monitoring or managing risks to patients".
    The report said staff did not feel supported or valued, with morale low, and some told inspectors not all incidents were reported.
    CQC report
    Read full story
    Source: BBC News, 21 August 2019
  8. Patient Safety Learning
    Morale among community nurses is low and many are leaving the service due to stress and an increased workload, a report has claimed.
    The report from a Welsh assembly committee said the changing nature of healthcare, in particular the move to provide more help in the home and the ageing population, made the role of community nurses increasingly important. But it said many community nurses feel they do not get the support they need and some see themselves as the “invisible service”.
    One of the biggest issues raised by nurses in Wales during a committee inquiry was their inability to access to technology to enable them to do their job effectively.
    Read full story
    Source: The Guardian, 21 August 2019
  9. Patient Safety Learning
    Action to help tens of thousands more people avoid lengthy spells in hospital is being rolled out nationwide as part of the NHS Long Term Plan.
    NHS doctors, nurses and other staff are being encouraged to ask themselves ‘Why not home? Why not today?’ when planning care for patients recovering from an operation or illness, as part of a campaign – called ‘Where Best Next?’ – which aims to see around 140,000 people every year spared a hospital stay of three weeks or more.
    The campaign will see posters and other information placed in hospitals aimed at different staff groups, encouraging them to take practical steps every day to help get patients closer to a safe discharge – whether to their own home or a more suitable alternative in the community.
    Dr Taj Hassan, President of the Royal College of Emergency Medicine, said: “The ‘Why not home? Why not today?’ campaign is really important in helping staff to make sure patients are discharged promptly if it is medically appropriate... A greater length of stay increases the risk of hospital acquired infections and further illness. We know that extended stays in a hospital bed can lead to significant muscle loss, particularly in older people, so ensuring that patients do not stay any longer than they need really is vital."
    Read full story
    Source: NHS England, 19 August 2019
  10. Patient Safety Learning
    Frontline staff are well placed to identify failings in care, but speaking up requires a supportive organisational culture to be effective, say Russell Mannion and Huw Davies in a recent analysis published in the BMJ.
    Concerns about care are raised and ignored, staff are denigrated or bullied, the situation escalates into whistleblowing to outside authorities, and eventually, often years later, a formal inquiry is set up to get to the bottom of things. The long line of inquiries in the UK and elsewhere highlights the sentinel role of staff “speaking up” when they see unsafe or poor quality care.  But exhortations to speak up (encapsulated by the statutory duty of candour introduced in the NHS after the Francis inquiries into failures at Mid Staffordshire NHS Trust) belie the complexity and ambiguity that it creates for staff.
    Read full story (paywalled)
    Source: BMJ, 19 August 2019
  12. Patient Safety Learning
    A new study published in the Canadian Medical Association Journal has found that patients who suffered harm after being admitted in an Ontario hospital took longer to recover, spent more time in hospital, and required more healthcare to undo or mitigate the harm.
    Tessier et al. studied the records of 610,979 patients admitted to Ontario hospitals over a one-year period ending in March 2016. Overall, 36,004 or six per cent of the patients were harmed during their hospital stay. As part of the study, the researchers categorised the kinds of harms experienced by patients. Just over half suffered harm due improper treatment. This included failing to make the correct diagnosis or making an incorrect diagnosis that led to incorrect treatment and harm caused by medications. 
    The second biggest category (37%) was harm caused by an infection acquired during the hospital stay. The third leading cause (27.3%) was harm caused by a procedure, and the fourth (2.7%) was harm brought on by accidents such as falling off a hospital stretcher.
    The current study is one of the first to use a new method that enables researchers to capture all of the care the patient received during their stay in hospital and following discharge from hospital, including home care.
    In a commentary published alongside the study, Dr. Lauren Lapointe-Shaw and Dr. Chaim Bell wrote that reported rates of adverse events are widely considered to be the proverbial "tip of the iceberg."
    Read full story
    Source: CBC Radio Canada. 12 August 2019
  13. Patient Safety Learning
    In a major nationwide push to tackle sepsis, including a one hour identification and treatment ambition, new ‘alert and action’ technology is being introduced which uses algorithms to read patients’ vital signs and alert medics to worsening conditions that are a warning sign of sepsis.
    Three leading hospitals are using alerts to help identify sepsis and tell doctors when patients with the serious condition are getting worse, ahead of the measures being rolled out across England as part of the NHS Long Term Plan. 
    In Liverpool, the hospital’s digital system brings together lab results and patient observations into one place to help staff diagnose and treat suspected sepsis, saving up to 200 lives a year. In Cambridge, deaths from sepsis have fallen consistently over the last three years, with at least 64 lives saved in the past year thanks to the innovative alert and action feature. In Berkshire since introducing a digital system, the Trust has increased screening rates by 70% with nine in 10 patients now consistently screened for sepsis during admission as opposed to two in ten beforehand, allowing doctors to spot more cases sooner.
    The schemes are part of a national effort to push best practice and new technology across the NHS, to help hospitals learn from the success of others and spread use of the best technology further, faster.
    Dr Ron Daniels BEM, CEO of the UK Sepsis Trust, and the hub's topic leader, said: “Any kind of technology which assists clinicians in making prompt decisions when the warning signs of sepsis are detected should be embraced; with every hour that passes before the right antibiotics are administered the risk of death increases".
    Read full story
    Source: NHS England, 18 August 2019
  14. Patient Safety Learning
    A review of NHS health checks, which will look at tailoring checks based on risk and increasing the range of checks offered, must involve a “rigorous evaluation” to ensure they are safe, accurate and of benefit to patients, GPs have warned. The Department of Health and Social Care announced the review in the prevention green paper last month and has now fleshed out its scope.
    It says it will consider including additional checks to prevent musculoskeletal problems and hearing loss, as well as how the checks can be digitised and tailored so people are offered “personalised interventions” based on risk, location, predisposition to diseases and their DNA.
    While some experts welcomed the more targeted approach, others said the current scheme still needs to be evaluated for cost effectiveness and questioned how GPs will take on the extra work.
    Read full story (paywalled)
    Source: BMJ, 16 August 2019
  15. Patient Safety Learning
    Private hospitals may have made more than £3 million from the actions of the disgraced breast surgeon Ian Paterson, a think tank has claimed.
    Paterson was jailed in 2017 for carrying out unnecessary surgery on ten patients in private hospitals. However, it is believed he harmed about 750 patients, many of whom he wrongly led to believe they had cancer. He was paid each time he operated but the private hospitals would have received a separate payment for each operation, the Centre for Health and the Public Interest (CHPI) said. 
    CHPI wants the inquiry set up by the government into Paterson’s actions to examine the financial incentives that could affect how private hospitals treat patients. David Rowland, director of CHPI, said: “The current financial incentives to over-treat patients weigh heavily against the weak measures which are in place to protect patients.”
    Read full story (paywalled)
    Source: The Times, 19 August 2019
  16. Patient Safety Learning
    Twenty UK women are taking legal action after developing a rare form of cancer linked to their breast implants. More than 50 women have been diagnosed with the same condition in the UK, and hundreds more worldwide. A top surgeon said there were gaps in implant information and people were almost being "used as guinea pigs".
    One manufacturer has issued a worldwide recall of some textured implants, which have been linked to most cases of breast implant-associated lymphoma. The Medicines and Healthcare products Regulatory Agency (MHRA), which regulates medical devices in the UK, is currently collecting data on women affected by breast implant associated-anaplastic large cell lymphoma (BIA-ALCL).
    Tens of thousands of breast implant surgeries are thought to take place each year in the UK, mostly in private clinics.
    Read full story
    Source: BBC News, 16 August 2019
  17. Patient Safety Learning
    Patients waiting for hip replacements are suffering pain "worse than death", a study by Edinburgh University suggests. The research recorded the health states of more than 2,000 people on waiting lists and found 19% were in extreme pain or discomfort.
    The level is so poor it is defined by experts as "worse than death" - more painful than chronic health conditions such as diabetes, heart failure or lung diseases. Scientists who used the internationally approved EQ-5D measurement said the findings disprove perceptions that hip and knee arthritis only causes mild discomfort. Earlier this year research found that four in 10 clinical commissioning groups in England are rationing hip and knee operations.
    The Royal College of Surgeons has described the restrictions are “alarming” and “arbitrary”.
    Read full story
    Source: The Telegraph, 15 August 2019
  18. Patient Safety Learning
    A mobile phone app has speeded up the detection of a potentially fatal kidney condition in hospital patients. Acute kidney injury is caused by serious health conditions, including sepsis, and affects one in five people admitted to hospital. It accounts for around 100,000 deaths every year in the UK.
    During a trial at London's Royal Free Hospital, doctors and nurses received warning signals via a mobile phone app in an average of 14 minutes, when patients' blood tests indicated the condition. The new alerting system, known as Streams, developed by the Royal Free with technology firm DeepMind, sends results straight to front-line clinicians in the form of easy-to-read results and graphs.
    This could could save the NHS an average of £2,000 per patient by alerting clinicians to acute kidney injury sooner. However, although the findings, published in the journal Nature Digital Medicine, led to earlier recognition, it did not lead to any improvements in the primary outcome measure (renal recovery) or in secondary outcomes, which included survival, length of stay in hospital, and admission to the intensive care unit.
    Read full story
    Source: BBC News, 1 August 2019
  19. Patient Safety Learning
    Burnout is an occupational phenomenon and we need to look beyond the individual to find effective solutions, argue Montgomery and colleagues in a recent BMJ article 
    Burnout has become a big concern within healthcare and is associated with sleep deprivation, medical errors, poor quality of care and low ratings of patient satisfaction. Yet often initiatives to tackle burnout are focused on individuals rather than taking a systems approach to the problem. Evidence on the association of burnout with objective indicators of performance (as opposed to self report) is scarce in all occupations, including healthcare. But the few examples of studies using objective indicators of patient safety at a system level confirm the association between burnout and suboptimal care.
    Read full article (paywalled)
    Source: BMJ, 30 July 2019
  20. Patient Safety Learning
    About three quarters of GPs and hospital consultants have cut or are planning to cut their hours because of the doctors’ pensions crisis. About 42% of family doctors and 30 % of consultants have reduced their working times already, claiming that they are being financially penalised the more they work. A further 34% and 40 per cent respectively have confirmed that they plan to reduce their hours in the coming months because they fear losing out, according to a survey of more than 6,000 doctors by the British Medical Association.
    The government has launched an urgent consultation over the issue, which is the result of changes to pension rules limiting the amount that those earning £110,000 or more can pay into their pensions before they are hit with a large tax bill.
    Read full story (paywalled)
    Source: The Times, 1 August 2019
  21. Patient Safety Learning
    NHS Improvement's revised expectations of boards and board members in relation to Freedom to Speak Up plus supplementary resources and a self-review tool. 
    Effective speaking up arrangements protect patients and improve the experience of NHS workers. NHS Improvement's guide contributes to the need, set out by Sir Robert Francis in his Freedom to Speak Up review, to develop a more open and supportive culture that encourages staff to speak up about any issues of patient care, quality or safety.
    The importance of workers having the freedom to speak up and the role that executive directors play in this has been recently reaffirmed in the review of Liverpool Community Health NHS Trust, the Kark Report and the interim NHS People Plan. 
    Read full story
    Source: NHS Improvement, 31 July 2019
  22. Patient Safety Learning
    Junior doctors have won a court case against a hospital trust over rest breaks which could have far-reaching implications for the NHS. The 21 doctors said Derby Hospitals NHS Foundation Trust failed to make sure they either took proper breaks or were paid extra for working. Lord Justice Bean said the trust's method of calculating breaks was "irrational" and a breach of contract.
    Read full story (paywalled)
    Source: HSJ, 31 July 2019

  23. Patient Safety Learning
    Croydon Health Services NHS Trust has rolled out an app from Ryalto designed to improve the working and professional lives of its healthcare staff. Croydon NHS Trust is now offering all of its 3,800 workers access to Ryalto – a platform that enables healthcare professionals to manage their working day and acts as a safe and singular source of communication for all employees. Secretary of State for Health and Social Care, Matt Hancock, was present at the launch, and talked about the positive impact apps can have on the way health care staff manage their working lives.
    Matthew Kershaw, interim CEO, Croydon Health Services NHS Trust, said: "The app is reflective of how we live our lives today – on mobiles, with flexibility and in real-time. It offers a key digital channel for us to communicate with each other instantly, through the chat and news feed features, increasing opportunities for engagement and fostering a closer working environment where we work together to provide the best care for our patients. 
    Read full story
    Source: Health Tech Digital
  24. Patient Safety Learning
    Hundreds of mothers-to-be have lost access to their midwives after a community service was forced to close. Women across the north-west of England and in Essex have been affected after One to One announced it was withdrawing the services it provided for the NHS. 
    One to One specialises in home births, which means some women may have to give birth in hospital against their wishes. A spokesman for the NHS said emergency protocols had been put in place and women affected would be contacted by a dedicated team. He said the "priority" was ensuring those affected were provided with support, but he said he could not guarantee that they would be able to have a home birth.
    Read full story
    Source: BBC News, 31 July 2019
  25. Patient Safety Learning
    For too long, medicine has been a cult that deifies workaholism and mocks those who “fuss” about sleep, say Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Head of Research and Development at University Hospital of Wales, and Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at the University of Alberta, Canada.  But we know that lack of sleep kills. Data have consistently shown how it kills slowly and silently by increasing the likelihood of cancer, heart disease, immunosuppression and weight gain. Poor sleep also kills suddenly and loudly through motor vehicle crashes and workplace trauma. More and better sleep is needed for all but the question is do we care enough to do the right thing? 
    Regardless of whether insomnia is limited to medicine or is, instead, a society wide issue, we can likely all agree that we need a cultural shift. This starts by senior folks speaking up and standing side by side with junior colleagues. We should not, cannot, and need not stand by as doctors work hours that we would never condone for pilots or bus drivers. Lessons must be heeded. Fortunately, these are lessons that we have known for decades. Patient safety matters, and so does practitioner safety. 
    Read full story
    Source: BMJ Opinion, 28 July 2019

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