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Patient Safety Learning

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  1. Patient Safety Learning
    Plans for up to 150 new community diagnostic hubs to tackle the NHS’ ballooning diagnostic waiting lists are included in NHS England ‘blue print plans’ leaked to HSJ.
    The document pointed out the hubs “were highlighted in the phase 3 letter [from Sir Simon Stevens] and will be recommended as part of new service models for diagnostics in the forthcoming [Sir Mike] Richards’ Review of Diagnostics Capacity”.
    It said “at least 150 community diagnostic hubs should be established in the first instance (broadly equivalent to the number of acute hospitals)” although it appears many of these may be temporary facilities.
    The phase 3 letter said systems should mange the “immediate growth in people requiring cancer diagnosis and/or treatment returning to the service by… the development of community diagnostic hubs” among other measures
    The Richards review was commissioned by NHS England in 2019 as it had long been recognised that England has one of the lowest levels in Europe of diagnostic equipment as well as a shortage in facilities and staff. Last month think-tanks warned of significant worsening of cancer outcomes because of the backlog in diagnosis and treatment created by a fall in referrals during the pandemic..."
    Read full story (paywalled)
    Source: HSJ, 4 September 2020
  2. Patient Safety Learning
    NHS England must find hundreds of millions of pounds in last-minute savings to pay for ongoing covid staff tests, it has been revealed
    NHSE chief financial officer Julian Kelly told a meeting of NHS England’s board: “We have been asked to see if we can cut core NHS funding - at the moment that is probably to the tune of £500m.” Mr Kelly said achieving this would likely involve “slowing down” some transformation programmes and ambitions in the Long Term Plan.
    He added that rising inflation could add an extra £1bn in financial pressure, telling the board “we’re going to have to look at what that means for our ability to deliver NHS goals in the round.”
    It was reported in February that Health Secretary Sajid Javid and Chancellor Rishi Sunak were at loggerheads over whether the Department of Health and Social Care (DHSC) should receive additional funding for covid testing on top of the health service’s spending envelope. The row is said to have led to a delay in plans to scrap all remaining virus-related restrictions.
    The DHSC reduced its ask for extra cash down from £5bn to an eventual £1.8bn but even this lower sum was rejected by the Treasury, according to reports. This means continuing staff testing will have to paid for out of the existing NHS budget.
    Read full story (paywalled)
    Source: HSJ, 24 March 2022
  3. Patient Safety Learning
    A home care worker who did not wear protective equipment may have infected a client with a fatal case of coronavirus during weeks of contradictory government guidance on whether the kit was needed or not, an official investigation has found.
    The government’s confusion about how much protection care workers visiting homes needed is detailed in a report into the death of an unnamed person by the Healthcare Safety Investigation Branch (HSIB), which conducts independent investigations of patient safety concerns in NHS-funded care in England. It was responding to a complaint raised by a member of the public in April.
    The report shows that Public Health England published two contradictory documents that month. One advised care workers making home visits to wear PPE and the other did not mention the need. The contradiction was not cleared up for six weeks.
    The government’s guidance had been a shambles that had placed workers and their vulnerable clients at risk, the policy director at the United Kingdom Homecare Association, Colin Angel, said on Wednesday. The association also accused the government of sidelining its expertise and publishing new guidance with little notice, sometimes late on Friday nights, meaning that it was not always noticed by the people it was intended for.
  4. Patient Safety Learning
    In a keynote speech at the Healthtech Alliance on Tuesday, Secretary of State for Health and Social Care, Matt Hancock, stressed how important adopting technology in healthcare is and why he believes that it is vital for the NHS to move into the digital era. 
    “Today I want to set out the future for technology in the NHS and why the techno-pessimists are wrong. Because for any organisation to be the best it possibly can be, rejecting the best possible technology is a mistake.”
    Listing examples from endless paperwork to old systems resulting in wasted blood samples, Hancock highlights why in order to retain staff and see a thriving healthcare, embracing technology must be a priority.
    He also announced a £140m Artificial Intelligence (AI) competition to speed up testing and delivery of potential NHS tools. The competition will cover all stages of the product cycle, to proof of concept to real-world testing to initial adoption in the NHS.
    Examples of AI use currently being trialled were set out in the speech, including using AI to read mammograms, predict and prevent the risk of missed appointments and AI-assisted pathways for same-day chest X-ray triage.
    Tackling the issue of scalability, Hancock said, “Too many good ideas in the NHS never make it past the pilot stage. We need a culture that rewards and incentivises adoption as well as invention.”
    Read full speech
  5. Patient Safety Learning
    Endemic ill-health in England’s “left behind” neighbourhoods costs the country almost £30bn a year because people are often too ill to work and die earlier, a report claims.
    The cost of lost productivity results directly from those very deprived areas having much worse health than the rest of the country, according to parliamentarians and academics.
    Experts from the Northern Health Science Alliance (NHSA) have calculated that the economy would grow by that amount if health in those areas was improved to such an extent that local people began to enjoy the same health as those in better-off places.
    The report, by the NHSA and all-party parliamentary group for left behind neighbourhoods (LBNs), highlights the scale of the challenge Boris Johnson faces in meeting his pledge to level up England’s poorest and richest areas.
    “The health of people living in left behind neighbourhoods is considerably worse than the health of people living in the rest of the country,” said Dr Luke Munford, the report’s lead author and a lecturer in health economics at the University of Manchester. “This is true across all measures of health.”
    The report shows rates of obesity, lung conditions, high blood pressure, mental health problems and other diseases are much higher than the national average in the 225 LBNs. This means people there have less “healthy life expectancy” and also shorter lives and thus are less productive over their lifespan than those elsewhere.
    Read full story
    Source: The Guardian, 13 January 2022
  6. Patient Safety Learning
    The pharmaceutical giant Johnson and Johnson has agreed to pay an undisclosed sum to settle a legal action by hundreds of Scottish women who claimed they suffered serious injuries from the company’s pelvic mesh implants.
    The settlement came as four lead cases brought by women who suffered pain and other serious side effects from the implants, made by Johnson and Johnson subsidiary Ethicon, were about to reach court in Edinburgh.
    Read full story (paywalled)
    Source: BMJ, 2 June 2020
  7. Patient Safety Learning
    The BMA has written to the government to call for new legislation to ensure accountability for safe staffing levels and that “individual clinicians are not blamed when the system places them under unmanageable pressure.”
    The call came as the BMA published a year long study looking at the changes needed to improve care of patients and the working lives of doctors in the NHS, alongside a “manifesto for change” outlining all the recommendations.
    Read full story (paywalled)
    Source: BMJ, 13 September 2019
  8. Patient Safety Learning
    Tens of thousands more women tested themselves for autism last year with numbers seeking tests now far outstripping men, new data shows.
    Statistics seen by The Independent show around 150,000 women took an online test verified by health professionals to see if they have autism last year, up from about 49,000 in 2020.
    Health professionals said the increase was a consequence of women not being diagnosed with the neurodevelopmental disorder as children and teens due to autism wrongly being viewed as a male disorder.
    Experts told The Independent autistic women and girls are routinely overlooked and neglected by health services due to them being more likely to conceal or internalise symptoms.
    Data from Clinical Partners, one of the UK’s leading mental health care providers which works closely with the NHS, shows women made up 56 per cent of those using their autism tests last year. This is substantially higher than the 46 per cent of women testing themselves for autism in 2020.
    Hannah Hayward, neurodevelopmental specialist at Clinical Partners, who provided the exclusive data, explained: “Diagnosis is crucial – without which, women and men can be susceptible to symptoms of mental health conditions including anxiety and depression and it is common for them to be misdiagnosed with or develop other conditions such as anxiety, anorexia, depression or Borderline Personality Disorder,” 
    Read full story
    Source: The Independent, 23 March 2022
     
  10. Patient Safety Learning
    Several trust procurement leads have expressed frustration with the government’s response to covid-19, with HSJ being told of shortages of crucial personal protective equipment, unpredictable deliveries and a lack of clarity from the centre
    NHS Supply Chain, which procures common consumables and medical devices for trusts, has been “managing demand” for an increasing number of PPE and infection control products for since the end of February to ensure “continuity of supply”. Some products, like certain polymer aprons, are unavailable altogether because of the increased demand and disrupted supply caused by the covid-19 outbreak. 
    One procurement lead told HSJ: “They aren’t supplying enough, they aren’t fulfilling orders. It’s completely chaotic.” Another said his trust had “just enough to manage for the time being.”
    Read full story (paywalled)
    Source: HSJ, 20 March 2020
  11. Patient Safety Learning
    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
  12. Patient Safety Learning
    An ambulance trust has been accused of acting like a “criminal gang” and lying to dead patients’ families by an employee who repeatedly warned about paramedics’ mistakes being covered up.
    Paul Calvert, a coroner’s officer whose job was to produce reports on deaths, tried to raise concerns about managers at the North East Ambulance Service (NEAS) for three years before walking out last year on the verge of a breakdown.
    “My life was being made a misery,” said Calvert, who was previously a detective with Northumbria police. “They were basically like a criminal gang. I had tried everything I could to warn the proper authorities about how the service was destroying and concealing evidence meant for the coroner. I spoke to my managers, to human resources, to external auditors. I even made disclosures to the Care Quality Commission and Northumbria police. Nothing was done about it.”
    Despite their denials of a large-scale cover-up of mistakes, the NEAS this year offered Calvert £41,000 as part of a non-disclosure agreement it asked him to sign. One of the clauses meant destroying all the evidence he had collected. Another tried to stop him making any further disclosures to police.
    Reports and witness statements from ambulance staff were not being disclosed to the coroner “on a daily basis”, according to Calvert, amounting to key pieces of evidence relating to deaths being hidden from the public.
    Read full story (paywalled)
    Source: The Times, 29 May 2022
  13. Patient Safety Learning
    As part of the NHS Digital Child Health programme, Personal Child Health Records or “Redbook” will receive a digital makeover.

    NHS Digital has considered the limitations of the physical Redbook and decided that digitalisation is the way forward for parents to easily access important health and development information.

    Nurturey has been evolving its product to align with NHS' Digital Child Health programme. It aims to be an app that can make the digital Redbook vision a reality and currently in the process of completing all the necessary integrations and assurances.

    It is hoped that by using smart digital records, parents will be more aware of their child’s health information like weight, dental records, appointments and other developmental milestones.  

    Tushar Srivastava, Founder and CEO of Nurturey, said:

    “Imagine receiving your child's immunisation alert/notification on the phone, clicking on it to book the immunisation appointment with the GP, and then being able to see all relevant immunisations details on the app itself. As a parent myself, I see the huge benefit of being able to manage my child’s health on my fingertips. We are working hard to deliver such powerful features to parents by this summer.”
    Read full story
    Source: National Health Executive, 5 February 2020
  14. Patient Safety Learning
    Doctor shortages are jeopardising patient safety and rota gaps are pushing the NHS to “breaking point”, Scottish physicians have warned.
    A lack of doctors in NHS Scotland due to unfilled vacancies, sick leave and a shortage of staff is often putting patients’ welfare at risk, a survey of consultants has found. More than a third of Scottish doctors (34%) reported, in the Royal Colleges’ annual census, that trainee rota gaps occurred at least daily, while 16% warned they are causing “significant patient safety problems”.
    A further 78% of those who responded said rota gaps potentially cause patient safety problems, but that there are solutions in place.
    Read full story
    Source: The Scotsman, 14 October 2019
  15. Patient Safety Learning
    The high proportion of pregnant women from black and ethnic minority (BAME) groups admitted to hospital with COVID-19 "needs urgent investigation", says a study in the British Medical Journal.
    Out of 427 pregnant women studied between March and April, more than half were from these backgrounds - nearly three times the expected number. Most were admitted late in pregnancy and did not become seriously ill. Although babies can be infected, the researchers said this was "uncommon".
    When other factors such as obesity and age were taken into account, there was still a much higher proportion from ethnic minority groups than expected, the authors said.
    But the explanation for why BAME pregnant women are disproportionately affected by coronavirus is not simple "or easily solved," says Professor Knight, lead author.
    "We have to talk to women themselves, as well as health professionals, to give us more of a clue."
    Gill Walton from the Royal College of Midwives says, "Even before the pandemic, women from black, Asian or ethnic minority backgrounds were more likely to die in and around their pregnancy,"
    She said they were "still at unacceptable risk" and getting help and support to affected communities was crucial. 
    Ms Walton added: "The system is failing them and that has got to change quickly, because they matter, their lives matter and they deserve the best and safest care."
    Read full story
    Source: BBC News, 8 June 2020
  17. Patient Safety Learning
    An acute trust has been fined £2.5m after pleading guilty to charges of failing to provide safe care after the deaths of two patients.
    The Care Quality Commission brought charges against The Dudley Group Foundation Trust earlier this year over care failings in two separate cases which the regulator said exposed two patients to “significant risk of avoidable harm”.
    The trust pleaded guilty to the charges in July and was fined during a sentencing hearing today.
    The cases, involving 33-year-old mother of six Natalie Billingham, and 14-year-old Kaysie-Jane Bland [also known as Kaysie-Jayne Robinson], were both in 2018 and  related to care at the trust’s Russells Hall Hospital in Dudley.
    Ms Billingham was admitted to Dudley’s Russells Hall Hospital with numbness in her right foot on 28 February 2018 and died on 2 March of organ failure caused by a “time critical” infection.
    The court was told she was initially thought to have a deep vein thrombosis after a three-minute triage that failed to identify "disordered" observations. The hospital then had multiple reasons to reconsider the initial diagnosis, but opportunities for review were "missed or ignored".
    In the case of Kaysie-Jane, who had cerebral palsy, an "early warning score" was inaccurate, meaning a sepsis screening tool was not triggered.
    The CQC said the care both patients received at Russells Hall Hospital was undermined by the Dudley Group’s failure to address known safety failings which the regulator repeatedly raised with the trust in the months before their deaths. The CQC said the trust did not take all reasonable steps to make improvements, despite its intervention. The trust has denied it did not react to the concerns raised. 
    Failings included errors in the hospital’s initial assessments and monitoring of both patients, which hindered the timely escalation of concerns.
    A lawyer acting on behalf of the Dudley Group NHS Foundation Trust had admitted the trust failed to provide treatment in a safe way, resulting in harm, in February and March 2018.
    Read full story (paywalled)
    Source: HSJ, 19 November 2021
  18. Patient Safety Learning
    At last week’s meeting in Perth, Australia, the COAG Health Council discussed a number of national health issues, one of which was the Quality Use of Medicines.
    The Council’s resulting communique highlights that medicines are the most common intervention in healthcare and can contribute to significant health gains – but can also be associated with harm.
    “Half of all medication related harm is preventable and a coordinated national approach that identifies and promotes best practice models and measures progress towards reducing medication related harm has the potential to improve the health of Australians and create savings across the health care system,” it notes.
    At the meeting, the Health Ministers agreed to make the Quality Use of Medicines and Medicines Safety the 10th National Health Priority Area
    Read full story
    Source: Australian Journal of Pharmacy, 4 November 2019
  19. Patient Safety Learning
    A Scottish mum has made an emotional plea to other parents to push for blood tests for their children if they feel ‘something isn’t right’ after her son’s leukaemia symptoms were dismissed numerous times by doctors.
    Jayke Steel, aged 5 years, was diagnosed with acute lymphoblastic leukaemia (cancer of the blood) in February after months of being ill.
    His mum Cara took him to the doctor on various occasions but time and time again she was told he was fine and it was “probably just a virus”.
    When he started getting night sweats,  instead of the doctor Cara him to Forth Valley Hospital where they ran tests and said they believed he was suffering from leukaemia.
    “He was then transferred to Glasgow’s Queen Elizabeth Hospital where they immediately took a bone marrow test which showed he definitely had leuklaemia."
    Read full story
    Source: The Scotsman, 15 September 2019
  20. Patient Safety Learning
    A ‘culture of distrust’ between consultants and the use of incident reporting as a tool of ‘reprisal’ impacted patient care at a trust’s cardiology department, a review has concluded.
    An external review undertaken for Hull University Teaching Hospitals Trust has made a series of recommendations after looking into allegations of bullying and several examples of poor care within its cardiology services.
    In a report published in the trust’s board papers, the Royal College of Physicians reported a “perceived tendency to downplay clinical incidents, and, to undermine those who wanted to raise patient safety issues”.
    It added: “We met a group of individual consultants who did not work well as a team. There is a culture of distrust, a lack of departmental cohesion and allegations of bullying in the department. All of which reinforce a clear divide between the interventional and non-interventional consultant cardiologists."
    “There have been a number of allegations of belittling, intimidation and undermining…The review team heard accounts of a culture where datix has been used as a tool for possible personal reprisal along with ignoring/downplaying incidents that have been raised.”
    The review concludes: “This behaviour is impacting on patient care and therefore, all medical staff should be reminded of good medical practice as the [General Medical Council] code of conduct of how doctors must work collaboratively with colleagues.”
    Read full story (paywalled)
    Source: HSJ, 16 November 2021
  21. Patient Safety Learning
    Pharmacy staff in England are facing growing abuse and aggression from patients frustrated that drug shortages mean they cannot get their usual medications, a survey reveals.
    The hostility, including swearing and spitting, comes as availability of medicines is becoming more uncertain as a result of Brexit, the Covid pandemic and ingredient supply problems. Hormone replacement therapy drugs are in short supply in many places, affecting women undergoing menopause, for example.
    Half of pharmacists and counter staff say the unpredictability is causing problems for customers managing their health, according to research by the Pharmaceutical Services Negotiating Committee (PSNC), which represents community pharmacies in England.
    The PSNC’s survey of 1,132 staff from and 418 bosses of 5,000 pharmacies found:
    75% of pharmacies have seen patients turn aggressive when told they cannot have the medication they have been prescribed. 49% of staff say patient abuse is undermining their mental wellbeing. 51% believe supply chain issues affect patients every day. “It is really worrying to hear that pharmacy staff are so routinely facing aggression from patients,” said Janet Morrison, the PSNC’s chief executive. “Pharmacists tell us anecdotally that this can include verbal abuse, swearing, spitting and threatening to report staff to regulators.
    “Many community pharmacies are having to deal with medicine supply issues on a daily basis. This adds pressures on to already busy pharmacy teams and can also be worrying for patients if they have to wait longer for the medicines that they need.”
    Patients were left “frustrated and inconvenienced” by drug shortages, she added.
    Read full story
    Source: The Guardian, 25 April 2022
  22. Patient Safety Learning
    An epilepsy drug that caused disabilities in thousands of babies after being prescribed to pregnant women could be more dangerous than previously thought.
    Sodium valproate could be triggering genetic changes that mean disabilities are being passed on to second and even third generations, according to the UK’s medicines regulator.
    The Medicines and Healthcare Products Regulatory Agency (MHRA) has also raised concerns that the drug can affect male sperm and fertility, and may be linked to miscarriages and stillbirths.
    Ministers are already under pressure after it emerged in April that valproate was still being prescribed to women without the legally required warnings. Six babies a month are being born after having been exposed to the drug, the MHRA has said. It can cause deformities, autism and learning disabilities.
    Cat Smith, the Labour chairwoman of the all-party parliamentary group on sodium valproate, said: “This transgenerational risk is very concerning. There have been rumours that this was a possibility, but I had never heard it was accepted until last week by the MHRA."
    “The harm from sodium valproate was caused by successive failures of regulators and governments, and this news means it could be an order of magnitude worse than we first thought. It underlines the need for the Treasury to step up to their responsibilities around financial redress to those families.”
    Read full story (paywalled)
    Source: Sunday Times, 19 June 2022
  23. Patient Safety Learning
    There are not enough nurses to safely care for patients in the UK, according to the body that represents the profession, and many of those who are working are suffering from anxiety and burnout after a gruelling nine months treating Covid patients.
    A year after the prime minister pledged during the 2019 election campaign to add 50,000 nurses to the NHS, the Royal College of Nursing has accused Boris Johnson of being “disingenuous” for claiming the government is meeting this 2025 target.
    Johnson claimed last week that the government had “14,800 of the 50,000 nurses already” during prime minister’s questions in the Commons.
    Yet the latest NHS figures show there were 36,655 vacancies for nursing staff in England in September, with the worst shortages affecting mental health care and acute hospitals. Staff in some intensive care units (ICUs) have quit since the pandemic, with those whom the Observer spoke to choosing to work instead in supermarkets or as dog-walkers.
    Dame Donna Kinnair, the RCN’s chief executive and general secretary, said: “The simple, inescapable truth is that we do not have enough nursing staff in the UK to safely care for patients in hospitals, clinics, their own homes or anywhere else.”
    She said that even before the pandemic, “heavy demand” was rising faster than the “modest increases” in staff numbers.
    Read full story
    Source: The Guardian, 12 December 2020
  24. Patient Safety Learning
    Staff at the Care Quality Commission (CQC) have been left ‘in fear of speaking out’ against structural changes to the organisation which they believe ‘pose a significant risk’ to the CQC’s ability to regulate health services, trade unions have told the health and social care secretary.
    A letter signed by senior officers of Unison, Royal College of Nursing, Unite, Prospect and the Public and Commercial Services union has called on Therese Coffey to urge the CQC to pause its organisational change and enter into “meaningful discussions” with the unions.
    The unions have raised concerns that organisational changes to the CQC have been drawn up by consultants with no frontline experience in health and social care, or in regulation, and that staff have had limited input into the changes.
    They allege that staff raising concerns about the changes have been dismissed as being “disruptive” or “negative”, and significant numbers of experienced staff have recently left the regulator.
    The CQC said in response to the letter that the changes it was proposing were needed to enable the regulator to “work more effectively across the health and care system”, and that it has engaged with trade unions throughout the process.
    Read full story (paywalled)
    Source: HSJ. 23 September 2022
  25. Patient Safety Learning
    On January 2020, Patient Safety will be on the G20 agenda (among other five health key priorities), but Abdulelah M. Alhawsawi, Saudi Patient Safety Center, asks "what is patient safety doing on an economic forum like the G20?"
    Patient harm is estimated to be the 14th leading cause of the global disease burden. This is comparable to medical conditions such as tuberculosis and malaria. In both US and Canada, patient safety adverse events represent the 3rd leading cause of death, preceded only by cancer and heart disease. In the US alone, 440,000 patients die annually from healthcare associated infections. In Canada, there are more than 28,000 deaths a year due to patient safety adverse events. In low-middle income countries,  134 million adverse events take place every year, resulting in 2.6 million deaths annually. 
    In addition to lives lost and harm inflicted, unsafe medical practice results in money loss. Nearly, 15 % of the health expenditure across Organization of Economic Cooperative Development countries is attributed to patient safety failures each year, but if we add the indirect and opportunity cost (economic and social), the cost of harm could amount to trillions of dollars globally.
    When a patient is harmed, the country loses twice. The individual will be lost as a revenue generating source for society and the individual will become a burden on the healthcare system because he or she will require more treatment. Unless we do something different about patient safety, we would risk the sustainability of healthcare systems and the overall economies. 
    Alhawsaw proposed establishing a G20 Patient Safety Network (Group) that will combine Safety experts from healthcare and other leading industries (like aviation, nuclear, oil and gas, other), and economy and fFinancial experts
    This will function as a platform to prioritise and come up with innovative patient safety solutions to solve global challenges while highlighting the return on investment (ROI) aspects. 
    This multidisciplinary group of experts can work with each state that adopts the addressed global challenge to ensure correct implementation of proposed solution.
    Read full story
    Source: The G20 Health & Development Partnersip, 10 February 2020
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