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Patient Safety Learning

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  1. Patient Safety Learning
    Prosecutions and other criminal enforcement actions against unsafe care homes and NHS hospitals have risen a third in a year, amid warnings of a growing crisis. Charities said older people were being put at risk by “a broken social care system and an overstretched NHS” as they urged ministers to act. Official figures show that last year, watch dogs enforced 211 criminal enforcement actions against failing providers - a rise from 159 the year before. The statistics from the Care Quality Commission, covering prosecutions, cautions and fixed penalty notices, come along side a sharp rise in civil actions taken against providers. There were 906 such cases in 2018/19, compared with 781 the year before. 
    Caroline Abrahams, Charity Director at Age UK, said: “The fact that the CQC felt the need to use their enforcement powers a lot more often last year than the year before is a worry, and given all we know about the pressures in the system it is hard to avoid the conclusion that this reflects an overall decline in care standards, as providers struggle to make ends meet and the temptation to cut corners in terms of quality and safety inexorably grows.”
    Read full story
    Source: The Telegraph, 26 July 2019
  2. Patient Safety Learning
    The response to physician burnout often overlooks a potentially life-threatening condition, major depressive disorder (MDD), researchers in the US found.
    Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published last year found that burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism and lower patient satisfaction. In fact, researchers estimate that a physician commits suicide every day.
    In an article published this month in JAMA Psychiatry, a trio of physicians led by Maria Oquendo of the University of Pennsylvania's Perelman School of Medicine in Philadelphia, wrote that the widespread focus on burnout could lead to missed diagnoses of serious mental illnesses among clinicians.
    Symptoms of burnout such as exhaustion overlap with symptoms of MDD, and signs of MDD in clinicians should prompt a thorough psychiatric evaluation.
    Read full story
    Source: MEDPAGE Today, 28 July 2019
  3. Patient Safety Learning
    Almost half (47%) of patients with cancer do not think that they have been sufficiently involved in deciding which treatment option is best for them, a new survey shows. The survey of nearly 4000 patients across 10 countries also found that around four in 10 (39%) said that they were never or only sometimes given enough support to deal with symptoms and side effects.
    Read full story (paywalled)
    Source: BMJ, 25 July 2019
  4. Patient Safety Learning
    An independent investigation is to be launched into a deadly outbreak of an infection which has claimed 13 lives in Essex. The Mid Essex Clinical Commissioning Group (CCG) has called in a team to probe the spread of the invasive Group A Streptococcus (iGAS) bacterium. The strain has been linked to at least 31 confirmed cases, including the 13 fatalities. The investigation will take about six months and results "will be shared and implemented," said the CCG. It has been ordered through the NHS Serious Incident Framework.
    Read full story
    Source: BBC News, 25 July 2019
  5. Patient Safety Learning
    A deceased NHS consultant could have been charged with manslaughter over the deaths of haemophiliac patients given blood infected with HIV and hepatitis C, a lawyer for families has claimed. Des Collins said the reputation of Prof Arthur Bloom "cannot remain intact". The role of Prof Bloom has been mentioned by families of a number of victims giving evidence to the ongoing contaminated blood inquiry in Cardiff. 
    Cardiff and Vale University Health Board said it was co-operating fully with the inquiry. It added: "We cannot comment on historical allegations at this stage and will await the findings of the inquiry and then take any necessary steps. "We are committed to an open and transparent approach and have been working with Haemophilia Wales to support patients and families who are likely to be involved in the inquiry."
    Read full story
    Source: BBC News, 26 July 2019
  6. Patient Safety Learning
    Unlike many research lab, the Surgical Simulation Research Lab (SSRL) at the University of Alberta in Canada  is focusing on healthcare providers; specifically, they aim to know capacities and limitations of physicians and surgeons, and design a system to support them. 
    "Our goal is to create a simulation system for young physicians and surgeons to practice surgical skills without harming the patient..." said Bin Zheng, Associate Professor and the Director of SSRL. "This includes a better simulation programme for their skills training. We do everything to create a simulation model to replace patients being used as a training model".
    Read full story
    Source: Xinhua News, 21 July 2019
  7. Patient Safety Learning
    Hundreds of patients, including children, dependent on intravenous nutrition to keep them alive are experiencing delays in vital deliveries, because of restrictions placed on the manufacturer by the MHRA. Clinicians warn patients may need to be admitted to hospital, rather than stay at home, if delays continue.
    Read full story (paywalled)
    Source: HSJ, 23 July 2019
  8. Patient Safety Learning
    A type of anaesthetic machine that has been used in NHS hospitals can be hacked and controlled from afar if left accessible on a hospital computer network, says CyberMDX, a cyber-security company. For example, a successful attacker would be able to change the amount of anaesthetic delivered to a patient or alarms designed to alert anaesthetists to any danger could be silenced.
    GE Healthcare, which makes the machines, said there was no "direct patient risk". But CyberMDX's research suggested the Aespire and Aestiva 7100 and 7900 devices could be targeted by hackers if left accessible on hospital computer networks.
    Read full story
    Source: BBC News, 10 July 2019
  9. Patient Safety Learning
    GPs’ receptionists will divert patients to see pharmacists in a bid to relieve pressure on family doctors. The NHS plan aims to prevent 20 million GP appointments, with many of those telephoning for help instead offered a "same day” slot at a local chemist. Health officials said the moves would mean more accessible and convenient access to services. But patients’ groups said the measures were “worrying”, with fears that critical decisions could end up being taken by those with little training in how to assess patients. 
    From October, those calling 111 will be offered appointments at their local pharmacists if call handlers believe they are suffering from a minor ailment. Meanwhile, the NHS will pilot the same system for patients trying to make a GP appointment - with hopes to introduce the system nationally within nine months. 
    Health Secretary Matt Hancock said the moves were similar to “the French model” where pharmacists have a stronger role providing healthcare. Officials said the plans may be extended still further, to divert patients attempting to seek help from Accident & Emergency departments. 
    The changes are part of a five-year contract with pharmacists. 
    Read full story
    Source: The Telegraph, 22 July 2019
  10. Patient Safety Learning
    UK babies are missing out on checks for rare but serious health conditions, putting lives at risk, according to a report from the charity Genetic Alliance UK. The NHS offers newborns a blood test to screen for up to nine conditions, whereas many other European countries look for 20 or more illnesses and the US screens for more than 50, the charity says. 
    The UK National Screening Committee says its recommendations are based on evidence and are regularly reviewed. It is up to the governments in England, Scotland, Wales and Northern Ireland to decide which tests to provide. Genetic Alliance UK says affordable ways to expand the screening exist, but are not being used.
    Read full story
    Source: BBC News, 23 July 2019
  11. Patient Safety Learning
    Hospital admissions for sepsis in England have more than doubled in three years, according to new figures that shows a rise in recorded admissions among all age groups, including the very young.
    The NHS Digital data shows there were 350,344 recorded hospital admissions with a first or second diagnosis of sepsis in 2017/18, up from 169,125 three years earlier. This includes 38,401 admissions among those aged four years and under, up from 30,981 in 2015/16. For all children and young people aged 24 years and under, there were 48,647 admissions in 2017/18.
    Dr Ron Daniels, Chief Executive of the UK Sepsis Trust, and Patient Safety Learning topic leader, said the scale of the problem in children looks “alarming”, adding: “What this means is that parents need to continue to be aware of meningitis, but to arguably be even more aware of sepsis as it affects far more children and can be equally deadly.” He said: “These potentially alarming data show that the number of recorded episodes of sepsis has more than doubled in just three years, a period coinciding with the recent focus on sepsis by the NHS in England."
    Read full story
    Source: Mirror, 22 July 2019
  13. Patient Safety Learning
    NHS England together with Ipsos MORI, have published the latest Official Statistics from the GP Patient Survey. The survey provides information on patients’ overall experience of primary care services and their overall experience of accessing these services.
    Read results of the survey
  15. Patient Safety Learning
    The Professional Records Standard Body (PRSB) has published a new standard for shared care records that determines the vital information about a person that should be shared between health and care systems so care is safer, timely and more effective. Working with NHS England, the PRSB has asked citizens and health and care professionals to help produce a ‘core information standard’ that defines exactly what information should be shared in a person’s care record throughout their life. 
    Read full story
    Source: PRSB, 17 July 2019
  16. Patient Safety Learning
    The parents of Claire Roberts said those responsible for their daughter's care should "hang their heads in shame". Alan and Jennifer Roberts were speaking after an inquest found that the nine-year-old's death in October 1996 was caused by the treatment she received in hospital. Outside Laganside courthouse, Mr and Mrs Roberts welcomed the coroner's findings but said the public can have "no confidence in patient safety" in Northern Ireland. 
    Mr Roberts said that after a two decade wait the inquest had finally delivered the truth about how their daughter died. "We would like to thank the coroner for reaching a verdict after 22 years of cover-up that finally identifies the truth. The coroner has confirmed an unnatural cause of death. We have known as a family since 2004 the true cause of death - this has not been news to us but the coroner reaffirming what we have always known."
    Mr Roberts also issued a demand to health officials for accountability, saying those responsible for failings in his daughter's care should "hang your heads in shame."
    Source: Belfast Telegraph
  17. Patient Safety Learning
    NHS bosses have been accused of “burying” a damning report into child cancer services commissioned following complaints that patients were “dying in agony”. Completed in 2015, the document highlights failings at the Royal Marsden NHS Foundation Trust, one of the UK’s flagship cancer organisations. It found that, despite being supposedly a centre of excellence, children admitted for cancer treatment were routinely transferred between hospitals to get the care they needed.
    Compiled by Professor Mike Stephens, the report was commissioned after a coroner found “astonishing” failures in the care of a two-year-old girl, Alice Mason, leading to her suffering irreversible brain damage and dying in 2011. It recommended a radical shake-up of the Marsden’s services. The document was never made public, however, and former NHS medical director for London, Dr Andy Mitchell, accused the head of NHS England, Simon Stevens, and Cally Palmer, England’s National Cancer Director and Chief Executive of the Royal Marsden, of suppressing its publication.
    Dr Mitchell told the Health Service Journal (HJS): “I can’t imagine any other individuals having the power and influence to be able to stop this report moving forward.”
    NHS England has denied that its then Medical Director, Sir Bruce Keogh, was improperly leaned on and said the report remained unpublished because it made “implausible suggestions” which would have forced children with cancer to travel further for care. But Gareth Mason, Alice’s father, said: “To write a report, shelve it and not debate it, that is a cover-up [and] it has left children since Alice and danger, and the Marsden won’t acknowledge that.”
    The controversy surrounds the performance of a so-called “shared care system”, with the Marsden’s Sutton site forming part of a network for South London, Surrey, Sussex and Kent.
    Critics say the format meant children were transferred between sites more regularly than they should have been and were put in danger because information was not properly shared.
    Read full story
    Source: The Telegraph, 19 June 2019  
  18. Patient Safety Learning
    Nearly half of care workers in care homes have been both physically and verbally abused by the residents they are supporting, according to new research.
    A poll of 2,803 staff working in care homes revealed 17% have received verbal abuse from residents and 11% have been subject to physical abuse.
    A spokesperson for carehome.co.uk, said: “All over the UK, care workers are doing physically and emotionally demanding jobs on often low pay and long hours. Yet at the same time, the rewards of working in a care home can be huge, as you can build strong relationships with the people you care for and make deep, emotional connections."
    “Lashing out at staff is often a sign of frustration and it is vital care homes give staff dementia training so they can find the reasons behind this challenging behaviour. Care workers do such an important job and with around three-quarters of people in care homes having dementia, it is vital care workers are given adequate support and specialist training to care for them.”
    Read full story
    Source: Carehome.co.uk, 10 May 2019
  19. Patient Safety Learning
    Regina Stepherson needed surgery for rectocele, a prolapse of the wall between the rectum and the vagina. Her surgeons said that her bladder also needed to be lifted and did so with vaginal mesh, a surgical mesh used to reinforce the bladder.
    Following the surgery in 2010, Stepherson, then 48. said she suffered debilitating symptoms for two years. An active woman who rode horses, Stepherson said she had constant pain, trouble walking, fevers off and on, weight loss, nausea and lethargy after the surgery. She spent days sitting on the couch, she said.
    In August 2012, Stepherson and her daughter saw an ad relating to vaginal mesh that mentioned 10 symptoms and said that if you had them, to call a lawyer.
    Vaginal mesh, used to repair and improve weakened pelvic tissues, is implanted in the vaginal wall. It was initially — in 1998 — thought to be a safe and easy solution for women suffering from stress urinary incontinence.
    But over time, complications were reported, including chronic inflammation, and mesh that shrinks and becomes encased in scar tissue causing pain, infection and protrusion through the vaginal wall.
    More than 100,000 lawsuits have been filed against makers of mesh, according to ConsumerSafety.org, making it “one of the largest mass torts in history.”
    Read full story
    Source: Washington Post, 20 January 2019
  20. Patient Safety Learning
    An unfortunate series of events involving a magnetic resonance imaging (MRI) machine led to the death of a man at a hospital in India.
    Rajesh Maruti Maru, a 32-year-old, was thrust into the MRI machine  while he was visiting an elderly relative at the BYL Nair Charitable Hospital in Mumbai, India. As the Hindustan Times reports, the man was apparently told by a junior member of staff to carry a metal cylinder of liquid oxygen into a room containing an MRI machine.
    Unbeknownst to everyone, the MRI machine was turned on. This caused Maru to be suddenly jolted pulled towards the machine, causing the oxygen tank to rupture and leak. The man later died after inhaling large amounts of oxygen. His body also bled heavily as a result of the accident.
    "When we [the hospital staff] told him that metallic things aren't allowed inside an MRI room, he said 'sab chalta hai, hamara roz ka kaam hai' [it's fine, we do it every day]. He also said that the machine was switched off. The doctor, as well as the technician, didn't say anything,” Harish Solanki, Maru's relative, told NDTV.
    "It's because of their carelessness that Rajesh died," Solanki added.
    Police are currently examining the CCTV footage of the incident and have arrested at least two members of hospital staff for the negligence. The local government has also awarded the man's family 500,000 rupees ($7,855) in compensation.
    Read full story
    Source: IFL Science, 29 January 2018
  21. Patient Safety Learning
    A public inquiry will be held to examine safety and wellbeing issues at the new children's hospital in Edinburgh and the Queen Elizabeth University Hospital in Glasgow. The inquiry will determine how vital issues relating to ventilation and other key building systems occurred. It will also look at how to avoid mistakes in future projects.
    In January, it was confirmed two patients had died after contracting a fungal infection caused by pigeon droppings at the Queen Elizabeth University Hospital. Health Secretary Jeane Freeman later ordered a review of the design of the building and said there was an "absolute focus on patient safety". 
    Meanwhile, the new £150m Royal Hospital for Children and Young People in Edinburgh has been dogged by delays over health concerns. The hospital was supposed to open in 2017 - but will now not be ready until next autumn at the earliest - after problems with the specification of the ventilation system.
    Scottish Labour's Monica Lennon said the inquiry was "the only way to get to the bottom of this outrageous series of errors". She added: "Children in Scotland are being let down because the hospitals they were promised are not fit for purpose. We have two hospitals built by the same contractor that are mired in controversy, and all the while patients are suffering. The public need to know the truth of what has gone so badly wrong at these two vital hospitals."
    Read full story
    Source: BBC News, 17 September 2019
  22. Patient Safety Learning
    Suspended Belfast neurologist Michael Watt has offered his "sincere sympathy" to those affected by Northern Ireland's biggest patient recall.
    Dr Michael Watt worked at the Royal Victoria Hospital as a neurologist diagnosing conditions like epilepsy and Parkinson's Disease. He was suspended after 3,000 patients were given recall appointments last year.
    Dr Watt said he recognised the "distress these events have caused".
    On Tuesday, a BBC Spotlight investigation found that he had carried out hundreds of unnecessary procedures on patients.
    The programme also obtained details of a Department of Health report, as yet unpublished, that said one-in-five patients of the consultant neurologist were misdiagnosed.
    Read full story
    Source: BBC News, 22 November 2019
  23. Patient Safety Learning
    A hospital for men with learning disabilities has been placed in special measures after the Care Quality Commission (CQC) identified “serious risks to patient safety”.
    The CQC said it had also suspended its current rating of “good” for caring for Cygnet Woodside, Bradford, West Yorkshire, following an inspection in September.
    The commission said it carried out the unannounced inspection following allegations of abuse by staff towards a patient, which are subject to an ongoing police investigation.
    The hospital said it was “disappointed” with the CQC’s assessment, stressing that the inspection was triggered by its own management notifying the commission of a concern it had identified. It said the report “does not provide an entirely accurate representation” of the hospital.
    Dr Kevin Cleary, the CQC deputy chief inspector of hospitals and lead for mental health, said: “Our latest inspection of Cygnet Woodside found that the hospital was not ensuring its patients’ safety.”
    Cleary added: “The service showed warning signs that increased the likelihood of a closed culture developing. This would have put people at serious risk of coming to harm if we didn’t take action.”
    He said care was compromised because there was not always the right number or skill level of staff looking after patients.
    Read full story
    Source: Guardian, 23 December 2020
  24. Patient Safety Learning
    Long Covid is no respecter of youth, health or fitness. It afflicts more women than men but it can strike anyone down, including people whose initial infection seemed mild, or even asymptomatic. In some cases, long Covid could mean lifelong Covid.
    The effects can be horrible. Among them are lung damage, heart damage and brain damage that can cause memory loss and brain fog, kidney damage, severe headaches, muscle and joint pain, loss of taste and smell, anxiety, depression and, above all, fatigue. We should all fear the lasting consequences of this pandemic.
    Long Covid is shorthand for a range of conditions. Some scientists divide them into three broad categories, others into four. Of these, one seems to ring a bell. It’s a cluster of symptoms that bear a strong similarity to myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS). This is a devastating condition that affects roughly a quarter of a million people in the UK, and is often caused, like long Covid, by viral infection.
    Among the common symptoms of ME/CFS are extreme fatigue that is not relieved by rest, and “post-exertional malaise”: even mild physical or mental effort can make patients extremely unwell. Many sufferers are confined to their home or even their bed, with their working life, social life and family life truncated. There is, so far, no diagnostic test and no cure.
    Yet ME/CFS has been disgracefully neglected by science and medicine. 
    The NHS is now setting up specialist clinics to treat long Covid. But already, apparent mistakes are being made. Without the necessary caveats, the NHS recommends steadily increasing levels of exercise for people suffering from post-Covid fatigue. But as ME/CFS patients with post-exertional malaise know, this prescription, though it sounds intuitive, could be highly damaging.
    We need massive research programmes into both long Covid and ME/CFS, coupled with better information for doctors. 
    Read full story
    Source: The Guardian, 21 January 2021
  25. Patient Safety Learning
    Patients being assessed remotely in general practice, rather than face-to-face, has been raised as a risk in reports on five deaths by a single coroner since the pandemic hit.
    Senior coroner for Greater Manchester Alison Mutch has written five prevention of future deaths reports highlighting concerns that doctors were missing details in telephone appointments which may have been spotted, had the patient been seen in person. The reports cover a variety of conditions, including covid, a broken femur, and anxiety and depression.
    In March 2020, NHS England guidance instructed GPs to adopt a “total triage” approach, where face-to-face appointments should generally only follow a phone, video or digital consultation. But, in May, NHSE wrote to GPs to ask them to “ensure they are offering face to face appointments”, adding remote appointments “should be done alongside a clear offer of appointments in person”.
    There have been growing calls in the media for increased face-to-face appointments, while, in March 2021, a report by Healthwatch concluded: “While telephone appointments are convenient for some, others are worried that their health issues will not be accurately diagnosed.”
    Maureen Baker, former chair of the Royal College of GPs and Patient Safety Learning trustee told HSJ she was “not aware pre-pandemic of any major concerns with remote consulting”, adding: “It’s not that things don’t go wrong. They do, but things can and do go wrong in face-to-face consultations as well.”
    “Many practices have been using remote consulting very successfully for many years [but for GPs introducing remote consultations during the pandemic] the concern is that practices will have had to change and implement it very quickly.”
    Read full story (paywalled)
    Source: HSJ, 9 September 2021
    You may also be interested in a recent blog from Trish Greenhalgh: 'Why remote consultation with a doctor is difficult – and how it can be improved'

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