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Patient Safety Learning

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  1. News Article
    Lawyers have begun legal action on behalf of 200 UK women against the makers of a sterilisation device, after claims of illness and pain. The device, a small coil called Essure, was implanted to prevent pregnancies. Manufacturer Bayer has already set aside more than $1.6bn (£1.2bn) to settle claims from almost 40,000 women in the US. It has withdrawn the device from the market for commercial reasons but says it stands by its safety and efficacy. The metal coil was inserted into the fallopian tube to cause scarring, blocking the tube and preventing pregnancy. Introduced in 2002, it was promoted as an easy, non-surgical procedure - a new era in sterilisation. But many women who had the device fitted have now either had hysterectomies or are waiting for procedures to remove the device. Tracey Pitcher, who lives in Hampshire, felt she had completed her family and did not want any more children. Her doctor strongly encouraged her to have an Essure device fitted, she says. But after it had been, she began to feel very unwell. "I just started to have heavy periods, migraines, which I had only ever had when I was pregnant so they were hormonal," she says. "My back was so painful I'd wake up crying in the middle of the night with pains in my hips and my back." Tracey says she battled to persuade doctors to take her symptoms seriously. But the only information she received was from a Facebook group. "... there's nobody there, there's no support apart from people that we've found ourselves, no-one will listen, because it's just 'women's things'." Read full story Source: BBC News, 15 November 2020
  2. Content Article
    "When good science is suppressed by the medical-political complex, people die." Kamran Abbasi believes politicians and governments are suppressing science. They do so in the public interest, they say, to accelerate availability of diagnostics and treatments. They do so to support innovation, to bring products to market at unprecedented speed. Both of these reasons are partly plausible, as Abbasi explores in this BMJ Editorial.
  3. Content Article
    The pandemic has challenged managers as never before, but one powerful leadership strategy is being overlooked, say Boris Groysberg and Susan Seligson in this blog for the Harvard Business School. Be kind.
  4. Content Article
    COVID-19 has disrupted many industries and reshaped the way most organisations operate. Healthcare organisations have been especially affected by the disruptive force of this global pandemic. Yet all hope is not lost. Gallup analytics discovered that business units experiencing disruption are at an increased advantage and more resilient than their peers when employee engagement is strong.
  5. Content Article
    Recording for the Session on Patient Safety held on 31 October as a part of the Global Indian Physician COVID-19 Collaborative.
  6. Content Article
    Presentation from Paul Bowie, Programme Director, NHS Education for Scotland on human factors and ergonomics.
  7. Content Article
    In medical schools, students seek robust and mandatory anti-racist training. Activists especially want to see their institutions recognise their own missteps, as well as the racism that has accompanied past medical achievements. Read Elizabeth Lawrence's article in the Washington Post.
  8. Content Article
    Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Patel et al., following a near-miss and subsequent educational and training efforts at their institution, they conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. They found only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.
  9. Content Article
    Nearly a year into the global coronavirus pandemic, scientists, doctors and patients are beginning to unlock a puzzling phenomenon: For many patients, including young ones who never required hospitalisation, COVID-19 has a devastating second act. Many are dealing with symptoms weeks or months after they were expected to recover, often with puzzling new complications that can affect the entire body—severe fatigue, cognitive issues and memory lapses, digestive problems, erratic heart rates, headaches, dizziness, fluctuating blood pressure, even hair loss. What is surprising to doctors is that many such cases involve people whose original cases weren’t the most serious, undermining the assumption that patients with mild COVID-19 recover within two weeks. Doctors call the condition “post-acute Covid” or “chronic Covid,” and sufferers often refer to themselves as “long haulers” or “long-Covid” patients. “Usually, the patients with bad disease are most likely to have persistent symptoms, but Covid doesn’t work like that,” said Trisha Greenhalgh, professor of primary care at the University of Oxford and the lead author of an August BMJ study that was among the first to define chronic Covid patients as those with symptoms lasting more than 12 weeks and spanning multiple organ systems. Other viral outbreaks, including the original SARS, MERS, Ebola, H1N1 and the Spanish flu, have been associated with long-term symptoms. Scientists reported that some patients experienced fatigue, sleep problems and joint and muscle pain long after their bodies cleared a virus, according to a recent review chronicling the long-term effects of viral infections. What differentiates COVID-19 is the far-reaching nature of its effects. While it starts in the lungs, it often affects many other parts of the body, including the heart, kidneys and the digestive and nervous systems, doctors said. “I haven’t really seen any other illness that affects so many different organ systems in as many different ways as Covid does,” said Zijian Chen, medical director for Mount Sinai Health System’s Center for Post-Covid Care. Read the full article in the Wall Street Journal.
  10. Content Article
    The global coronavirus (COVID-19) pandemic has taken a dramatic toll on virtually all aspects of life, from the economy, to employment, relationships, public health, and personal health.  In the United States, more than 200,000 individuals have died of the coronavirus. As of October, hundreds of thousands of Americans are filing unemployment claims each week. For all of us, the pandemic has become a time marked by uncertainty, fear, and grief.  According to a survey conducted by the Centers for Disease Control and Prevention (CDC), about 40 percent of US adults reported struggling with mental health or substance use issues.  Although much of the general population has admitted to feeling more anxious and depressed during the pandemic, those with substance use and mental health issues face unique challenges.
  11. Content Article
    In commemoration of World Patient Safety Day 17 September 2020, WHO Patient Safety Flagship: A Decade for Patient Safety 2020-2030, organised a Global Virtual Event “One world: Global solidarity for health worker safety and patient safety”.  Here is the video recording of the Global Virtual Event.
  12. Content Article
    New analysis by the Health Foundation shows there were 4.7 million fewer people referred for routine hospital care – for things like hip, knee and cataract surgery – between January and August 2020 compared to the same period in 2019, representing a potential hidden backlog of unmet care needs. The research highlights the scale of the challenge facing the NHS as it looks to resume services following the disruption caused by the first wave of COVID-19. The number of patients in hospital with COVID-19 is growing as we head into winter, a time when the NHS always experiences greater pressures from flu and other seasonal illnesses. If the virus is not controlled and emergency pressures surge, even more routine treatment will need to be postponed which will only add to the challenge of recovering from the pandemic.
  13. Event
    The Deteriorating Patient Summit focuses on recognising and responding to the deteriorating patient through improving the reliability of patient observations and ensuring quality of care. The conference will include National Developments including the recent recommendations from the Royal College of Physicians on NEWS2 and COVID-19, and implementing the recommendations from the Healthcare Safety Investigation Branch Report Investigation into recognising and responding to critically unwell patients. The conference will include practical case study based sessions on identifying patients at risk of deterioration, improving practice in patient observations, responding to the deteriorating patient, improving escalation and understanding success factors in escalation, sepsis and COVID-19, involving patients and families in recognising deterioration, and improving the communication and use of NEWS2 in the community, including care homes, and at the interface of care. Follow the conference on Twitter #deterioratingpatient Register
  14. News Article
    Thousands of frontline workers delivering treatments where the risk of transmitting coronavirus is heightened are still being denied personal protective equipment (PPE), according to multiple unions and professional bodies. Eleven organisations, including Unison and the British Association of Stroke Physicians, believe numerous procedures have been “wrongly excluded” from the list of 13 “aerosol generating procedures” that require PPE, despite the NHS now having adequate supplies. They say their members are “facing illness and even death” while performing procedures such as chest physiotherapy, introducing feeding tubes, and assessing whether a patient can swallow safely. The unions have formed an alliance to lobby on the issue, and its chair Dr Barry Jones told HSJ: “We’ve asked ministers and the Department of Health and Social Care again and again to take action and provide PPE to frontline NHS staff carrying out procedures which are not currently listed as AGPs but which the scientific evidence shows should be. Read full story Source: HSJ, 13 November 2020
  15. Content Article
    Patients from ethnic minority groups are disproportionately affected by Coronavirus disease (COVID-19). Sze et al. performed a systematic review and meta-analysis to explore the relationship between ethnicity and clinical outcomes in COVID-19. They found that individuals of Black and Asian ethnicity are at increased risk of COVID-19 infection compared to White individuals; Asians may be at higher risk of ITU admission and death. These findings are of critical public health importance in informing interventions to reduce morbidity and mortality amongst ethnic minority groups.
  16. News Article
    Black and Asian people are up to twice as likely to be infected with COVID-19 compared to those of white ethnicities, according to a major new report. The risk of ending up in intensive care with coronavirus may be twice as high for people with an Asian background compared to white people, data gathered from more than 18 million individuals in 50 studies across the UK and US also suggests. The report, published in the EClinicalMedicine by The Lancet, is the first-ever meta-analysis of the effect of ethnicity on patients with COVID-19. The scientists behind it said their findings should be of "importance to policymakers" ahead of the possible roll out of a vaccine. Read full story Source: The Independent, 12 November 2020
  17. News Article
    People with learning disabilities are dying of coronavirus at more than six times the rate of the general population, according to “deeply troubling” figures that have prompted a government review. A report from Public Health England (PHE) found that 451 in every 100,000 people registered as having learning disabilities died after contracting Covid-19 in the first wave of the pandemic, when the figures were adjusted for age and sex. Because not all Covid deaths among people with learning disabilities are registered as such, the true figure is likely to be 692 in every 100,000, or 6.3 times the UK average, the report estimated. Campaigners said the figures showed the government had failed to protect the most vulnerable. The report found that Covid deaths among those with learning disabilities were also more widely spread across age groups, with far greater mortality rates among younger adults. Those aged 18-34 were 30 times more likely to die with the virus than their counterparts in the general population. The higher death rate is likely to reflect the greater prevalence of health problems such as diabetes and obesity among those with learning disabilities, the report said. It also noted that some learning disabilities, such as Down’s syndrome, can make people more vulnerable to respiratory infections. People with learning disabilities are also likely to have difficulty recognising symptoms and following advice on testing, social distancing and infection prevention, the report said. It may also be harder for those caring for them to recognise symptoms if these cannot be communicated, it added. Read full story Source: The Guardian, 12 November 2020
  18. Content Article
    Healthcare organisations have struggled to move from a culture of blame to a ‘just culture’, despite this being stated as a goal for several years. As a result of this cultural inertia, the original principles of a just culture require critical examination. A just culture is still seen primarily as a linear mechanism to apportion liability. Within our complex healthcare organisations, this approach is inadequate. In this article, Paul Stretton proposes a revised approach to creating a just culture, which enables learning from all events, irrespective of outcome. There should be a focus on learning, rather than liability, with a presumption of good intention until proven otherwise. This more compassionate and respectful approach can help to move healthcare organisations towards a just culture and create an atmosphere of trust.
  19. Content Article
    The Royal College of General Practitioners have put together guidance for those working in primary care.
  20. News Article
    A trust in the south east is coming under increasing pressure from a growing number of covid patients, leading to long delays in ambulance handovers. HSJ has been told that ambulances have been waiting up to five hours to hand over patients at Medway Foundation Trust, which has around 90 covid patients. The trust is currently continuing with elective work but covid patients are taking up close to 20% of its beds. Sources have told HSJ that bed occupancy at the trust is already very high – with a high proportion of acutely ill patients - and there are issues with discharging patients into nursing homes which is affecting the ability to admit patients swiftly through A&E. Read full story (paywalled) Source: HSJ, 11 November 2020
  21. News Article
    A community trust was told to urgently review prescribing of stimulant medications for children after concern that some were posted to families but never arrived. Bridgewater Community Healthcare Foundation Trust was told that sending prescriptions through the post may be a potentially unsafe practice by the Royal College of Paediatrics and Child Health. The warning came in a report from the college after it was invited by the trust to review its community paediatrics service The trust was urged to work with primary care and clinical commissioning groups to establish shared care for children who needed these medications. Stimulant medicines are often used for children with attention deficit hyperactivity disorder. The review also found there was a “a very significant risk for patient care” with letters, reports and prescriptions being delayed or going missing due to “recurrent issues” with the post in the building used by the team covering St Helen’s. It highlighted issues with the safeguarding procedures at the trust, with each locality team having its own processes and handling a small number of cases, and called for urgent work to streamline services. Read full story (paywalled) Source: HSJ, 11 November 2020
  22. News Article
    Lockdown measures in England led to thousands fewer children receiving vital immunisations for a range of diseases include measles, diphtheria and whooping cough, Public Health England (PHE) has warned. PHE has warned parents they should continue to get their children immunised regardless of lockdown and restrictions brought on by coronavirus. During the first wave of coronavirus the government advised that children should continue to receive vaccinations as scheduled but despite these some appointments were delayed and the numbers of children vaccinated against common diseases fell compared to 2019. PHE looked at data from almost 40% of GP surgeries for use of the common 6-in-1 vaccination for diseases including diphtheria, tetanus, whooping cough, and polio as well as uptake of the measles, mumps and rubella (MMR) vaccine to 19 October. In total 167,322 children had the 6-in-1 vaccine, a drop of 6,600 on the same period in 2019, a fall of almost 4%. A total of 167,670 children had the MMR jab, 4,700 fewer than in 2019, a drop of 2.8%. Although the vaccinations recovered after lockdown the rates are still lower overall than 2019. Dr Mary Ramsay, head of immunisations at Public Health England, said: “Vaccines remain the best defence against infection. It’s essential we maintain the highest possible uptake to prevent a resurgence of serious and sometimes life-threatening diseases. “Routine vaccinations are still available throughout the pandemic – it’s vital that we continue to make it as easy and safe as possible for parents to take their children to appointments.” Read full story Source: The Independent, 11 November 2020
  23. Content Article
    Identifying improvements in maternity care to help reduce the risk of delays in crucial interventions during labour when a baby is suspected to be unwell is the focus of this latest Healthcare Safety Investigation Branch (HSIB) report. The report was compiled after a review of 289 of our maternity investigations into intrapartum stillbirths, neonatal deaths and potential severe brain injuries. In 14.9% of the cases the delay was a contributory factor. The review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to the delays. Evidence from national reports confirms that such delays are a recognised patient safety risk. 
  24. Event
    Dr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a multidisciplinary group of experts, including clinicians, administrators, and patients and family members, to understand the background of pressure ulcer prevention and management, discuss multi-faceted opportunities for organization-wide improvement, and explore mechanisms for improved patient and family member involvement in prophylaxis. The group will tailor aspects of the dialogue to assess the COVID-19 impact on pressure ulcer prevalence and management. Register
  25. Content Article
    Lecture presentation slides from Professor Carl Philpot, University of East Anglia, on losing your sense of smell with coronavirus.
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