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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    After new analysis showed pregnant black women were eight times more likely and Asian women four times as likely to be admitted to hospital with COVID-19, the NHS is rolling out additional support for pregnant women of a Black, Asian and Ethnic Minority (BAME) background. Given evidence of the heightened risk to BAME expectant mums, urgent action is being taken in England including increasing uptake of Vitamin D and undertaking outreach in neighbourhoods and communities in their area. Research carried out by Oxford University has shown 55% of pregnant women admitted to hospital with coronavirus are from a BAME background, even though they represent only a quarter of the births in England and Wales. In response, England’s most senior midwife, Jacqueline Dunkley-Bent, has written to all maternity units in the country calling on them to take four specific actions to minimise avoidable COVID-19 risk for BAME women and their babies. The steps include: Increasing support of at-risk pregnant women – e.g. making sure clinicians have a lower threshold to review, admit and consider multidisciplinary escalation in women from a BAME background. Reaching out and reassuring pregnant BAME women with tailored communications. Ensuring hospitals discuss vitamins, supplements and nutrition in pregnancy with all women. Women low in vitamin D may be more vulnerable to coronavirus so women with darker skin or those who always cover their skin when outside may be at particular risk of vitamin D insufficiency and should consider taking a daily supplement of vitamin D all year. Ensuring all providers record on maternity information systems the ethnicity of every woman, as well as other risk factors, such as living in a deprived area (postcode), co-morbidities, BMI and aged 35 years or over, to identify those most at risk of poor outcomes. Read full story Source: NHE, 29 June 2020
  2. News Article
    Some hospitals have sought to water down PPE requirements in order to “accelerate” the return of planned surgery, senior doctors have said, as they issued new guidance aiming to inform the decision. The Royal College of Anaesthetists, along with partners including the Faculty of Intensive Care Medicine, released a document to members to tackle “marked uncertainty amongst operating theatre team members as to which infection prevention and control precautions should be taken when treating screened patients in planned surgical pathways”. The document provides recommendations for teams on how to adjust PPE usage, which the college said was “supportive and consistent” with current Public Health England guidance. Professor William Harrop-Griffiths, consultant anaesthetist and council member of the Royal College of Anaesthetists, told HSJ some hospitals wanted to decrease the amount of PPE used as it might enable them to “accelerate and increase the workload”. However, the college has argued that there is currently “no clear guidance on when you might consider making that change”. “You have to balance that to the risk to the staff,” Professor Harrop-Griffiths stressed. Read full story (paywalled) Source: HSJ, 29 June 2020
  3. News Article
    London’s Nightingale hospital recorded 144 patient safety incidents during its 29 days treating 54 patients, it has emerged. There were two serious incidents at the field hospital, a doctor told a Royal Society of Medicine webinar. Dr Andrew Wragg, consultant cardiologist and director of quality and safety at Barts Health NHS Trust, said a study of the long-term outcomes of the 54 patients was ongoing, as 20 of those treated at the ExCel conference centre site were still recovering in hospitals across London. Johanna Cade, a nurse at Guy’s and St Thomas’ NHS trust and who worked at the Nightingale, said: “We had quite high incident reporting at 144 incidents reported and I think that demonstrates that Nightingale really did well at building a no blame safety culture for resolution and learning. This system manifested itself and staff were really striving to make things better continually. We knew who to report to and how to escalate things.” She showed data revealing the largest number of safety incidents involved medical devices. There were 25 incidents that included the ventilators used to keep patients alive. Staffing issues and medication, as well as pressure ulcer and communication incidents, were also among the highest numbers. Read full story Source: The Independent, 27 June 2020
  4. News Article
    Regulators have uncovered multiple examples of patients being put at risk when junior doctors are left with tasks they are not trained for, lacking support, and facing bullying and inappropriate behaviour. Inspection teams have had to intervene – in some cases contacting senior trust staff – to ensure urgent issues are addressed, after the inspections. Health Education England oversees training nationally, which includes making the checks at trusts which have been put under “enhanced monitoring” by the professional regulator, the General Medical Council, because of concerns from trainees. HSJ has obtained and examined 20 reports, all produced since the beginning of 2019. Themes running through the reports included: Lack of support from consultants. Trainees struggled to contact consultants out of hours. Bullying and inappropriate behaviour was reported at several trusts. Inspectors found a reluctance to report concerns and/or a lack of knowledge of how to do it. Teaching was often of poor quality or cancelled – and sometimes trainees struggled to attend sessions because of how their shifts and rotations were scheduled. Trainees in several trusts reported IT problems, such as being locked out of systems so being unable to access clinical notes and blood tests, and IT systems taking up to 30 minutes to start up, sometimes delaying patient care. Read full story (paywalled) Source: HSJ, 29 June 2020
  5. News Article
    People who were seriously ill in hospital with coronavirus need to be urgently screened for post-traumatic stress disorder (PTSD), leading doctors say. The Covid Trauma Response Working Group, led by University College London and involving experts from south-east England, said those who had been in intensive care were most at risk. The experts said regular check ups should last at least a year. More than 100,000 people have been treated in hospital for the virus. The experts say tens of thousands of these would have been seriously ill enough to be at risk of PTSD. The working group highlighted research which showed 30% of patients who had suffered severe illnesses in infectious disease outbreaks in the past had gone on to develop PTSD, while depression and anxiety problems were also common. Tracy is just one of many people who has been left with psychological scars from her coronavirus experience. She was admitted to Whittington Hospital in north London in March and spent more than three weeks there - one of which was in intensive care. "It was like being in hell. I saw people dying, people with the life being sucked from them. The staff all have masks on and all you saw was eyes - it was so lonely and frightening." Since being discharged in April the 59-year-old has been struggling to sleep because of the thought she will die and she has constantly suffered flashbacks. She is now receiving counselling. Read full story Source: BBC News, 29 June 2020
  6. News Article
    Brain complications, including stroke and psychosis, have been linked to COVID-19 in a study that raises concerns about the potentially extensive impact of the disease in some patients. The study, published in Lancet Psychiatry, is small and based on doctors’ observations, so cannot provide a clear overall picture about the rate of such complications. However, medical experts say the findings highlight the need to investigate the possible effects of COVID-19 in the brain and studies to explore potential treatments. “There have been growing reports of an association between COVID-19 infection and possible neurological or psychiatric complications, but until now these have typically been limited to studies of 10 patients or fewer,” said Benedict Michael, the lead author of the study, from the University of Liverpool. “Ours is the first nationwide study of neurological complications associated with Covid-19, but it is important to note that it is focused on cases that are severe enough to require hospitalisation.” Scientists said the findings were an important snapshot of potential complications, but should be treated with caution as it is not possible to draw any conclusions from the data about the prevalence of such complications. Read full story Source: The Guardian, 26 June 2020
  7. News Article
    A healthcare app which was investigated over failing to meet clinical and governance standards has been dropped by north London commissioners after it was deemed “clinically unsafe”. The Health Help Now app, currently used in eight north London boroughs, will be scrapped by the end of June and patients will be directed to the NHS app. In a statement, the North West London Collaboration of Clinical Commissioning Groups said it decided to carry out a review of the app as it had low uptake and dwindling funds, despite reporting in 2017 that it was being used by 500,000 patients. During the reivew, stakeholders told commissioners that a lack of clinical oversight meant the app was “unsafe” and financial constraints meant it was unsustainable. Read full story Source: HSJ, 26 June 2020
  8. News Article
    A dramatic collapse in standards at a care home where a dozen people died from COVID-19 has been revealed by inspectors who discovered hungry and thirsty residents living with infected wounds in filthy conditions. Infection control was inadequate, residents with dementia were left only partially dressed and one family complained of finding their loved one smeared in dried faeces at Temple Court care home in Kettering, which is operated by Amicura, a branch of Minster Care which runs more than 70 homes in the UK. Amicura said the home had been “completely overwhelmed” by COVID-19 infections which it said arrived with 15 patients discharged from hospitals in the second half of March. They were overrun,” one relative told the inspectors. “They were short-staffed and then with the influx of people, they couldn’t cope.” Residents’ wounds had become necrotic and infected, requiring hospital treatment and several people had experienced falls, some of which resulted in injuries needing hospital treatment, the inspectors found. The conditions discovered by the Care Quality Commission on 12-13 May were so poor that surviving residents were moved out immediately. The CQC report into the service, published on Friday, found multiple breaches of the health and social care act. Northamptonshire police have launched an investigation to identify whether any offences may have been committed. Read full story Source: The Guardian, 26 June 2020
  9. News Article
    More children died after failing to get timely medical treatment during lockdown than lost their lives because of coronavirus, new research by the Royal College of Paediatrics and Child Health (RCPCH) suggests. Six children under the age of 16 have died from COVID-19 in Britain since the pandemic began, according to the Office for National Statistics (ONS). However, seeking medical help too late was a contributory factor in the deaths of nine children in paediatric care new analysis has found, with the figure likely to be higher. A survey of 2,433 paediatricians, carried out by the RCPCH, found that one in three handling emergency admissions had dealt with children who turned up later than usual for diagnosis or treatment. Read full story (paywalled) Source: The Telegraph, 25 June 2020
  10. News Article
    The government’s contact-tracing programme failed to reach almost 30% of people who tested positive for the coronavirus in England last week, the latest figures show. Only 70% of the 6,923 people who tested positive for COVID-19 during the period were reached by NHS Test and Trace staff, according to the Department of Health and Social Care. This means that 2,054 people with the virus – and potentially thousands of their close contacts – could not be traced by the new system. The fact that one in four people with the virus had not been reached since the launch was “surprising and worrying”, said Keith Neal, emeritus professor of the epidemiology of infectious diseases at the University of Nottingham. Read full story Source: The Independent, 26 June 2020
  11. News Article
    More than two-thirds of black, Asian and minority ethnic pharmacists have not had workplace risk assessments for coronavirus, a survey suggests. Of the 380 hospital and community-based pharmacists surveyed by the Royal Pharmaceutical Society and the UK Black Pharmacists Association, 236 were from a BAME background. Of those, 166 (70%) said they had not been approached by their employer to have a risk assessment. The RPS called the results "shocking". It has called on employers to take urgent action to ensure ethnic minority pharmacists are risk assessed. Read full story Source: BBC News, 26 June 2020
  12. Content Article
    Some of the serious findings of external reviews of NHS services from recent years, previously unpublished, have been released to HSJ.  An HSJ investigation has found the NHS has kept secret dozens of external reviews into care failings in local services including: A hospital where surgery may have “shortened life expectancy”. An alleged “cartel” of private patients said to be put on NHS lists. “Very high risk” consultant on-call arrangements. Problems with fetal heart monitoring in a maternity service. Potentially unnecessary operations being carried out. Rows among doctors putting patients at risk. Read their full report below.
  13. Content Article
    A framework designed by Dr Jane McCarthy, Human Factors and Patient Safety Consultant, for the measurement and monitoring of safety in the COVID-19 second wave.
  14. Content Article
    COVID-19 is an unprecedented crisis which has had a profound impact on health and care services across the UK and will continue to have an impact for the months and years to come. To guide the restoration of services, 25 cancer charities have come together and developed this document to set out a ‘12-point plan’, supported by available data and intelligence, for what they believe the health service in England will need to do to enable cancer services to recover from the pandemic.
  15. Content Article
    One of many legal, ethical, and patient safety issues raised by the COVID-19 pandemic across the NHS is that expectant mothers are considering freebirthing more after home births are cancelled. The charity AIMS (Association for Improvements in the Maternity Services) states that while there is no specific definition of freebirthing, “…broadly speaking, a woman freebirths when she intentionally gives birth to her baby without a midwife or doctor present. Some women prefer to use the term ‘unassisted childbirth’ or UC to describe this.” This may carry major health risks. For example, if complications occur during a freebirth, professional clinical help will not be at hand to help. John Tingle explores this further in his blog for the Bill of Health. John Tingle is a regular contributor to the Bill of Health blog and is a Lecturer in Law at Birmingham Law School in the UK and a Visiting Professor of Law, Loyola University Chicago, School of Law.
  16. Content Article
    Health care law is evolving particularly rapidly during the COVID-19 pandemic. For example, as the COVID-19 pandemic continues, families in England who have lost loved ones to the virus are considering filing clinical negligence claims. Perhaps in part due to the general, heightened public awareness of rights to sue for clinical negligence, people in the UK are now considering taking legal action against the National Health Service (NHS) for improper, negligent COVID-19 treatment. In cases of clinical negligence during COVID-19, a key issue centers around whether medical practitioners followed relevant clinical guidelines. John Tingle explores this further in his blog for the Bill of Health. John Tingle is a regular contributor to the Bill of Health blog and is a Lecturer in Law at Birmingham Law School in the UK and a Visiting Professor of Law, Loyola University Chicago, School of Law.
  17. News Article
    The NHS has kept secret dozens of external reviews of failings in local services – covering possible premature deaths, unnecessary and harmful operations, and rows among doctors putting patients at risk – an HSJ investigation has found. At least 70 external reviews by medical royal colleges were carried out from 2016 to 2019, across 47 trusts, according to information provided by NHS trusts, but more than 60 of these have never been published – contrary to national guidance – while several have not even been shared with the Care Quality Commission (CQC) and other regulators. These include reviews which uncovered serious failings. Bill Kirkup’s review into the Morecambe Bay scandal in 2015 recommended trusts should “report openly” all external investigations into clinical services, governance or other aspects of their operations, including notifying the CQC. Since then the CQC has asked trusts for details of external reviews when it reviews evidence, and in July 2018 it began to ask for copies of their final reports, but HSJ’s research suggests this does not always happen. James Titcombe, the patient safety campaigner whose son’s death led to the inquiry by Bill Kirkup into the Morecambe Bay maternity care scandal, said a review was now needed of whether its recommendations had been implemented. “It is not acceptable that five years [on], there are still secretive royal college reports and patients are kept in the dark,” he said. Read full story Source: HSJ, 25 June 2020
  18. News Article
    COVID-19 antibody tests for NHS and care staff are being rolled out without "adequate assessment", experts warn. The tests could place an unnecessary burden on the NHS, the 14 senior academics say in a letter in the BMJ, Last month, the government said it had bought 10 million antibody tests and asked NHS trusts and care homes to make them available to staff in England. Officials say the blood tests - to see if someone has had the virus - will play an "increasingly important role". The group of scientists say as a positive result is unable to prove immunity, the tests offer "no benefit" to hospitals and care staff. The results do not change what personal protective equipment staff must wear, for example. The academics also suggest there is little data on how well the test works for people at highest risk - including people belonging to some ethnic minorities and older patients. Instead, they call for other carefully designed strategies to help monitor the spread of the virus. Read full story Source: BBC News, 25 June 2020
  19. Content Article
    Now that hospitals are resuming elective surgery, what should surgeons tell patients about the perioperative risks of COVID-19? Many surgeons are now resuming elective work, yet some make no mention of the additional covid-related risks. Although the British Association of Spine Surgeons and some private hospitals have produced information sheets for patients undergoing surgery during the pandemic, to our knowledge no formal guidance has been issued by the General Medical Council or the Royal College of Surgeons on obtaining consent in such circumstances. The surgical community remains unclear as to what to tell patients about to undergo elective surgery. In this BMJ Opinion article, Daniel Sokol  and Rupen Dattani argue that patients who undergo elective surgery should be told that, despite measures to limit the risk of infection, there remains a risk of contracting covid-19 in hospital, whether before, during or after the operation. 
  20. Content Article
    Newly qualified nurses often fear making or identifying a clinical error so it is vital to know how best to prevent errors and manage them when they have occurred. This Nursing Times article looks at the most common clinical errors that are made, explains where to find the policies and procedures that should be followed, and highlights tips and tools that can be used to help rectify the issue or prevent it from happening in the first place.
  21. News Article
    Commenting on the newly-released Office for National Statistics (ONS) data on deaths registered weekly in England and Wales, the Health Foundation’s Chief Executive, Dr Jennifer Dixon, has expressed concerns that people are still avoiding visiting hospitals over fear of catching COVID-19. Hospital admissions have plummeted in the wake of the coronavirus outbreak as people look to avoid exposure to the virus, but as we begin to emerge out of the other side of the pandemic and begin the restoration of services there has been a need to rebuild that faith in patients. Dr Dixon said: “Today’s data show that deaths from COVID-19, and overall excess deaths, are decreasing. But while deaths in hospital are now below normal levels, deaths at home – just over 900 excess deaths in the week ending 12 June – remain higher than usual for this time of year. “As COVID-19 now recedes from hospitals, a key question is whether enough has been done to reassure people of their safety when accessing care, balanced against the risks of not seeking care.” Read full story Source: National Health Executive, 24 June 2020
  22. News Article
    The Care Quality Commission (CQC) has launched a review into its own regulatory response to a troubled autism service. The CQC has asked its head of inspection for child and justice services, Nigel Thompson, to examine its response to concerns that were raised about an autism service in south Staffordshire in 2019. Concerns were reported directly to the CQC in early 2019, by parents of children under the services, while similar issues were highlighted in a report from the local Healthwatch branch last July. In a statement, the CQC said: “Following concerns raised with us by families, in relation to The Hayes autism service run by Midlands Psychology, we are looking at the evidence we received about this service and how we assessed this to inform our regulatory response. “We are looking into these concerns in accordance with our complaints process. As a learning organisation, we welcome all feedback and we have already met with some of the families, but some meetings have been delayed due to the covid-19 pandemic.” Read full story Source: HSJ, 25 June 2020
  23. News Article
    A High Court judge has ruled that an NHS trust was negligent in failing to consider early enough that a toddler with fever, lethargy, and vomiting might have had a serious bacterial infection and to give her intramuscular antibiotics. Mr Justice Johnson said that doctors from University Hospital Southampton NHS Foundation Trust should have ordered a lumbar puncture on the 15 month old girl on the day she was first seen or the next day. The girl, referred to in court as SC, was sent by her GP to the hospital by ambulance on 26 January 2006 with a note describing his findings on examination and ending “?meningitis.” The GP, Mark Dennison, had given her intramuscular penicillin. Read full story (paywalled) Source: BMJ, 22 June 2020
  24. Content Article
    The Chartered Institute of Ergonomics & Human Factors has issued today their White Paper on Adverse Events. This report states what good practice should be in incident investigation across all industries, including health and social care. The White Paper is designed to: 1. Help organisations understand a human factors perspective to investigating and learning from adverse events. 2. Provide key principles organisations can apply to capture the human contribution to adverse events. How organisations learn, and fail to learn, from adverse events is discussed.
  25. Content Article
    The role of the Academic Health Science Network (AHSN) is to drive the uptake of innovation and technology and develop safer systems of care nationally and in a way that is specific and useful to regional partners. This Impact Report looks back over the last year (April 2019 until the end of March 2020) and some of the impacts that the East Midlands AHSN programmes have had.
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