The Department of Health and Social Care (DHSC) indicates that more than a million machines are still on the decade-old operating system with less than six months until Microsoft ceases support for Windows 7.
In answer to a written parliamentary question from shadow Cabinet Office Minister Jo Platt, former Department of Health and Social Care Minister Jackie Doyle-Price said that the NHS operates about 1.37 million PCs. As of the end of last month, some 1.05 million of these, equating to 76% of the overall total, still run on Windows 7, she added.
Platt – whose parliamentary question recently revealed that there are still 2,300 computers across the NHS running Windows XP, for which support ended five years ago – claimed that the widespread use of Windows 7 is “deeply concerning”. She added: “The WannaCry cyberattack two years ago starkly proved the dangers of operating outdated software. Unless the government swiftly acts and learns from their past mistakes, they are risking a repeat of WannaCry. Protecting public data and computer systems should be a highest priority of government...".
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Source: Public Technology.net, 30 July 2019
In a recent BMJ 'Head to head', the authors argue whether the World Health Organization's (WHO) surgery safety checklist saves lives.
Studies show that the WHO's surgery checklist saves lives around the world, say Alex Haynes and Atul Gawande. But David Urbach and Justin Dimick argue that there’s not enough evidence to say for sure.
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Source: BMJ, 5 August 2019
A leading expert on learning disability services will work with the NHS to review the circumstances and lessons of the death of Oliver McGowan, a young teenager with learning disabilities. NHS England has announced that Dr Celia Ingham Clark, England’s Medical Director for Professional Leadership and Clinical Effectiveness, will oversee the completion of the learning disability mortality review (LeDeR) of Oliver’s death.
Fiona Ritchie, an independent consultant, will chair the review which aims to ensure there is the necessary learning from deaths of people with a learning disability, working with the McGowan family. Ms Ritchie, the independent chair, will now take forward – with the family and Dr. Ingham Clark – finalising the terms of reference for review and overseeing the completion. Following agreement with Oliver’s family, further experts will join an oversight group, which will provide specialist clinical input and advice as needed to Ms Ritchie ensuring that the review process is thorough and the final findings are robust.
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Source: NHS England, 7 August 2019
More than 4,000 women in the Republic of Ireland were not told the results of cervical cancer smear tests due to an IT problem, a report has revealed.
It found in about 870 of the cases, results letters were not issued to the women or their GP. In the other 3,200 cases the results were issued to GPs, but not the women. The report concluded there was not proper due diligence and risk assessment in appointing a new lab as a cervical check test facility.
Quest Diagnostics Chantilly Laboratory was appointed in an effort to help clear a major backlog of cervical cancer test samples. This, the review said, was well intentioned but no testing took place to see if it could be seamlessly integrated into the way the system operated.
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Source: BBC News, 6 August 2019
The Healthcare Safety Investigation Branch (HSIB) has launched a new online feedback form so that anyone involved or interested in HSIB's healthcare safety investigations can "tell us what they think".
There are options to give feedback on national investigations in general, specific national investigations, maternity investigations and HSIB in general.
The feedback form is available from the HSIB website
Source: HSIB, 1 August 2019
Twenty hospitals in England due to receive an extra £850m funding for upgrades to outdated facilities and new equipment have been revealed. Prime Minister Boris Johnson will formally announce the plans – part of NHS spending pledges totalling £1.8bn – at a Lincolnshire hospital today. Ahead of his visit to Lincolnshire, Mr Johnson said the new money – less than 1% of the annual NHS budget – would mean "more beds, new wards, and extra life-saving equipment".
But responding to the funding announcement, the Health Foundation said "years of under-investment in the NHS's infrastructure means this extra money risks being little more than a drop in the ocean". Ben Gershlick, from the charity, added that NHS facilities in England were "in major disrepair", with a £6bn maintenance backlog.
GPs say they are misdiagnosing patients because appointment slots are too short. A survey of family doctors found more than one in three said they had failed to properly diagnose cases because they did not have enough time to fully assess them. Typically, the time slot to see a patient is around 10 minutes. The poll of 200 GPs found that 95 per cent of those surveyed said such slots were too short to do their jobs safely.
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Source: The Telegraph, 25 July 2019
Nurses from Northwest Pennsylvania convened at a billboard calling for greater limitations on the number of patients a nurse can attend to during a shift. The advertisement, located on state Route 8 outside of Centerville, is one of two billboards that Nurses of Pennsylvania, a non-profit advocacy group in the US for nurses and patients, crowd funded in order to raise awareness about the issue of safe staffing and possible legislation.
Registered nurse Kimberly Aldrich, said: “What gets me is that this is not an unprecedented idea in Pennsylvania... When we drop our kids off at daycare, we can rest assured that the facility is legally required to adhere to limits on the number of kids a childcare worker can be assigned. Why should we accept less if our kids are in the hospital?”
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Source: The Titusville Herald, USA, 24 July 2019
The Care Quality Commission (CQC) has been found guilty of maladministration over its handling of a fit and proper person test complaint which led to a £200,000 investigation by an NHS trust. A Parliamentary and Health Service Ombudsman (PHSO) investigation identified “several instances of maladministration” in the CQC’s handling of a complaint by former consultant paediatrician David Drew.
Ombudsman Rob Behrens has now written to the Health Secretary, NHS England, Chair of the Commons Health Committee Sarah Wollaston, and Chair of the Parliamentary and Constitutional Affairs Committee Bernard Jenkin with a copy of the PHSO investigation. In his letter. Mr Behrens said: “I believe this case exemplifies the damaging impact that poor handling of allegations can have on people’s faith in the ability of the CQC to identify and act on misconduct when whistleblowers come forward. This underlines the need for reform to the [fit and proper person] system and the recommendations from the Kark review to be swiftly implemented.”
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Source: HSJ, 24 July 2019
Dr Max Pemberton, columnist for the Daily Mail, gives his opinion of the app that offers patients a GP consultation via their mobile phone. In theory, it sounds great: the patient can dial up, speak to and (via phone camera) see a doctor, who could be anywhere. However, how effective can such consultations be? "I have been able to test this service for myself — and what I have experienced left me worried", says Dr Pemberton.
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Source: The Spectator, 20 July 2019
In a recent interview in The Times, former Chief Medical Officer, Professor Sir Harry Burns considers the symptoms of the country’s drug deaths epidemic. The total of 1,187 fatalities in 2018 represents 218 drug deaths per million of the population and a 27% year-on-year rise. The death rate is three times higher than in the UK as a whole and worse than that of the United States. Politicians should listen to people working on the front line to tackle rising deaths, according to Sir Harry. The trouble is, he says, “public policy tends to be made because someone has a clever idea which then gets picked up by a politician. Very few outcomes in society are determined by one thing.” He believes that health and social benefit on a national scale comes with incremental change over an extended period of time.
When asked what one thing would you do to improve the health of the nation, Sir Harry said "Scotland has made enormous strides in improving patient safety using the concepts of improvement science in which front line staff have tested many different ideas and applied at scale the changes which they have seen work. It’s the principle of marginal gains that has been successful in sport. I would use this approach to improve wellbeing across society."
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Source: The Times, 20 July 2019
The Association for Perioperative Practice (AfPP), has launched the AfPP Perioperative Audit Tool; 2019 Edition, a robust audit tool that will assist both private sector and NHS theatre practitioners in creating a safer perioperative environment.
The tool comprises peer-reviewed standards and recommendations for safe perioperative practice and forms a ‘gold standard’ framework for operating theatre departments to examine service performance and identify potential improvements in patient care.
As the UK’s leading membership organization for operating theatre practitioners who put patient safety at the heart of all they do, AfPP created the tool for the theatre practitioners to review their current policies and processes to invest in the safety of their patients.
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Source: News Medical Life Sciences, 19 July 2019
A response from Tom Kark, QC, in relation to some of the issues raised recently in the HSJ relating to the Fit and Proper Person Test (FPPT)
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Source: HSJ, 12 June 2019
NHS patients could be sent text messages or emails urging them to call their doctor if X-rays or scans show abnormal results. Under plans put forward to prevent delays in treatment, patients with worrying results would receive an automated message saying they need to speak to their GP. The idea is that this would act as a safety net in case results go missing in NHS systems, or if a doctor fails to act on results.The move comes after the Healthcare Safety Investigation Branch (HSIB) investigated a case where a 76-year old woman had a chest X-ray showing possible lung cancer which was not followed up. Her findings were sent to two hospital departments as well as her GP, but nobody acted on them. She died just over two months later but could have received treatment earlier.
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Source: Yahoo UK, 18 July 2019
The Leapfrog Group, an independent national healthcare watchdog organisation, today released Safety In Numbers: The Leapfrog Group’s Report on High-Risk Surgeries Performed at American Hospitals. The report analyses eight high-risk procedures to determine which hospitals and surgeons perform enough of them to minimise patient harm or death, and whether hospitals actively monitor to assure that each surgery is necessary. Findings on these measures pointed to alarmingly poor performance across the board and red flags for patient safety. The voluntary survey found that the vast majority of participating hospitals do not meet The Leapfrog Group’s minimum hospital or surgeon volume standards for safety. Rural hospitals are particularly challenged in meeting the standards.
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Source: The Leapfrog Group, 18 July 2019
Patients treated at US hospitals that earned 'D' or 'F' grades when it comes to patient safety face a 92% higher risk of death from avoidable medical errors than at hospitals with an 'A' grade, according to a new report from The Leapfrog Group, a national nonprofit healthcare watchdog. In Leapfrog's Annual Hospital Safety Grades, about 32% of the 2,600 hospitals evaluated received an 'A' grade for safety, 26% earned a 'B' grade and 36% earned a 'C' grade. The hospital safety group awarded a 'D' or an 'F' grade to about 7% of the hospitals it examined. Patients at hospitals with a "C" grade when it came to safety were 88% more likely to die from an avoidable error compared with patients treated at hospitals that received an 'A'.
"It was pretty shocking to us and should be pretty sobering to hospitals that are not getting an 'A.' It's really time to take this seriously. You know you can do better," said Leah Binder, president and CEO of The Leapfrog Group.
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Source: FierceHealthcare, 15 May 2019
People have been put at risk because the NHS has stopped funding the automatic investigation of all killings by mental health patients, according to psychiatrists and victims’ families. Experts who had looked into every such homicide for 20 years had to stop doing so last year after NHS England stopped paying the £100,000-a-year cost involved, the Guardian has reported.
Previously, for 26 years until last year, researchers from Manchester University had looked into the mental health history and NHS care received by the perpetrator of every such homicide to try to identify patterns and flaws which could be tackled to reduce the risk of similar attacks in the future. Their findings had led to improved care of potentially dangerous mental health patients.
“This is a risky and reckless decision.... It’s outrageous,” said Julian Hendy, the founder of Hundred Families, a charity that helps bereaved families.
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Source: The Guardian, 17 July 2019
Matt Hancock’s new tech unit is assuming new controls of the sharing of NHS patient data with industry, after banning trusts from striking their own exclusive deals.
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Source: HSJ, 16 July 2019
The Patient Safety Learning Awards 2019 are here!
The Patient Safety Learning Awards publicly acknowledge and celebrate important work in patient safety, while sharing learning and successes to improve patient safety. This year, our Awards are inspired by our latest report, A Blueprint for Action. A Blueprint for Action sets out actions needed to progress towards a patient-safe future. These address six foundations of safer care for patients - one of these foundations is shared learning.
The Awards this year have six different categories, based on our foundations for safer care:
shared learning for patient safety
leadership for patient safety
professionalising patient safety
patient engagement for patient safety
data and insight for patient safety
patient safety culture.
A seventh award, the Patient Safety Learning Award, will be made to the individual, team or organisation who our judges believe has gone above and beyond. Each winning entry will receive a cash prize to enable them to visit another team or organisation to learn more about patient safety. As well as this prize, winners will receive two complimentary tickets to our annual conference, awards and drinks reception, held in London on 2 October 2019.
Enter now
The deadline for entries is midnight on Friday 30 August.
Patients have died after the government overruled multiple safety concerns raised about an IT system used to triage 16 million NHS patients a year. An HSJ investigation has uncovered at least three instances where patients triaged by the NHS Pathways software died months, sometimes years, after central agencies were alerted to safety concerns by ambulance trusts, but declined to make changes requested.
NHS Digital, the organisation that oversees NHS Pathways, told HSJ it had assessed the complaints but made changes only where “clinically necessary”. It has repeatedly asked coroners to “strike from the record” concerns raised about the safety of NHS Pathways’ advice.
Since 2015, coroners investigating 11 patient deaths have called for changes to the NHS Pathways software, used by NHS 111 and 999 services to triage patient calls, to prevent future deaths. Coroners have raised these concerns with health and social care secretary Matt Hancock, his predecessor Jeremy Hunt, NHS England, NHS Digital, the Care Quality Commission and service providers. Although NHS Pathways is run by NHS Digital, overall responsibility rests with NHS England.
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Source: HSJ, 15 July 2019
Medical errors aren’t uncommon in Canada. In 2013, 28,000 people died from safety incidents in acute and home care settings, according to the Canadian Patient Safety Institute. Those preventable incidents may include errors with medication, preventable infections and injurious falls. Last year, more than 900 new medical lawsuits were filed in Canadian courts. About half of all medical mistakes are considered preventable, researchers say. In many cases, injured patients are unable to work and require financial assistance to pay the bills.
The widespread problem has grown to epidemic levels in Canada, according to Kathleen Findlay, CEO and Founder of the Center for Patient Protection. “I think it is a national health care crisis and it’s not getting nearly the attention it deserves,” said Findlay, who founded the advocacy group after her mother suffered a series of medical errors during a six-month hospitalisation.
What’s worse, critics say, is that the system in place to hold doctors accountable is unfairly stacked against patients, who can only get compensation by taking legal action against their doctor. Critics say that doctors often have a financial leg up over patients thanks to the Canadian Medical Protective Association (CMPA), which has access to more than $3 billion to cover legal defense.
“I believe we have a rigged system that does more to help doctors than the patients they have harmed,” said Findlay, who described the CMPA as a Frankenstein-like creation designed specifically to help doctors. “We are paying as taxpayers for a healthcare system that harms us, and the perversity of it is that we have to pay again to defend the doctors who have done the harm. If that isn't perverse I don't know what is.”
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Source: CTV News, Canada, 14 July 2019
Allergy patients are being warned of a potential fault with Emerade adrenaline pens. The Medicines and Healthcare products Regulatory Agency (MHRA) said some have blocked needles, so cannot deliver adrenaline. Around two in every 1,000 pens are thought to be affected and patients are advised to follow the existing advice to carry two pens at all times. If patients follow the advice to carry two pens at all times, the risk of not being able to deliver a dose of adrenaline falls to virtually nothing - 0.23% to 0.000529%.
The MHRA added: "Healthcare professionals should contact all patients, and their carers, who have been supplied with an Emerade device to inform them of the potential defect and reinforce the advice to always carry two in-date adrenaline auto-injectors with them at all times."
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Read MHRA alert
Source: BBC News, 12 July 2019
Most patients who want to see their own GP can no longer get an appointment with them, according to new figures suggesting the days of the family doctor are over. The statistics show record numbers of patients struggling to even get through on the telephone, and increasingly long waits for an appointment. For the first time, the majority of patients who wanted to see a particular doctor were unable to do so, the survey of more than 770,000 patients shows. The research comes amid mounting evidence of a wider NHS crisis, with waiting lists reaching an all-time high.
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Source: The Telegraph, 11 July 2019
Patient Safety Learning's Helen Hughes, Chief Executive, and Clive Flashman, Chief Digital Officer, recently spoke to Digital Health about the development of the hub and expectations for the the launch.
Read the full article in Digital Health
Following the 'Promoting professionalism, reforming regulation' consultation, ministers will not reduce the number of professional regulator bodies until further work and a second public consultation have been carried out.
Read the consultation outcome in full
