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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    Prompt referral to early pregnancy services can make the difference between life and death in the diagnosis of ectopic pregnancies. This Healthcare Safety Investigation Branch (HSIB) report into the diagnosis of ectopic pregnancy found that differing levels of provision and a mismatch between capacity and demand in early pregnancy units (EPUs) heightens the risk that the diagnosis of this time-critical condition is delayed or missed.
  2. News Article
    There is significant variation in ambulance response times to patients with serious conditions such as suspected strokes or heart attacks, which is not fully explained by how rural an area is, an HSJ analysis has revealed. The exclusive analysis represents the first time ambulance performance for category two calls, which have an 18-minute response time target, have been broken down to clinical commissioning group level. Category two, known as emergency calls, covers a wide range of conditions, including suspected stroke and heart attacks (except cardiac arrests), major burns and epileptic seizures. They account for well over half of ambulance responses. The findings — described as “alarming” by the Stroke Association — lay bare the incredibly long waits which are usually hidden, because average waiting time data is usually published for ambulance trusts, which cover far larger areas than CCGs. Mark MacDonald, Deputy Director of Policy at the Stroke Association, said: “It is alarming to hear that in some cases ambulance staff are taking over an hour to reach patients because when it comes to stroke, being assessed quickly and then, if necessary, transferred to hospital, is really important.” Read full story (paywalled) Source: HSJ, 5 March 2020
  3. News Article
    The health service lacks the beds, staffing and resources to cope with a serious outbreak of the coronavirus, The Independent has been told by senior doctors and nurses. NHS staff from across the country warned hospitals are already unable to cope, with patients being looked after in spill-over wards and waiting hours for a bed, with one doctor saying it was already a “one in, one out mentality” for intensive care. Other staff reported delays in lab tests, rationing of protective masks and equipment, and a lack of isolation areas for suspected coronavirus patients. Suggestions from the Health Secretary Matt Hancock that the NHS would use “home ventilation kits”, and that an extra 5,000 intensive care beds could be created, were labelled “fanciful” by the chair of the British Association of Critical Care Nurses today. Nicki Credland said: “If you already have a system running at 100 per cent capacity, the idea you can get a significant amount of additional beds is just not realistic. There simply aren’t enough beds for them. We will need to make difficult decisions about which patients are going to be admitted to intensive care." Read full story Source: The Independent, 5 March 2020
  4. News Article
    The parents of a baby who nearly died after a series of failings during his birth said they were "heartbroken" mistakes continued to be made East Kent Hospitals told Harry Halligan's parents they would learn lessons from his delivery in 2012. But similar failings recently came to light after the death of Harry Richford in 2017 and the trust is now being probed over up to 15 baby deaths. The trust said it made "many changes to the maternity service" after 2012. Parents Dan and Alison Halligan, from New Romney, said watching news coverage of an inquest into Harry Richford's death earlier this year, which laid bare the failings, had brought back stressful memories. Mr Halligan said the trust "clearly haven't learned from [the] mistakes" made in his son's care, adding that it was "heartbreaking" to see "the same mistakes being repeated". Read full story Source: BBC News, 5 March 2020
  5. News Article
    The failure to address the mental-health needs of people with HIV could lead to an increase in infections, a cross-party group of MPs suggests. People with HIV are twice as likely to experience mental-health difficulties. However, in those with depression, support raises adherence to medication by 83%. But most HIV clinics have no mental-health professionals on staff, which, the MPs say, could be reversing progress made over the past decade toward ending the epidemic in the UK. The All-Party Parliamentary Group (APPG) on HIV and AIDS met with patients living with HIV at a range of hospital trusts throughout England, as well as numerous healthcare professionals. Unless serious mental-health treatment shortfalls are addressed, the government will fail to achieve its target of zero transmissions by 2030, its report says. Read full story Source: BBC News, 5 March 2020
  6. Content Article
    Patient Safety Right Now, the Canadian Patient Safety Institute’s (CPSI) 2018-2023 strategy defines a vision that “Canada has the safest healthcare in the world.” CPSI’s mission is: “to inspire and advance a culture committed to sustained improvement for safer healthcare.” CPSI develops system-wide strategies to ensure safe healthcare in two ways: by demonstrating what works to improve safe care in Canada, and by strengthening commitment to patient safety priorities among all healthcare stakeholders. It has, however, become clear that not only are more robust commitments required to advance patient safety in Canada, but health systems need additional evidence and support to complete end-to-end patient safety improvements and to measure and sustain results. To this end, CPSI drafted the Strengthening Commitment for Improvement Together: A Policy Framework for Patient Safety to stimulate conversation and action on the following policy levers: legislation, regulations, standards, organizational policies and public engagement.
  7. Content Article Comment
    Another great blog @MartinL! Thank you for sharing. You may be interested in another blog we published today from an anonymous nurse. She is frustrated at the lack of outcomes and learning from reporting at her hospital... https://www.pslhub.org/learn/improving-patient-safety/stories-from-the-front-line/florence-in-the-machine/marking-your-own-homework-r1726/
  8. News Article
    Technology and healthcare companies are racing to roll out new tools to test for and eventually treat the coronavirus epidemic spreading around the world. But one sector that is holding back are the makers of artificial-intelligence-enabled diagnostic tools, increasingly championed by companies, healthcare systems and governments as a substitute for routine doctor-office visits. In theory, such tools, sometimes called “symptom checkers” or healthcare bots,sound like an obvious short-term fix: they could be used to help assess whether someone has Covid-19, the illness caused by the novel coronavirus, while keeping infected people away from crowded doctor’s offices or emergency rooms where they might spread it. These tools vary in sophistication. Some use a relatively simple process, like a decision tree, to provide online advice for basic health issues. Other services say they use more advanced technology, like algorithms based on machine learning, that can diagnose problems more precisely. But some digital-health companies that make such tools say they are wary of updating their algorithms to incorporate questions about the new coronavirus strain. Their hesitancy highlights both how little is known about the spread of Covid-19 and the broader limitations of healthcare technologies marketed as AI in the face of novel, fast-spreading illnesses. Some companies say they don’t have enough data about the new coronavirus to plug into their existing products. London-based symptom-checking app Your.MD Ltd. recently added a “coronavirus checker” button that leads to a series of questions about symptoms. But it is based on a simple decision tree. The company said it won’t update the more sophisticated technology underpinning its main system, which is based on machine learning. “We made a decision not to do it through the AI because we haven’t got the underlying science,” said Maureen Baker, Chief Medical Officer for Your.MD. She said it could take 6 to 12 months before sufficient peer-reviewed scientific literature becomes available to help inform the redesign of algorithms used in today’s more advanced symptom checkers. Read full story Source: The Wall Street Journal, 29 February 2020
  9. News Article
    Northern Ireland's infant mortality rate remains the highest of any UK region although it has decreased, according to a new report. Infant mortality is a measure of deaths of children under one year of age. The report from the Royal College of Paediatrics and Child Health (RCPCH) shows the current rate is 4.2 deaths per 1,000 live births. In 2017, the figure stood at 4.8 deaths. Infant mortality rates decreased in Northern Ireland, Scotland and Wales but remained unchanged in England, which has the second highest rate of 3.9 deaths per 1,000. The report also highlights an increase in the suicide rate among young people aged 15–24 years. Responding to the figures, Health Minister Robin Swann said the physical and mental health of children and young people was a "priority" for the for the Northern Ireland Executive. "My department is already investing in a number of programmes and strategies which seek to address child health inequalities and improve the wellbeing of our children." Dr Ray Nethercott, RCPCH officer for Ireland acknowledged the current healthcare crisis as well as concerns about waiting lists and standard of care but added that "children's health and wellbeing should not be seen as being in competition with adult services or health provision". "Acting early to treat and prevent conditions, and reducing the impact of factors such as poverty, can really improve health outcomes. A healthier population of children and young people will reduce many of the pressures on adult services in the long term." Read full story Source: BBC News, 4 March 2020
  10. News Article
    Neglect and serious failures by the Home Office and multiple other agencies contributed to the death of a vulnerable man who died from hypothermia, dehydration and malnutrition in an immigration removal centre, an inquest has found. Prince Fosu, a 31-year-old Ghanaian national, died in October 2012 when his naked body was found on the concrete floor of his cell in Harmondsworth, a detention centre near Heathrow. He had been experiencing a psychotic episode but he was not referred for a mental health assessment due to “gross failures” by all agencies to recognise the need to provide appropriate care to a person unable to look after himself. Four GPs, two nurses, two Home Office contract monitors, three members of the Independent Monitoring Board (IMB) and countless detention custody officers and managers who visited him failed to take any meaningful steps, the inquest found. Three doctors have since been referred to the UK’s medical watchdog for their alleged failures relating to the death of Mr Fosu on recommendation of the Prison and Probation Ombudsman (PPO), who said the care he received fell “considerably below acceptable standards”. Read full story Source: The Independent, 3 March 2020
  11. News Article
    Women in labour are being refused epidurals in breach of official guidelines, a government inquiry has found. In findings reported by the Guardian, an investigation by the Department of Health and Social Care also found that women may not be being kept fully informed that if they choose to give birth at home or in a midwife-led unit they may have to be transferred if they want an epidural. Failing to make women aware of that possibility would also be in breach of National Institute for Health and Care Excellence (NICE) guidelines. As a result of the inquiry, the Health Minister Nadine Dorries will write to all heads and directors of midwifery and medical directors at NHS trusts this week to remind them of the NICE guidance regarding pain relief during childbirth and to ensure it is being followed. Clare Murphy, Director of external affairs at the British Pregnancy Advisory Service, said the “results of the government’s inquiry are sadly not surprising”. She added: “We have spoken with many women who have been so traumatised by their experience of childbirth that they are considering ending what would otherwise be wanted pregnancies. Pain relief is sometimes treated as a ‘nice extra’ rather than an integral part of maternity care, and women and their families can suffer profoundly as a result." Read full story Source: Guardian, 3 March 2020
  12. News Article
    Every week for nearly a year, Lorraine Shilcock attended an hour-long counselling session paid for by the NHS. She needed the therapy, which ended in November, to cope with the terrifying nightmares that would wake her five or six times a night, and the haunting daytime flashbacks. Lorraine, 67, a retired textile worker from Desford, Leicester, has post-traumatic stress disorder (PTSD). Her psychological scars due to a routine NHS medical check, which was supposed to help her, not leave her suffering. In October 2018, Lorraine had a hysteroscopy, a common procedure to inspect the womb in women who have heavy or abnormal bleeding. The 30-minute procedure, performed in an outpatient clinic, is considered so routine that many women are told it will be no worse than a smear test and that, if they are worried about the pain, they can take a couple of paracetamol or ibuprofen immediately beforehand. Yet for Lorraine, and potentially thousands more women in the UK, that could not be further from the truth. Many who have had a hysteroscopy say the pain was the worst they have ever experienced, ahead of childbirth, broken bones, or even a ruptured appendix, commonly regarded as the most agonising medical emergency. Yet most had no warning it would be so traumatic, leaving some, like Lorraine, with long-term consequences. But, crucially, it is entirely avoidable. Do you have an experience you would like to share? Join our conversation on the hub on painful hysteroscopy. We are using this feedback and evidence to help campaign for safer, harm-free care. Read full story Source: Mail Online, 3 March 2020
  13. Content Article
    Do you see female patients? Do they have painful periods? Pain pre or post their periods? Painful sex? Do they suffer chronic pain, which may be intermittent or constant? Do they have pain when passing urine or with bowel movements? Is it painful to place a speculum for a smear test? Have you considered endometriosis? The Royal College of Nursing has provided a factsheet for nurses with guidance on how to recognise symptoms, setting out pathways of care and signposts to useful online resources.
  14. Content Article
    In this article, Berlanda et al. discuss the safety of different medical treatments for endometriosis to relieve pain.
  15. News Article
    The Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent report suggests little progress has been made to prevent errors within the perioperative environment. The patient safety charity made the call following the release of NHS Improvement’s latest Never Event report; Provisional publication of Never Events reported as occurring between 1 April and 31 December 2019, which revealed an alarming 81% (284) of the never events recorded happened while a patient was on the operating table. Lindsay Keeley, patient safety and quality lead at AfPP said: “The survey highlighted that there’s a need to take action now if we are to support the healthcare profession in reducing the occurrence of never events. It has become clear that receptive team culture, a strong leadership team and better support for staff is what will help to reduce the risk of a never event occurring. It’s vital that those in leadership positions begin to understand the contributory factors in the recurrence of never events and the challenges faced by staff." She went on to highlight some of the recent initiative taking place: “What is promising is that there are practitioners who are developing new, practical and simple solutions every day that can support other team members and can be used within theatres across the country." "One example is Rob Tomlinson’s introduction of the 10,000 Feet initiative – a safety initiative designed to cut through noise and distraction within the theatre environment, particularly at critical points of the patient’s journey. If correctly implemented, initiatives like this can cut through the hierarchies that stop people feeling unable to speak up when they see something that shouldn’t be happening, thus reducing the occurrence of never events" “We of course need to be mindful that there will always be challenges within perioperative practice in the form of interruptions and distractions, but the key is how as practitioners we engage with this to recognise and reduce never events.” Read full story Source: Clinical Services Journal, 25 February 2020
  16. Content Article
    The aim of the Patient Safety and Access Initiative of India Foundation is to improve accessibility to safe and quality healthcare for all under Universal Health Coverage (UHC) and tackling the menace of spurious and not of standards medicines in the supply chain globally.
  17. News Article
    Hundreds of women have said they’ve undergone “distressing” diagnostic tests at NHS hospitals which were not carried out in line with recommended practice. Around 520 women who attended NHS hospitals in England to undergo hysteroscopies — a procedure which uses narrow telescopes to examine the womb to diagnose the cause of heavy or abnormal bleeding — have told a survey their doctors carried on with their procedures even when they were in severe pain. This is despite the Royal College of Obstetricians and Gynaecologists advising clinicians should offer to reschedule with the use of general anaesthetic, epidural or sedation if the pain becomes unbearable. The Campaign Against Painful Hysteroscopy patient group has surveyed 860 women who had had the procedure at an English NHS hospital, and shared the results with HSJ. Of them, 750 said they were left distressed, tearful or shaken by the procedure, with around 466 of them saying that feeling remained for longer than a day. Many of the women said their painful hysteroscopies damaged their trust in healthcare professionals, had made cervical smears more painful and had a negative impact on sexual relationships. Patient Safety Learning have connected with the campaigning group 'Hysteroscopy Action' on this issue. We have seen stories and comments posted on the hub from patients who have suffered similar distressing experiences. We are using this feedback and evidence to help campaign for safer, harm-free care. We welcome others to join in the conversation. Read full story (paywalled) Source: HSJ, 2 March 2020
  18. News Article
    A new poll has found only 8 out of the 1,618 respondents believed the health service was ready to deal with an outbreak when asked by The Doctors’ Association UK (DAUK), despite the prime minister’s insistence that the NHS will cope if it is hit by a surge in the number of people falling ill. Common concerns included difficulties coping with increased demand, a shortage of beds and poor staffing levels, according to the group who led the poll. Some doctors asked said they were worried that there could be not enough laboratory space to do testing in the case of a pandemic. Others claimed that NHS 111 had been giving out “inappropriate advice” to go to A&E and GP practices, according to DAUK. “The NHS has already been brought to its knees and many frontline doctors fear that our health system simply will not cope in the event of a Coronavirus (Covid-19) outbreak,” Dr Rinesh Parmar, the DAUK chair, said. “Many hoped the threat of Covid-19 would prompt an honest conversation to address the issue of critical care capacity and our ability to look after our sickest patients. By simply saying ‘the NHS is well prepared to deal with coronovirus’ it seems that yet again doctors’ concerns have been brushed under the carpet.” The findings come after the number of people infected with the coronavirus which rose to 39 in the UK on Monday. Read full story Source: The Independent, 3 March 2020
  19. Content Article
    This leaflet has guidance for the person who has or may have an eating disorder, anyone supporting them, and their GP. It’s based on the guideline on eating disorders from the National Institute for Health and Care Excellence (NICE), which the GP should use when making decisions about patients’ healthcare.
  20. News Article
    A senior NHS nurse was fired after warning the increased workload on her pressured staff had contributed to a patient’s death. Linda Fairhall, 60, had an unblemished record of almost 40 years’ service when she turned whistleblower at North Tees and Hartlepool NHS trust. In 2015 she raised concerns over a new requirement for district nurses to monitor patients’ prescriptions. She said it meant a sudden increase of around 1,000 extra visits a month for her hard-pressed team of 50 nurses with no extra resources. Over the next 10 months she reported 13 matters, alleging the health or safety of patients and staff was being or was likely to be put at risk. After a patient died in 2016 she claimed it may have been prevented if her concerns had been addressed. She told the trust’s care group director Julie Parks she wished to start the formal whistle-blowing procedure. Soon after she was suspended over allegations of potential gross misconduct relating to her leadership, and then sacked. Dr Henrietta Hughes, the UK’s national NHS guardian, said: “Workers who speak up should be thanked for doing so and the organisation should demonstrate they are taking action to address the issues raised.” North Tees and Hartlepool NHS Trust said it will appeal the decision. Read full story Source: The Mirror, 2 March 2020
  21. Event
    until
    What does effective change leadership actually look like and how do we know when we're getting it right? The need for change in safety critical industries has never been greater. Leadership teams are facing challenges on an unprecedented scale. This conference will provide you with a unique opportunity to: Challenge and change your perspectives with world class change leaders in other industries. Gain new insights and insights from real world accounts of success and failure, adaptation and disruptive innovation. Go beyond the theory and discover the unexpected. The Philosophical Breakfast Club.pdf
  22. News Article
    Although community-based treatment can improve outcomes for people with eating disorders, it must not be at the expense of vital inpatient services, says Lorna Collins in an article today in the Guardian supporting Eating Disorders Awareness Week. No single treatment or approach works for every patient experiencing an eating disorder and it is extremely hard to get help; there is too little money in the system to provide enough care. "Speaking to patients, carers and clinicians, I am struck by the sheer desperation of so many people saying the system has failed them. Too many find that nothing is done until they are at death’s door. Others say no one talks about binge-eating disorder, which is still too often seen as a weakness or a problem that dieting can fix, rather than a real eating disorder," says Lorna. Clinicians, too, paint a gloomy picture of the state of services. Oxford-based eating disorder consultant Agnes Ayton, who chairs the faculty of eating disorders at the Royal College of Psychiatrists, is frank about the problems. She believes NHS eating disorder services are on their knees and desperately need more money after years of austerity. However, there are some encouraging signs. In West Yorkshire and Harrogate, consultant psychiatrist William Rhys Jones, who works for the Connect community and inpatient eating disorders service, says he is seeing real change. Connect’s community outreach teams deliver home-based treatment for people with severe and enduring eating disorders. This is one of the NHSE new care models and Jones says results so far have been very positive. Clinical community services and early intervention result in a good prognosis, he says – and it is cost effective. While inpatient treatment costs about £434 a day, community treatment costs about £20 to £35 a day, with similar or even improved clinical outcomes. While there are concerns about limiting inpatient treatment and prioritising community treatment simply because it may be cheaper, positive examples like this can help hold the NHS to its promise to make treatment truly open to all who need it. Read full story Source: The Guardian, 2 March 2020
  23. News Article
    The NHS is currently rolling out services on NHS sites to test people for coronavirus, including a new service now in action in west London, offering ‘drive through’ coronavirus testing. The new service, provided by Central London Community Healthcare NHS Trust in Parsons Green, is only accessed through a referral from NHS 111, and means people worried about the virus can safely and quickly get checked close to home. The model is one of the ways in which community testing and home testing are being rolled out nationwide, with the NHS’ strategic incident director for coronavirus, asking health services in every part of England to set up home and community testing. After being referred through NHS 111, people are invited to an appointment in their car, during which two community nurses carry out a swab in the nose and mouth, which are checked and assessed within 72 hours. People are asked to self-isolate while checks are completed, to prevent any potential onward transmission of the virus. Dr Joanne Medhurst, medical director for Central London Community Healthcare NHS Trust, said: “Anyone who is worried about coronavirus should call NHS 111 for up to date advice. We’ve set up the ‘drive through’ service to make sure people in our community can get safe, convenient and quick checks for coronavirus, as part of NHS efforts to keep everyone safe." “It’s crucial that, as a community service, we help residents in our area to get accurate, timely advice while managing extra pressure on the NHS, and so far this week we’ve had good feedback from people that the swabbing service offers reassurance at what can be a difficult time.” Read full story Source: NHS England, 28 February 2020
  24. News Article
    Prime Minister Boris Johnson will say there is “little doubt” the coronavirus will present a “significant challenge” for the UK as he chairs a Cobra meeting to discuss the government’s response to the outbreak. The health secretary, Matt Hancock, has warned it was now “inevitable” the deadly virus would “become endemic” in the UK as 13 more cases of Covid-19 were announced, bringing the total number to 36. The Cobra meeting will bring together senior ministers and the Chief Medical Officer, Professor Chris Whitty and Chief Scientific Adviser Sir Patrick Vallance. Meanwhile the worldwide death toll from the disease has passed 3,000, with more than 80,000 cases worldwide. Several countries in Europe, the Middle East and the Americas have banned large gatherings and imposed stricter travel restrictions in an attempt to limit infections.the Americas have banned large gatherings and imposed stricter travel restrictions in an attempt to limit infections. Read full story Source: The Indpendent, 2 March 2020
  25. Content Article
    Roger Kline, Consultant on Workforce Culture, describes the “lifecycle” of a whisltleblower and the stages and steps they will go through. It's one many whistleblowers will recognise in part or in full.
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