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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Large numbers of people are being discharged from hospital following COVID-19 without assessment of recovery. Mandal et al. followed 384 patients who had tested positive and had been treated at Barnet Hospital, the Royal Free Hospital or UCLH. Collectively the average length of stay in hospital was 6.5 days. The team found that 54 days after discharge, 69% of patients were still experiencing fatigue, and 53% were suffering from persistent breathlessness. They also found that 34% still had a cough and 15% reported depression. In addition 38% of chest radiographs (X-rays) remained abnormal and 9% were getting worse. The study has identified persisting symptoms and radiological abnormalities in a significant proportion of subjects. These data may assist with the identification of people outside expected recovery trajectories who could benefit from additional rehabilitation and/or further investigation to detect post-COVID complications.
  2. News Article
    Patients, including those with the coronavirus, are being kept “head to toe” on trolleys in accident and emergency departments in Manchester, with some forced to wait up to 40 hours for a bed. The “dangerous” situation has sparked warnings from the president of the Royal College of Emergency Medicine over the “potentially lethal” crowding of patients in A&Es across the country this winter. Katherine Henderson said she was “absolutely terrified” by what was happening in some departments. She said she had warned NHS England about the dangers of crowding patients in A&E but that not enough action had been taken. She told The Independent: “Crowding in A&E is unsafe, but with coronavirus it is potentially lethal. We have said this endlessly to NHS England." “Everyone agrees crowding is bad, but what they’re not doing is translating that into action.” After hearing of the situation in Manchester, she added: “Exactly what we said should not happen is happening. I am absolutely terrified by this. What more can I do? I have highlighted this risk everywhere I can over the past few months.” Read full story Source: The Independent, 11 November 2020
  3. News Article
    An acute trust’s record of eight never events in the last six months has raised concerns that quality standards have slipped since it was taken out of special measures. The never events occurred at Royal Cornwall Hospitals Trust. They included three wrong site surgeries within the same speciality and an extremely rare incident in which a 30cm (15 inch) wire was left in a cardiology patient. Kate Shields, chief executive of the trust, said the incidents have led to a “great deal of soul searching”. Prior to the incidents the trust had gone 13 months without recording a never event, and Ms Shield acknowledged that pressure created by the pandemic was likely to have been a contributing factor behind the cluster of never events. She stressed that none of the patients affected had suffered physical harm. Read full story (paywalled) Source: HSJ, 12 November 2020
  4. News Article
    A nurse is due in court charged with eight counts of murder following an investigation into baby deaths at the Countess of Chester hospital neonatal unit in Cheshire. Lucy Letby, 30, is due to appear at Warrington magistrates court on Thursday. She was arrested for a third time on Tuesday as part of the investigation into the hospital, which began in 2017. A force spokesman said: “The Crown Prosecution Service has authorised Cheshire police to charge a healthcare professional with murder in connection with an ongoing investigation into a number of baby deaths at the Countess of Chester hospital.” He said Letby was facing eight charges of murder and 10 charges of attempted murder relating to the period from June 2015 to June 2016. On Tuesday, police said parents of all the babies involved were being kept fully updated on developments and were being supported by officers. Read full story Source: The Guardian, 11 November 2020
  5. News Article
    Early results from trials of a Covid vaccine developed in Russia suggest it could be 92% effective. The data is based on 20 cases of COVID-19 from 16,000 volunteers given the Sputnik V vaccine or a dummy injection. While some scientists welcomed the news, others said the data had been rushed out too early. It comes after Pfizer and BioNTech said their vaccine could prevent 90% of people getting Covid-19, based on a study of 43,500 people. Although the Sputnik data is based on fewer people being vaccinated and fewer cases of Covid developing during the trial, it does confirm promising results from earlier research. The Sputnik V vaccine, developed at the National Research Centre for Epidemiology and Microbiology in Moscow, is currently going through phase III clinical trials in Belarus, UAE, Venezuela and India. So far there are no safety issues, with Russian researchers saying there were "no unexpected adverse events" 21 days after volunteers received their first of two injections. Read full story Source: BBC News, 11 November 2020
  6. News Article
    A Tory peer has attacked the Department of Health and Social Care’s ‘woeful’ response to the patient safety review she authored and has revealed she intends to create a cross-party group to force action. Baroness Julia Cumberlege - who led the “First Do No Harm” report on device and medicine safety– has said she has “not had a whisper” from the department over the report’s key recommendations since it was published in July. She told HSJ’s Patient Safety Congress she is setting up a cross-party parliamentary group to “pressure” the department to adopt the report’s recommendations. The report arose from The Independent Medicines and Medical Devices Safety Review, which spoke to more than 700 people, mostly women, who suffered avoidable harm from surgical mesh implants, pregnancy tests and the anti-epileptic drug sodium valproate. The report discovered “a culture of dismissive and arrogant attitudes” including the unacceptable labelling of many symptoms as “attributable to ‘women’s problems’”. It concluded that the NHS has “either lost sight of the interests of all those it was set up to serve or does not know how best to do this.” Health and social care secretary Matt Hancock and minister Nadine Dorries have apologised to the women who were harmed but the department has so far not responded to the report’s other eight recommendations in detail. Baroness Cumberlege said the cross party group would “[try] to open up a firmly shut departmental door. A department that doesn’t seem to get it.” She said: “We have been disappointed [in the department’s response] because we hoped by now we would have some sort of inclination about what’s going on." “The response from the department on the other key recommendations has been woeful. The reason they give is ‘there is a terrible amount of work to do’”. Read full story (paywalled) Source: HSJ, 11 November 2020
  7. News Article
    Planning around what the NHS can deliver this winter must be based on how many nursing staff are available and the workload they can safely take on, the Royal College of Nursing (RCN) has warned. Amid widespread nursing shortages, the union has called on the government to “be honest” about nurse vacancies and address what steps need to be taken to keep staff and patients safe. “It is essential that learning is applied to planning for this winter, including what service can be delivered safely with the workforce available” Last week NHS England moved to its highest level of emergency preparedness. But the RCN warned it still had grave concerns around how services would be safely staffed, claiming it was too late to find the nurses needed to meet the anticipated demands of the incoming winter. Despite an increase in the number of nurses registered with the Nursing and Midwifery Council this year, the college said there were still around 40,000 nurse vacancies in the NHS in England alone. These shortages, which were felt across all areas of nursing, had been exacerbated because of staff self-isolating or being off sick because of COVID-19, the RCN noted. The impacts of workforce shortages meant there was “enormous responsibility” on the nurses working and “intolerable pressure” on senior nursing leaders, it said. Unless local staffing plans prioritised safe and high-quality care, the few nurses in post were at risk of “burn out” this winter, the college added. Read full story (paywalled) Source: Nursing Times, 9 November 2020
  8. Content Article
    The purpose of the US Joint Commission's National Patient Safety Goals is to improve patient safety. The goals focus on problems in healthcare safety in the USA and how to solve them. They include identifying patients correctly, improving staff communication, use medicine safely, use alarms safely, prevent infection, identify patient safety risks and prevent mistakes in surgery.
  9. Content Article
    Many risks faced by patients in acute mental health settings are similar to those that occur in other areas of healthcare, for example medication errors and cross-infection. In addition, however, there are unsafe behaviours associated with serious mental health problems, including violence and self-harm; the measures taken to address these, such as restraint or seclusion, may result in further risks to patient safety. This article by Catherine Gilliver in the Nursing Times discusses the need for a physical and psychosocial environment in which staff, patients and visitors feel recognised and valued.
  10. Content Article
    When Giancarlo Gaglione’s brother, Lanfranco, died by suicide at the age of 26, it came like a lightning bolt out of the blue. None of his family or friends had noticed anything different about him leading up to the moment he took his own life, and he only confided briefly, a week before, in two people: his best friend and his girlfriend. In this article, the World Health Organization (WHO) focuses on how masculinity norms can discourage men from recognising and seeking help for mental health problems. A new Health Evidence Network (HEN) report on Mental health, men, and culture, launched by the WHO Regional Office for Europe, gives concrete recommendations on how policy-makers can address certain mental health issues arising from traditional patterns of masculinity.
  11. Content Article
    The National Institute for Health and Care Excellence (NICE) is developing the COVID-19 guideline: management of the long-term effects of COVID-19 and has published the final scoping document and associated project papers. The Royal College of General Practitioners (RCGP) has produced a summary and included some top tips to aid the care of your patients whilst waiting for the national guidance to be produced.
  12. News Article
    A controversial exercise technique used to manage chronic fatigue syndrome is no longer being recommended by National Institute for Health and Care Excellence (Nice). The decision to stop recommending graded exercise therapy (GET) – which involves incremental increases in physical activity to gradually build up tolerance – represents a crucial win for patient advocates who have long said the practice causes more harm than good. Patient groups have argued that the use of exercise therapy suggests that those with chronic fatigue syndrome (also known as ME) have no underlying physical problem but are suffering symptoms due to inactivity. “We have been so widely dismissed and had our suffering at the hands of this condition constantly diminished by the inappropriate and damaging guidance/notion that we can simply exercise or think our way out of a physical illness none of us asked for nor deserve,” said ME patient Glen Buchanan. Chronic fatigue syndrome is thought to affect about 250,000 people in the UK and has been estimated to cost the economy billions of pounds annually. One in four are so severely affected they are unable to leave the house and, frequently, even their bed. Read full story Source: The Guardian, 10 November 2020
  13. Event
    This Westminster Health Forum conference will discuss the priorities for improving the health outcomes in babies and young children and the next steps for policy. It is taking place as The Rt Hon Andrea Leadsom MP, Government's Early Years Health Adviser - who is a keynote speaker at this conference - leads a review into improving health outcomes in babies and young children as part of the Government’s levelling up policy agenda. With the first phase of the review expected in early 2021, this conference will be an opportunity for stakeholders to discuss the priorities and latest thinking on improving health outcomes. The discussion is bringing together stakeholders with key policy officials who are due to attend from DHSC and the DfE. The agenda: The priorities for improving health outcomes for babies and young children. Understanding the importance of the first 1,000 days in child development' Improving child public health, reducing inequalities and the impact of social adversity in childhood. Identifying measures for supporting vulnerable and disadvantaged young children and families - and learning from the COVID-19 pandemic. Priorities for system-wide collaboration to address underlying health inequalities and key opportunities for improving health outcomes in young children going forward. Next steps for the commissioning of health services for children in the early stages of life. Improving health outcomes for young children across health and care - integrating services, care pathways, workforce training, and partnership working. Register
  14. Event
    This Westminster Health Forum conference will focus on key issues for clinical negligence in the NHS and priorities for NHS resolution. The discussion is bringing together stakeholders with a range of key policy officials who are due to attend from DHSC; the Government Legal Department; HM Treasury; the MOJ and the NAO. The discussion at a glance: a patient safety culture - assessing progress and next steps in its development in the context of the NHS Patient Safety Strategy and the publication of the first Annual progress report COVID-19 - the impact on clinical negligence risk and increased clinical negligence claims the workforce - priorities for support through a period of unprecedented pressure legal costs - options for mitigation and policy. Register
  15. News Article
    A new NHS treatment programme targeting young people with eating disorders has been launched amid a rise in numbers needing treatment during the coronavirus pandemic. Recent NHS data showed record numbers of children and young people are currently being treated across England for eating disorders while waiting times in some places are dangerously long. On Monday, children’s charity NSPCC warned that counselling sessions for eating and body image disorders rose by 32% after lockdown was introduced in March. The new scaling up of intervention services for those with eating disorders such as anorexia and bulimia will mean young people can gain access to rapid specialist NHS treatment across England. The service will be rolled out to 18 sites, building on a successful trial model at King's College London, where one patient described the treatment as the “gold standard” of care. Nadine Dorries, Minister for Health, said: “Eating disorders can have a devastating impact on individuals and their families – and can very sadly be fatal. I am committed to ensuring young people have access to the services and treatment they need which can ultimately save lives." Read full story Source: The Independent, 10 November 2020
  16. News Article
    Older women could be less likely to receive ovarian cancer treatment. A new report analysed data from more than 17,000 cases of ovarian cancer diagnosed across England between 2016 and 2018. Three in five (60%) of women with ovarian cancer over the age of 79 did not receive either chemotherapy or surgery, while 37% of women over the age of 70 did not receive any treatment. The nature of ovarian cancer means surgery is essential in the large majority of cases to remove the tumour. The researchers cautioned that with an ageing population it is vital that women of all ages have access to the best possible treatments. Researchers also examined the various rates of treatments for ovarian cancer among women in different parts of England. They found the probability of receiving any treatment fell below the average in the East Midlands, the East of England, Greater Manchester and Kent and Medway. The report was jointly funded by The British Gynaecological Cancer Society, Ovarian Cancer Action, Target Ovarian Cancer and delivered by analysts at the National Cancer Registration and Analysis Service. Commenting on the report, Cary Wakefield, chief executive of Ovarian Cancer Action, said: "Neither your age nor location should decide your chance of survival if you are diagnosed with ovarian cancer." "Our audit is the first step in addressing the health inequalities women across England face, so we can begin to dismantle them." Read full story Source: The Independent, 11 November 2020
  17. Content Article
    The COVID-19 Evidence Network to support Decision-making (COVID-END) helps: those supporting decision-making about COVID-19 to find and use the best available evidence (i.e. to support the evidence-demand side of the pandemic response) researchers to avoid waste by reducing duplication in and better coordinating the COVID-19 evidence syntheses, technology assessments and guidelines being produced (i.e., to support the evidence-supply side of the pandemic response). COVID-END is a time-limited network that brings together more than 50 of the world’s leading evidence-synthesis, technology-assessment and guideline-development groups around the world. It covers the full spectrum of the pandemic response, from public-health measures and clinical management to health-system arrangements and economic and social responses. It also covers the full spectrum of contexts where the pandemic response is playing out, including low-, middle- and high-income countries.
  18. News Article
    Keyhole surgery can allow complicated procedures to be carried out with just a few access cuts, helping to reduce patient recovery times and potential risk of infection. But the remote controlled robots that can perform this type of surgery are often very large, expensive and not widely available. Now a new robo-surgeon with a modular design could be about to change that. View video Source: BBC News, 9 November 2020
  19. News Article
    Several NHS trusts are offering a ‘treatment’ for birth trauma which uses a technique which lies outside national guidelines and which is criticised by specialists as potentially causing ‘more harm than good’. The ‘Rewind’ technique is promoted as a fast treatment for post-natal post-traumatic stress disorder (PTSD) – also known as birth trauma - which involves the “reprocessing” of painful memories. HSJ has learned of several trusts, including East and North Herts Trust, Chelsea and Westminster Hospital Foundation Trust and James Paget University Hospital FT, where the therapy is being offered. It is thought there are other trusts which are providing it or have explored it. Typically, it is provided by midwives who have undergone training in the technique. But Nick Grey, a clinical psychologist who was on the National Institute for Health and Care Excellence panel which looked at PTSD, said it was “absolutely clear cut” that it was bad practice to offer the technique as a branded therapy for PTSD, although he said it could be embedded as part of other treatments. He told HSJ: “It should not be offered to mothers with PTSD… they are being done a disservice if they are not given evidence-based treatment. There is no evidence that this [provides] treatment for sub-clinical PTSD or trauma,” he said. Read full story (paywalled) Source: HSJ, 11 November 2020
  20. Content Article
    Dr John Campbell, a retired A&E nurse, discusses the current news, research and evidence on COVID-19 in the US and UK, the new coronavirus cases linked to mink farms, and free supplies of vitamin D to care home residents and clinically extremely vulnerable people in England.
  21. Content Article
    On the same day that the nation went into a second lockdown, the Government published revised guidance on Visiting Arrangements for Care Homes. Whereas previous versions of this guidance had adopted a more neutral approach, the steer from the Government is now clear; the expectation is for care homes to be facilitating visits wherever possible. This Bevan Brittan article looks at what the law says, what the new guidance says and what care homes should be doing.
  22. Content Article
    Fifth Sense is a UK charity that supports people affected by smell and taste disorders across the world and provides direct support, advice, and a signpost to potential diagnosis and treatment to people affected by such conditions. They regularly update their repository of information about smell/taste loss and COVID-19. It contains articles, interviews and video presentations to keep those affected by the virus and experiencing smell and taste loss informed with the latest news and research.
  23. News Article
    The mutated strain of coronavirus from Danish mink could have “grave consequences”, Matt Hancock warned today. The Health Secretary said the new variant was a “significant development”. And he told MPs the new form of the virus “did not fully respond to Covid-19 antibodies” - hinting it might not respond in the same way to a vaccine. The UK banned travel and freight from Denmark on Saturday, going further than the current 14-day quarantine system. Those who had already passed from Denmark to Britain in the previous 14 days must isolate for two weeks. Updating the House of Commons, Mr Hancock said: “We’ve been monitoring the spread of coronavirus in European mink farms for some time, especially the major countries for mink farming like Denmark, Spain, Poland and the Netherlands. “On Thursday evening last I was alerted to a significant development in Denmark of a new evidence that the virus had spread back from mink to humans in a variant form that did not fully respond to Covid-19 antibodies. “Although the chance of this variant becoming widespread is low, the consequences should that happen would be grave.” Read full story Source: The Mirror, 10 November 2020
  24. Content Article
    On 23 September, Improvement Cymru, the all-Wales Improvement service for NHS Wales, hosted an online session with colleagues from Holland to talk about patient flow in hospital. 
  25. Content Article
    Covid has been a traumatic experience for many who work in the NHS. Battlefield scenes, redeployment and it can seem there is little end in sight. However, there have been positives. Improved team work, new ways of delivering care and better use of technology. How can we use this learning? How can we ensure that we capture the good stuff, and make sure that we don’t go back to old habits?  Improvement Cymru, the all-Wales Improvement service for NHS Wales, has developed a ‘Learning from COVID’ toolkit’. It is based on the idea that bringing teams together to consider these questions in a facilitated discussion is not only practically helpful in supporting the service to develop – it is important in helping those individuals involved reflect on and come to terms with what they have experiences.
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