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Patient-Safety-Learning

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News posted by Patient-Safety-Learning

  1. Patient-Safety-Learning
    A 25-year-old who died from a heart haemorrhage after being diagnosed with a panic attack had been seen by a non-medical school trained physician associate (PA) but not a doctor, it has emerged.
    Ben Peters, 25, attended the emergency department at Manchester Royal Infirmary on the morning of 11 Nov 2022 with chest pain, arm ache, a sore throat and shortness of breath.
    While waiting, he endured a “severe episode of vomiting”.
    Peters was diagnosed with a panic attack and gastric inflammation by the PA and sent home with two medications, after a supervising consultant, who the coroner found never reviewed the patient in person, agreed with the diagnosis.
    Less than 24 hours later, Peters died from a rare complication of the heart that had resulted in a tear of the heart’s major artery, known as aortic dissection, and led to a fatal haemorrhage.
    The Aortic Dissection Charitable Trust (TADCT) says around 2,000 people in Britain die from the condition each year, which can be “reliably diagnosed or excluded” using a CT scan, but “misdiagnosis affects one-third of patients”.
    A prevention of future deaths notice issued by Chris Morris, the area coroner for Greater Manchester South, written to Manchester University Foundation Trust, said: “It is a matter of concern that despite the patient’s reported symptoms, in view of his age and extensive family history of cardiac problems, Mr Peters was discharged from the Ambulatory Care Unit without being examined or reviewed in person by a doctor."
    Read full story
    Source: The Telegraph, 21 October 2023
  2. Patient-Safety-Learning
    Doctors recruited from some of the world's poorest countries to work in UK hospitals say they're being exploited - and believe they're so overworked they fear putting patients' health at risk.
    A BBC investigation has found evidence that doctors from Nigeria are being recruited by a British healthcare company and expected to work in private hospitals under conditions not allowed in the National Health Service.
    The British Medical Association (BMA) has described the situation as "shocking" and says the sector needs to be brought in line with NHS working practices.
    Dr Jenny Vaughan of the Doctors Association UK said, "This is a slave-type work with… excess hours, the like of which we thought had been gone 30 years ago. It is not acceptable for patients for patient-safety reasons. It is not acceptable for doctors. "
    Read full story
    Source: BBC News, 11 October 2022
  3. Patient-Safety-Learning
    Senior leaders of an ambulance trust have been told their ‘extreme positivity’ has made them appear ‘out of touch’ as the Care Quality Commission downgraded the organisation’s rating to ‘inadequate’.
    The health watchdog has dropped the overall rating of South Central Ambulance Service Foundation Trust, as well as the provider’s ratings for safety, leadership and for its urgent and emergency care services, from “good” to “inadequate”.
    The CQC has served SCAS with a warning notice and has criticised the trust’s board for its “extreme positivity about its performance”, which “could feel dismissive of the reality to frontline staff.” The regulator also said it saw evidence “of executive leaders attempting to discredit people raising valid concerns” and was told that serious concerns including sexual harassment had been “brushed under the carpet”.
    The CQC, which published the report today, also said there was “no evidence” of action being considered by SCAS to manage risk for patients suffering long handover delays outside A&E departments, and that serious issues “had not been addressed internally”.
    Will Hancock, chief executive of SCAS, said the trust had an “extensive improvement plan” and is “committed to making things better”.
    Read full story (paywalled)
    Source: HSJ (25 August 2022)
  4. Patient-Safety-Learning
    Fresh Air NHS, Patient Safety Learning and the Safer Healthcare and Biosafety Network are calling for urgent change to the UK government’s guidelines on Personal Protective Equipment (PPE), which are failing to adequately protect healthcare workers against the airborne nature of the Covid 19 virus.
    In March 2020, UK PPE guidance for Covid-19 facing healthcare workers was downgraded, from requiring airborne protection for all staff, to only those in areas where aerosol generating procedures were commonly performed – mainly the ICU. To-date, approximately 1,500 UK health and care workers have died from Covid-19, with non-ICU healthcare workers experiencing far greater risk of infection than their better protected ICU colleagues. It is estimated that a further 122,000 health service workers who contracted Covid-19 are struggling with prolonged symptoms, often referred to as Long Covid.
    Commenting on this, Helen Hughes, Chief Executive of Patient Safety Learning, said: “Providing enhanced PPE to everyone working in non-ICU Covid-19 wards would offer much-needed reassurance that our leaders are committed to protecting both patients and staff from avoidable infection and the associated consequences.
    “The lack of recognition of the airborne nature of Covid-19 transmission from the UK government puts at risk the safety of healthcare staff, their loved ones and patients. There needs to be an urgent review of the PPE guidance to ensure that it is lawful, evidence-based, reflective of the airborne nature of the Covid-19 virus, and that safety is prioritised.”  
    Read full story.
    Source: Safer Healthcare and Biosafety Network, 06 July 2021
  5. Patient-Safety-Learning
    The average life expectancy of Americans fell precipitously in 2020 and 2021, the sharpest two-year decline in nearly 100 years and a stark reminder of the toll exacted on the nation by the continuing coronavirus pandemic.
    In 2021, the average American could expect to live until the age of 76, federal health researchers reported on Wednesday. The figure represents a loss of almost three years since 2019, when Americans could expect to live, on average, nearly 79 years.
    The reduction has been particularly steep among Native Americans and Alaska Natives, the National Center for Health Statistics (NCHS) reported. Average life expectancy in those groups was shortened by four years in 2020 alone.
    “Even small declines in life expectancy of a tenth or two-tenths of a year mean that on a population level, a lot more people are dying prematurely than they really should be,” said Robert Anderson, chief of mortality statistics at the NCHS.
    Read full story (paywalled)
    Source: The New York Times (31 August 2022)
  6. Patient-Safety-Learning
    Nottingham University Hospitals Trust has been served with a section 29a warning notice by the Care Quality Commission requiring it to ensure a ‘more positive culture’.
    A CQC spokeswoman confirmed: “The trust was issued with a warning notice requiring it to take action to improve corporate and clinical governance and oversight of risk, and to ensure a more positive, open and supportive culture across the organisation. We will report on the full findings from the inspection as soon as we are able to.”
    Although it is still not clear why the warning was issued, the trust is currently engaged in concerns over their accident and emergency department and maternity services. 
    “We accept the CQC’s comments and work is already underway to learn from the findings and make improvements so that the organisation is led as effectively as possible and we continue to provide world class care for our patients.” Nottingham University Hospitals Trust acting chief executive and chief finance officer Rupert Egginton has said. 
    Read full story (paywalled).
    Source: HSJ, 18 August 2021
  7. Patient-Safety-Learning
    According to reports, a hospital in the northeast of England is having to turn away non-emergency patients from A&E due to "unrelenting" pressures on the service. This new policy was announced on Tuesday by Hull Teaching Hospitals Trust, warning patients they may need to travel up to 30 miles in order to receive care. 
    Dr Makani Purva, chief medical officer said in a statement on the trust website on Tuesday: “Staff are working incredibly hard to provide care for patients in challenging circumstances but we need people to use the full range of services available. One in four patients who attend A&E in Hull could have been treated more appropriately elsewhere, that’s around 100 patients every day. So from today, after an initial screening process, those arriving at A&E who could safely be cared for elsewhere will be referred on to one of several alternative care centres and providers. Doing so will help us to reduce waiting times for more seriously ill patients and ensure they receive the priority care they need in hospital, while enabling those patients with non-urgent needs to receive care more quickly from a suitably skilled health professional elsewhere.”
    Read full story.
    Source: The Independent, 24 August 2021
  8. Patient-Safety-Learning
    Senior doctors in the radiology services at the University Hospitals North Midlands Trust have reported a ‘toxic’ culture and feelings that managers had been ‘excessively authoritarian’.
    In a letter sent by medical director John Oxtoby on 13 July, consultants who had been interviewed as part of an external review, have reported the culture within the department was “unhealthy and even toxic, and that this was impacting to some degree nearly all of the consultants interviewed”
    “It is clear from this work that as well as the need to tackle working relationships and some behaviours in the department, there is a huge amount of collective pride in the services delivered by the department.” Said Mr Oxtoby. 
    Read full story (paywalled).
    Source: HSJ, 3 August 2021
  9. Patient-Safety-Learning
    NHS leaders and experts have warned healthcare staff will leave their roles in a "mass exodus" unless exhausted doctors and nurses are given better support. This comes as reports earlier this year showed many healthcare staff are suffering from burnout. 
    “From April onwards we’ve seen a significant rise in mental health cases, and it shows no sign of stopping,” Steve Carter, director of consulting services at FirstCare, told a panel of MPs and peers on Tuesday. “We need to address the mental health issue quickly if we are to get through the winter.”
    Read full story.
    Source: The Independent, 25 August 2021
  10. Patient-Safety-Learning
    Appletree Hospital in Durham, a unit that provides female patients needing mental health care, has received an urgent enforcement notice from the Care Quality Commission.
    According to a report published by the CQC today, the hospital had “ineffective leadership”, also warning staff were carrying out “inappropriate” restraint on patients and that restraint was used “as a first line intervention”. The CQC report revealed staff had also claimed managers accepted the use of “unnecessary” restrictive practices.
    A spokeswoman for Cygnet’s Appletree unit said: “We move forward with strengthened local leadership, including a new hospital director and safeguarding and quality improvement leads.”
    Read full story (paywalled).
    Source: HSJ, 25 August 2021
  11. Patient-Safety-Learning
    The main corridor of an acute hospital has been closed to patients and staff and turned into a ‘makeshift ward’, in what sources describe as an ‘absolutely unprecedented’ situation.
    The move by Aintree Hospital comes after staff clashed with paramedics last week about whether ambulance patients could be brought into the crowded emergency department.
    One staff member, who wished to remain anonymous, said: “It’s exceptional for this to happen, but I can see it happening more over winter. It’s a rock and a hard place… either you wait in the ambulance if the queue is too long, or you wait in the main hospital corridor. Neither option is ideal.”
    Dr Adrian Boyle, president of the Royal College of Emergency Medicine, said: “Across the country, the urgent and emergency care system is in unprecedented crisis. Emergency medicine teams and our paramedic colleagues are doing their very best to deliver effective care in exceptionally difficult circumstances. Circumstances like these require ICB leaders to engage, take control of the situation and accept their responsibility. This will both help to de-escalate the situation and ensure the right decision is made for the patients, the ED teams and ambulance crews."
    Read full story
    Source: HSJ, 19 October 2022 (paywalled)
  12. Patient-Safety-Learning
    Record numbers of people have been hospitalised with heart attacks in the wake of the pandemic, official figures show.
    On Tuesday, health chiefs will launch a campaign urging those with symptoms to seek help, with fears that too many cases are being detected too late. The new figures for England show that more than 84,000 patients were admitted to hospital because of a heart attack in 2021/22 – a rise of more than 7,000 in a year. It follows warnings that heart deaths have risen by more than 500 a week since the first lockdown, with a fall in the numbers prescribed vital medication amid struggles to access GP care.
    Health officials are afraid that people are still failing to come forward, adding to the collateral damage caused by the pandemic.
    From this week, an NHS advert will encourage people to call 999 as soon as they experience symptoms of a heart attack, such as squeezing across the chest, sweating and a feeling of uneasiness, so people have the best chance of survival.
    Prof Nick Linker, a cardiologist and NHS national clinical director for heart disease, said: “Cardiovascular disease causes one in four deaths across the country, so it is vital that people are aware of the early signs of a heart attack. Every moment that passes during a heart attack increases heart muscle damage, and nearly all of the damage takes place within the first few hours, so if you experience symptoms such as a sensation of squeezing or tightness across the chest alongside sweating, nausea, or a sense of unease, please call 999 so you have the best chance of a full recovery”.
    Read full story (paywalled)
    Source: The Telegraph, 15 August 2023
  13. Patient-Safety-Learning
    An NHS consultant has told The Guardian "I work in an NHS Covid ward – and I feel so angry".
    Providing a first hand account of their experiences working on an NHS Covid ward, the consultant, who wishes to remain anonymous, has expressed their dismay at the rise in cases, the spread of misinformation and the exhaustion felt among staff members dealing with work place stress and mental illness. 
    Read full story.
    Source: The Guardian, 19 July 2021
  14. Patient-Safety-Learning
    The Modality Partnership, one of England's biggest general practice groups told HSJ that its GPs are regularly seeing more patients each day than is safe, after the number of people going to see their GP surged in the wake of Covid-19.
    Data has shown the provider’s GPs had an average of 20 patient contacts per day during April 2020, which has now risen to to an average of nearly 50 patient contacts per day. Modality, which had drawn up a report on the situation were quoted as saying, "There is just so much to cover – I am worried about missing something.” 
    One partner at Modality who is also quoted in the report said: “An increasing number of patients I see are broken, often in tears, and seeking help to cope with the new stresses of life.”
    Read full story (paywalled).
    Source: HSJ, 31 August 2021
  15. Patient-Safety-Learning
    Nursing and maternity staff have reported that they are unable to have water with them whilst working, meaning some are unable to drink water for 12 hours due to work pressures.
    The Royal College of Midwives in updated guidance are calling for "common sense" from NHS trusts and boards on staff access to water and other drinks, particularly as staff are having to wear more PPE than before the pandemic began. 
    Dr Mary Ross-Davie, director for professional midwifery at the RCM, said: “Some trusts and boards have banned water bottles in clinical areas, which means that our members are often going 12 hours with no break and no water. We are appealing to those services to apply common sense, to recognise that this application of infection control is misguided and to look after the health and wellbeing of their staff.”
    Read full story (paywalled).
    Source: Nursing Times, 11 August 2021
  16. Patient-Safety-Learning
    Midwives at Suffolk Hospital have spoken out in a whistleblowing letter describing problems in their department as ‘demoralising and heartbreaking’.
    In the letter, written by midwives who declined to give their names "for fear of retribution", describe constant staff shortages, a culture of blame and fear, a high pressure environment and substandard care, saying " We entered midwifery to be able to give women centred, holistic care. Instead it feels like we are being overwhelmed by the unmanageable and relentless workload, and as a result are giving substandard care which is demoralising and heartbreaking. We are all feeling like we are now desperate for change. This change is beyond what we can achieve ourselves so we urge you to please help us to generate it. It should not be accepted or tolerated for us to be forced into giving unsafe care entirely due to unsafe staffing". 
    In response, Karen Newbury, head of midwifery at the trust, said: “We are working exceptionally hard to recruit additional midwives and we are very grateful for the flexibility and dedication of our staff in ensuring that we provide a safe and caring service – this was recognised by our Care Quality Commission inspection in April which found we managed safety well. We have recently completed recruitment so there will be at least two senior midwives on every shift to provide flexible and experienced support to our maternity teams, and we are working with colleagues regionally to recruit staff both locally and internationally as well as running a full student training programme.”
    Read full story.
    Source: Suffolk News, 20 August 2021
  17. Patient-Safety-Learning
    England's Chief Nurse has announced every pregnant woman will be able to access their maternity records from their smart phone. 
    The move has been made so that pregnant women will be able to have more control over their pregnancy and will be able to see all the decisions and information made via a smart phone. 
    GPs and health professionals will also be able to access this information, it is hoped that by doing so, it will mean pregnant women will no longer have to repeat information to different clinicians they see whilst pregnant, which may also help improve safety.  
    Read full story
    Source: NHS England, 17 June 2021
  18. Patient-Safety-Learning
    The deadline for the NHS to move to a new system for safety incident reporting has been delayed after widespread concerns the rollout could be a ‘disaster’.
    A memo from NHS England to local teams yesterday, seen by HSJ, says the deadline to transition to the new “learning from patient safety events” database has been pushed back by six months to September 2023.
    The creation of LFPSE is a key strand of NHSE’s safety strategy, along with the overhaul of how serious incidents are investigated. It aims to make it easier for staff across all healthcare settings to record safety events, as the service will be expanded to include primary care.
    It will replace the current national reporting and learning system, a central database created in 2003 to help identify trends and maximise learning from mistakes. The new system is part of a national strategy that pledges to save 1,000 extra lives and £100m in care costs each year from 2023-24.
    Multiple patient safety managers at local trusts had raised concerns to HSJ about the previous March deadline, with one patient safety lead saying it would have been a “disaster” if enforced.
    Helen Hughes, chief executive of charity Patient Safety Learning, said NHSE also needs to change its way of working, as well as the deadline extension. She said:
    “We believe that NHS England needs to seriously reconsider their approach to engaging with trust leaders and staff on this issue, so that improvements can be made to the new LFPSE service to ensure it has the best possible chance of success, and to enable patient safety improvement.”
    Read full story (paywalled)
    Source: HSJ, 20 October 2022
  19. Patient-Safety-Learning
    Hospital staff at the Royal London Hospital have complained about bullying, harassment, racism and sexism during an inspection by the care watchdog.
    After conducting a review of the imagining department at the Royal London Hospital and Whipps Cross Hospital, there are now concerns over the culture of the service and conflict between staff.
    With both hospitals being overseen by Barts Health NHS Trust, chief executive Dame Alwen Williams has said “We will be ensuring staff have the resources to sustain improvements we need to make and there is appropriate oversight and processes in place for escalating wellbeing issues. We have a responsibility to listen to what our hard working team are saying, and respond appropriately and sensitively." 
    Read full story.
    Source: The Independent, 30 July 2021
  20. Patient-Safety-Learning
    Over 60 demonstrations took place on 3 July 2021 to protest over pay. 
    Figures have suggested that a band 5 nurse takes home around £5,000 less per year than they did a couple years ago due to austerity measures and a public sector pay cap. 
    The protest as arranged by groups Keep Our NHS Public, Health Campaigns Together, NHS Workers Say No and NHS Staff Voices with a separate demonstration by Nurses United UK have raised concerns for patient safety, arguing that the pay issue has a direct impact on recruitment and retention of nurses.
    Read full story.
    Source: Nursing Notes, 3 July 2021
  21. Patient-Safety-Learning
    The care watchdog has warned patient care may be being affected by the current pressures on the NHS with healthcare workers suffering significant levels of stress.
    Concerns have been raised in recent weeks after a surge in Covid-19 infections has resulted in record numbers of people calling for ambulances and attending emergency departments, overwhelming the service. 
    Professor Ted Baker, the Care Quality Commission’s chief inspector of hospitals has said “It's imperative that not only do we deal with the immediate pressures on the system, we also need to deal with the underlying problems with the models of care. If we don't do that, patients will not be able to receive the care we want them to, and the pressure on staff to provide care under these difficult circumstances will continue.”
    Read full story.
    Source: The Independent, 22 July 2021
  22. Patient-Safety-Learning
    A private ambulance company, KFA Medical,  which provided patient transport services for the NHS has been deregistered by the Care Quality Commission over concerns for patient safety. Concerns included lack of basic training and Disclosure and Barring Service checks on employees were not up to date or had not been carried out and when looking at four staff files none had current basic life support training.
    Sarah Dronsfield, the CQC’s head of hospital inspection, said: “We have been working with the provider since their suspension in January, however when we carried out this inspection, we found the provider had been unable to implement and sustain the necessary improvements to assure us that people were receiving safe care. This action should send a very clear message to all providers of independent health and care services that while taking enforcement action of this nature is not something we take lightly, we will always take action where appropriate to protect the health and safety of patients,” 
    Read full story (paywalled).
    Source: 03 September 2021
  23. Patient-Safety-Learning
    In April of last year, many people in America came out and cheered for the healthcare workers fighting to save lives during the height of the coronavirus pandemic, but now, nurses across the US are holding strikes due to staff shortages and inadequate equipment amid the pandemic.
    “Most of us felt like we went from heroes to zeroes quickly,” says Dominique Muldoon, a nurse for more than 20 years at Saint Vincent’s hospital in Worcester, Massachusetts. Muldoon, co-chair of the local bargaining unit has also said nurses are going home crying in their cars, working through breaks and staying up late just to get the work done as demand for patient care has increased. 
    “You’ll end up staying late or working through your break trying to fit the workload all in, but ultimately become so frustrated, because eventually you keep trying to overcompensate and cannot keep up with it." Muldoon has said. 
    Read full story.
    Source: The Guardian, 30 July 2021
  24. Patient-Safety-Learning
    Glen Burley, an acute trust chief executive has said NHS England risks ‘levelling down’ safety in some maternity services by ‘disproportionately’ directing additional funding to struggling trusts.
    This comes after NHS England said the funding prioritised the trusts which needed the most support to meet the essential actions in the Ockenden Report, where in March, NHSE invited trusts to bid for a share of £96m extra funding for maternity services. 
    A spokeswoman for NHS England has said: “The NHS made an additional £96m investment in maternity services following the Ockenden Review, the majority of which will bolster the workforce by funding an additional 1,200 midwives and 100 obstetricians. While the funding for additional workforce is for all NHS trusts, it is right that those who most need the support are prioritised.”
    Read full story.
    Source: HSJ, 02 September 2021
     
  25. Patient-Safety-Learning
    Some doctors say that however reasonable guidelines may seem, their cumulative burden causes “constant frustration” to medical practice.
    A team of doctors wrote a study last year for the Journal of General Internal Medicine which suggested that if an American doctor followed all of the guidelines for preventive, chronic and acute disease care issued by well-known medical groups, it would require nearly 27 hours per day.
    Guidelines have become “a constant frustration,” said Dr. Minna Johansson, a general practitioner in Uddevalla, Sweden, who also directs the Global Center for Sustainable Healthcare at the University of Gothenburg. “A lot of guidelines may seem reasonable when considered in isolation, but the cumulative burden of all guideline recommendations combined is absurd.”
    Read full story (paywalled)
    Source: New York Times, 14 February 2022
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