Patient Safety Learning

Tens of thousands of people infected with coronavirus were incorrectly given the all clear by England’s Lighthouse Laboratories, a High Court trial will be told next week. Court documents seen by The Independent show the labs are accused of unfairly selecting software that was shown in a test to produce significant numbers of errors and false negatives, samples that should have been positive or classed as needing to be re-taken. The two companies behind the Lighthouse Labs in England – Medicines Discovery Catapult Ltd and UK Biocentre Ltd – are accused of treating British company, Diagnostics.ai unfairly and giving preferential treatment to Belgian company UgenTec, despite the British firm’s software performing better in the test. The case, first revealed by The Independent in June, also includes a judicial review of the procurement decision against health secretary Matt Hancock – one of the first court hearings over the procurement processes followed by the government since the start of the pandemic. The Independent understands lawyers for Diagnostics.ai will accuse the laboratories of choosing a software solution that went on to produce tens of thousands of incorrect results which will have led to infected people going about their normal lives while at risk of spreading the virus. In June, UgenTec chief executive Steven Verhoeven told The Independent the suggestion its software had made errors was “incorrect”. The Department of Health refused to comment on the legal action but said in June that the UgenTec software had been used for several months and was subject to quality assurance processes, though it did not give any further details. Mr Justice Fraser will hear opening arguments in the case on Monday at the High Court. Read full story Source: The Independent, 25 September 2020

https://questions-statements.parliament.uk/written-questions/detail/2020-09-09/87501

See Rob Hackett's video on the hub: Indistinct Chlorhexidine: Patients suffer unnecessarily – the reason is clear Rob highlights the story of Grace Wang. In 2010 Grace Wang was left paralysed after an accidental epidural injection with antiseptic solution (indistinct chlorhexidine – easily mistaken for other colourless solutions). This same error continues to play out again and again throughout the world. Do you have evidence or data from your organisation or healthcare system. Comment below or email: info@pslhub.org We will ensure confidentiality.

Dr Neelam Dhingra, Coordinator, Patient Safety and Risk Management, World Health Organization, reflects on World Patient Safety Day 2020. "Dear Colleagues Congratulations. This is a moment of pride for all of us! The WHO Patient Safety Flagship would like to express its deepest appreciation to members of the Global Patient Safety Network for an outstanding commemoration of the World Patient Safety Day 2020 around the world. The response to the call was phenomenal and we have already received great stories and truly inspiring reports from multiple countries, regions, partners and stakeholders showcasing a variety of activities. A number of global virtual events amplifying the messaging for the day. “Safe health workers, Safe patients” and “Speak up for Health worker safety!”. Moreover, hundreds, if not thousands, of iconic monuments, landmarks and health care facilities were lit up in colour orange from all over the world. We are working on a short summary and a full report illustrating all these amazing contributions. Most importantly, the day was a witness to expression of strong commitment and leadership of ministries of health for urgent and sustainable action, from countries across the world. At WHO headquarters on 17 September 2020, a landmark Charter “Health worker Safety: A priority for patient safety”, was launched at a World Patient Safety Day Press Conference (https://twitter.com/who/status/1306496780649938944?s=24) by WHO Director General, Dr. Tedros Adhanom Ghebreyesus in the presence of International Labour Organization Director General, Dr Guy Ryder and Rt. Hon Mr Jeremy Hunt, Chair, Health and Social Care Select Committee, House of Commons of the UK, who played a key role in establishing World Patient Safety Day, an active campaigner on patient safety globally and also the Co-Chair of WHO Steering Committee on World Patient Safety Day. WHO Member States and all relevant stakeholders are invited to support health worker safety by endorsing and signing up to the Charter. Charter: Health worker safety: a priority for patient safety https://bit.ly/2FNEzRu   Sign up: https://www.who.int/campaigns/world-patient-safety-day/sign-up-to-the-charter---health-worker-safety A Global Virtual Event “One world: Global solidarity for health worker safety and patient safety” was held showcasing rich participations from members of this very network, regions and countries. WHO Deputy Director General, Dr Zsuzsanna Jakab, and also the Co-Chair of WHO Steering Committee on World Patient Safety Day, in her closing remarks emphasised 'World Patient Safety Day 2020 should not be seen only as Day but a platform for change. WHO will work with partners to advance the themes of the Day throughout the entire year'. A number of advocacy, policy, technical products were launched at the event including: 1. World Patient Safety Day 2020-21 Goals. From this year onwards, WHO will launch theme-related goals with the aim of achieving tangible and measurable improvements at the point of health service delivery. Ministries of health and health care organizations are encouraged to incorporate these goals into ongoing service improvement programmes and drives. As a new set of goals will be proposed each year, implementation teams at health care facilities are advised to institutionalize patient safety improvements achieved, and to take on new goals as well as sustaining action on goals from the previous year. WHO is setting up an online platform where health care facilities and organizations can report progress and learn from each other. A certificate of appreciation will be provided to the registered facilities. The World Patient Safety Day goals 2020–2021 are aimed at improving health worker safety. Please sign up to the goals. Goals https://www.who.int/publications/i/item/who-uhl-ihs-2020.8 Sign up: https://www.who.int/campaigns/world-patient-safety-day/sign-up-for-wpsd-2020-2021-goals 2. Patient safety incident reporting and learning systems: technical report and guidance: https://www.who.int/publications/i/item/9789240010338 3. WHO-ILO joint publication "Caring for those who care: National Programmes for Occupational Health for Health Workers" https://www.who.int/publications/i/item/caring-for-those-who-care 4. Protection of health and safety of health workers: Checklist for healthcare facilities https://www.who.int/publications/i/item/protection-of-health-and-safety-of-health-workers 5. An OpenWHO course on: Occupational health and safety for health workers in the context of COVID-19 https://openwho.org/courses/COVID-19-occupational-health-and-safety?tracking_user=79KWbMERvlyJs93otUBThL&tracking_type=news&tracking_id=5G2Mpe2LUQH0UI1yw8p8pV World Patient Safety Day provides a torch bearing platform, which brings spotlight on global, national and local patient safety issues. This year the World Patient Safety Day brought a spotlight on health worker safety and its impact and interaction with patient safety. This year’s WPSD came as a result of close collaboration between WHO and all stakeholders. We strongly believe that the amazing sense of ownership was the key factor for success. For that, we thank you all. Thanks and best regards," Dr Neelam Dhingra

Some 10,000 more deaths than usual have occurred in peoples’ private homes since mid June, long after the peak in Covid deaths, prompting fears that people may still be avoiding health services and delaying sending their loved ones to care homes. It brings to more than 30,000 the total number of excess deaths happening in people’s homes across the UK since the start of the pandemic. Excess deaths are a count of those deaths which are over and above a “normal” year, based on the average number of deaths that occurred in the past five years. In the past three months the number of excess deaths across all settings, has, in the main been lower than that of previous years. However, deaths in private homes buck the trend with an average of 824 excess deaths per week in people’s homes in the 13 weeks to mid-September. Experts are citing resistance from the public to enter hospitals or home care settings and “deconditioning” caused by decreased physical activity among older people shielding at home, for example not walking around a supermarket or garden centre as they might normally. Read full story Source: The Guardian, 24 September 2020

Hospitals have been ordered to allow partners and visitors onto maternity wards so pregnant women are not forced to give birth on their own. NHS England and NHS Improvement have written to all of the directors of nursing and heads of midwifery to ask them to urgently change the rules around visiting. The letter, which is dated 19 September and seen by The Independent, says NHS guidance was released on 8 September so partners and visitors can attend maternity units now “the peak of the first wave has passed”. “We thank you and are grateful the majority of services have quickly implemented this guidance and relaxed visiting restrictions,” it reads. “To those that are still working through the guidance, this must happen now so that partners are able to attend maternity units for appointments and births.” The letter adds: “Pregnancy can be a stressful time for women and their families, and all the more so during a pandemic, so it is vital that everything possible is done to support them through this time.” Make Birth Better, a campaign group which polled 458 pregnant women for a new study they shared exclusively, said mothers-to-be have been forced to give birth without partners and have had less access to pain relief in the wake of the public health crisis. Half of those polled were forced to alter their own childbirth plans as a result of the COVID-19 outbreak – while almost half of those who were dependant on support from a specialist mental health midwife said help had stopped. Read full story Source: The Independent, 23 September 2020

This has been picked up by HSJ today with a link to our letter to Simon Stevens. https://www.hsj.co.uk/commissioning/long-covid-clinics-still-not-operating-despite-hancock-claim/7028466.article