Patient_Safety_Learning

"Doctors aren't listening, and it is making us unwell". In her book, 'Unheard: The Medical Practice of Silencing', Dr Rageshri Dhairyawan takes us on a journey to show how not listening to patients has been ingrained in medicine since its inception. Join the Chief Executive of the Patient's Association's, Rachel Power, in a fireside chat with Dr Rageshri Dhairyawan, as they discuss the importance of engaged listening and it's place in the future of Healthcare. This event is free to attend and will take place Thursday 23rd January 2025, beginning at 7pm. Register here

The following account has been shared with Patient Safety Learning anonymously. We’d like to thank the patient for sharing their experience to help raise awareness of the patient safety issues surrounding IUD procedures. *Trigger warning: Some people may find the following account distressing to read. Please note that experiences of pain and the care given during gynaecological procedures vary greatly. I came across Patient Safety Learning's forum page about IUD experiences after having my first Mirena coil fitting. I felt unable to comprehend the sense of violation and trauma I had just experienced. A suspected cancer referral I was referred by my GP on the 'suspected cancer pathway' for some post menopausal bleeding. On a positive note, I cannot fault the system and the speed with which I was seen, but my treatment during the appointment was so awful I am actually shaking again as I write this. Although this was an urgent referral, I was not particularly anxious as I felt the erratic bleeding I was experiencing was likely due to my hormone replacement therapy (HRT) regime. I was expecting a consultation and a scan, possibly a hysteroscopy; with a change in my HRT regime being the likely outcome. Off to a bad start The appointment started off on the wrong foot with the consultant asking if I thought there was actually any benefit in taking HRT, likening it to long term antidepressant usage. I explained that, as a runner, I was largely taking it for the well researched bone health benefits but I found his question rather belittling with its implied suggestion of menopause being all in the mind. He went on to advise that a Mirena coil would be a better option for me for HRT which I agreed I would consider. He did not explain the procedure or the possible complications or risks. I will add here that I was sterilised at the age of 30 after my second child. Contraception wasn't something I'd had to consider for the past 23 years so it wasn't really something I'd chatted about with friends. I had heard rumours of bad experiences but took it with a pinch of salt - there are after all rumours of bad experiences in all walks of life. I could not have been more wrong. The procedure - I was frozen with shock I stripped to the waist, legs in stirrups and the consultant explained he would first perform a transvaginal ultrasound to check the thickness of the endometrium - this was reassuringly normal. Then without any warning, he told me he was just going to inject some anaesthetic into my cervix and fit a coil. I had no time to prepare myself at all for this - I didn't really feel I had consented but he and both nurses in the room were acting as though this was all very normal. The injections weren't pleasant in themselves, particularly as I wasn't expecting them. There was no pause at all before I felt awful searing pain and pulling sensations, nothing was being explained prior to it being performed. Something was said about my cervix needing to be dilated and it seemed to take forever. I didn't shout out, I didn't ask him to stop, i just let the tears come. I felt absolutely frozen with shock throughout the whole procedure - no one was asking if I was OK so I assumed I was being a bit of a baby. He announced the coil was in place and I was sat up. Lack of compassion Within seconds I was flooded with heat, I wanted to be sick and everything started to go black. The nurse laid me back down and I remember coming round with a fan on my face and my feet elevated on a stool. The nurse seemed very chilled about the whole thing and just said - oh you're a fainter! I am 53 and have only ever fainted once in my life and that was over 20 years ago. The consultant did not even look at me, let alone speak. I actually felt embarrassed and just wanted to get out as fast as possible. I was slowly sat up and the nurse went and got my daughter from the waiting room. My daughter was told that I felt a little bit wobbly and suggested we go get a coffee from the hospital coffee shop, no one checked my pulse or blood pressure and they seemed keen to get on so we dutifully left. I felt horrific. I couldn't make it to the coffee shop at first. I had to sit down with my head between my legs twice in the hospital corridor as I felt so faint, sick and hot. I've no idea how I dragged myself to the cafe as I continued to feel so awful. After 30 minutes of this my daughter went to get help. She was advised to get a wheelchair and take me back to the clinic which she did. We were laughingly told by the receptionist that I wasn't the first and wouldn't be the last and that we were welcome to sit in a quiet room until I felt better. She brought me a cup of tea but no nurse checked on me at all. It took almost an hour after the fitting before I could stand for long enough to get out to the car. We just sort of slunk out and that was it. Later when I felt better, I checked my sports watch data. My heart rate had averaged 46 for over 30 minutes with the lowest reading being 38 beats per minute. Left in disbelief but inspired to advocate for change How is this happening in 2024? The thought of ever having another pelvic exam, smear test or anything else makes me feel sick and shaky. Where do people go for support with this? It's not ok. I work in Primary Care and often refer women on the same pathway I have just been through. I will absolutely be raising my concerns with the care provider involved. I also have since spoken to a number of women of perimenopausal age and have been horrified to hear so many upsetting experiences from others. It does seem that there is an embedded culture within gynaecological care within which women are neither heard nor permitted agency over their own bodies. Two weeks on and I am feeling far less traumatised, but incredibly inspired to help bring an end to this poor treatment of women. It can be easier to speak up in advocacy than solely for oneself. Share your experience Have you had a gynaecological procedure recently? Would like to share your experience - positive or negative? What makes the difference when it comes to feeling safe or unsafe when accessing these services? You can comment below (sign up first for free), or contact our editorial team at [email protected]. You can also add your experience of a hysteroscopy or IUD procedure to our community forum. Pain during IUD fitting Painful hysteroscopy Related reading Pain experiences during intrauterine device procedures: a thematic analysis of tweets (11 June 2024) Failures of informed consent and the impact on women’s health: a Patient Safety Learning blog Gynecology has a pain problem Our discomfort is routine. What if it didn’t have to be? (1 June 2022) Fitting coils: developing a safe and supportive service The ripples of trauma caused by severe pain during IUD procedures (BMJ Opinion, July 2021)

Despite various initiatives to tackle the problem, safety incidents linked to the late administration of medicines, or medicines that have been omitted entirely, have remained stubbornly high for decades. In this article (link at bottom of page) for the Pharmaceutical Journal, David Lipanovic says a national focus may finally deliver a solution. Related reading: HSSIB investigation report: Medication not given: administration of time critical medication in the emergency department (5 December 2024)

Stephen Heard is a Patient Safety Partner at Norfolk Community Health and Care Trust. He is also, as an RAF veteran himself, employed by Arden and GEM Commissioning Support Unit as one of a small part time team of regional leads for the Royal College of GPs (RCGP) veteran friendly accreditation scheme. In this blog, he explains how GP practices can support veterans and their families in ensuring they are and remain safe after transiting from the services into civilian life. He lists a number of services that veterans (anyone who has served at least one day in HM Forces) can be signposted to as part of their civilian care. Stephen emphasises that many veterans are vulnerable on transition and access to these programmes preferably via a veteran friendly GP practice can be critical to their safety. Research has shown that the first port of call for a veteran seeking help will often be the local GP practice. I would like to emphasise to you and your colleagues the significance of the Royal College of General Practitioners Veteran Friendly Accreditation Scheme for primary care, as endorsed by NHS England in alignment with the Armed Forces Covenant. The Veteran Friendly Accreditation Scheme shows staff at GP practices how to handle queries from the 2.4 million veterans nationally (+3m dependents) and signpost them to the most appropriate pathway or support group as per the list below: Op Restore: The Veterans Physical Health and Wellbeing Service provides specialist care and support to veterans who have physical health problems as a result of their time in the Armed Forces. https://www.england.nhs.uk/commissioning/commissioned-services/ Op Courage: The Veterans Mental Health and Wellbeing Service is a dedicated mental health service for individuals leaving the Armed Forces (those within 6 months of leaving the military in England), veterans and reservists. NHS commissioning » Nationally commissioned services (england.nhs.uk) or [email protected] Op Nova: Provides one to one non clinical support to veterans who are at risk of being arrested or already have been, are due to leave prison or have been released from prison. Op NOVA | Forces Employment Charity Op Community: Provides care navigation and signposting to the wider Armed Forces community with a specific focus on Serving families. www.armedforcesnetwork.org/armed-forces-community/families/single-point-of-contact/ Op Fortitude: Delivers a centralised referral pathway into veteran supported housing. www.riverside.org.uk/care-and-support/veterans/opfortitude/ Op Sterling: Programme to help older LGBT+ veterans, service personnel and their families. www.ageuk.org.uk/our-impact/programmes/how-we-deliver-advice/operation-sterling/ Veterans Prosthetics Panel (VPP): Funding on a named veteran basis to NHS Disablement Service Centres (DSC) to ensure that veterans who have service attributable limb loss can access high quality prosthetics. www.nhs.uk/nhs-services/armed-forces-community/veterans-service-leavers-non-mobilised-reservists/ Integrated Personal Commissioning for Veterans Framework (IPC4V): Delivers a personalised care approach for the small number of Armed Forces personnel who have complex and enduring physical, neurological and mental health conditions that are attributable to injury whilst in Service. www.england.nhs.uk/commissioning/armed-forces/integrated-personal-commissioning-for-veterans-ipc4v/ Personalised care for veterans. NHS England and the MOD have published a new personalised care approach for those veterans who have a long-term physical, mental or neurological health condition or disability. www.england.nhs.uk/personalisedcare/ipc-for-veterans/personalised-care-for-veterans/ There are also the following linked programmes: Veteran Aware: Operated by the Veterans Covenant Healthcare Alliance (VCHA) to improve NHS care for the Armed Forces community by supporting trusts, health boards and other providers (Acute, Community and Mental Health) to identify, develop and showcase the best standards of care. https://veteranaware.nhs.uk/ Step into Health: NHS Employers scheme to facilitate employment for service leavers and their families. https://www.militarystepintohealth.nhs.uk/ Veteran Friendly Framework: Designed to accredit care homes to improve their awareness of the needs for veterans. https://www.britishlegion.org.uk/get-involved/things-to-do/campaigns-policy-and-research/campaigns/veteran-friendly-framework Many Veterans are vulnerable and access to these programmes is critical to their safety. Integrated Care Boards will often have Veterans within the Core20plus5 NHS England Health Inequality Improvement framework, designed to reduce healthcare inequalities.

Catherine Picton is a health and policy consultant who has worked for over 25 years for the NHS, professional bodies, health think tanks and patient charities. A pharmacist by professional background, her policy work is often connected to medicines. In this blog, Catherine talks about the recent report she co-authored for the Royal Pharmaceutical Society; Medicines Shortages Policy: Solutions for empty shelves, and minimising the risk to patient safety.  At the end of 2023 I was contacted by The Royal Pharmaceutical Society (RPS), the professional leadership body for pharmacists and pharmaceutical scientists. As an organisation they were increasingly hearing from their members about the number and extent of medicines shortages and the impact that was having on teams managing the shortages and the corresponding impact on patient care. The RPS decided that addressing medicines shortages was a priority for them and so commissioned me to ’hold the pen’ on a thought leadership report. A complex issue It soon became apparent that medicines shortages are a problem that touch all parts of the system from the regulation, manufacture and distribution of medicines through to the clinical teams prescribing and the pharmacy teams supplying those medicines. Not to mention the direct impact on patients. We wanted to produce a report that showed how all these parts of the system fit together and where problems arise. Ultimately, we wanted to highlight the need for collaboration across the system, to enable the UK to prevent and mitigate medicines shortages and to minimise the impact on patients when shortages do occur. Collaboration was key We engaged with many people and worked with an expert advisory group of stakeholders from across the medicines supply chain. Our engagement activity involved: Manufacturers Wholesalers. The Department of Health and Social Care. Think tanks. Academics. NHS teams managing medicines shortages nationally. NHS staff with expertise of procurement and managing shortages locally in both hospitals and in primary care. Most importantly, with the help of National Voices and their members, we worked with patients. and this gave us insight into the impact that medicines shortages are having on patients and their families. The impact on patient safety Patient safety concerns are multifactorial with medicines shortages. In the report we saw that different shortages can have different levels of safety risks, and therefore need to have different measures in place. Deterioration - At a fundamental level, if a patient is rationing or missing doses of their medicines because they are unable to obtain a supply, as has been reported with the current shortage of Pancreatic Enzyme Replacement Therapy, there is a significant risk of deterioration in the patient’s clinical condition. Dosing errors - In other cases, there may be a risk of dosing errors. For example, where one medicine is being substituted for another or a different route of administration is being used and healthcare professionals are less familiar with the guidelines for using these medicines. Delays - At another level, where professional staff are diverted from front line care to manage medicines shortages, access to healthcare professionals is delayed. This can subsequently cause delays to necessary treatment. Case study: medication for schizophrenia There has been a recent shortage of olanzapine which is given as a slow release injection monthly. It is typically used to manage symptoms of schizophrenia such as hallucinations, delusions, and disordered thinking. It is used in forensic settings to help people recover and return to the community. Slow release injections of olanzapine are also essential for patients once in the community, to help them remain stable. National medicines supply teams cascaded a Medicines Supply Notification about the shortage with management recommendations. Local pharmacy teams, working with their clinical colleagues, introduced a range of these solutions to manage the shortage. These included moving stock around the country and delaying starting olanzapine for new patients to conserve supplies for those already on established treatment. As a last resort when shortages were severe, vials of olanzapine were split so that two patients could be treated with one vial. A process that added an increased risk of error in medicine dosing as nursing teams were unfamiliar with the process. Pharmacy and clinical teams spent significant amounts of time looking for supplies of olanzapine and managing patients unable to be effectively treated. As well as pulling them away from seeing other patients, this took a toll on clinical teams who were aware that their decisions could lead to deteriorations in their patient’s mental state. The impact of deteriorations could, for example, lead to: readmission to forensic settings assaults on other patients or staff general decline in function which would likely delay their discharge. Reducing risk and improving communication Medicines shortages present a real risk to patient safety. On a national level we need to look across the supply chain to see how we can put systems into place that enable the UK to protect against these risks. It also means making sure that we have systems in place locally to manage medicines and communicate better with individual patients. When a medicine is in shortage patients need to know what steps to take and when their medicines will be available. We can work more closely with patient charities and the voluntary sector to ensure that accurate and reliable messages get out to patients and head off misinformation. For teams managing increases in medicines shortages the impact on their workloads has been substantial. This is coming on top of already busy stressed working environments. Anything we can do to help teams manage this new level of shortages and help to take away some of that load will benefit patient safety. The report recommendations include: Reducing unnecessary duplication of effort. Providing easily accessible, trusted information about the causes and expected duration of shortages. Facilitating easier communication between healthcare teams. Final reflections The causes of medicines shortages are complex and the current increase we are seeing is driven by a range of different factors. There is a lot of work already going on nationally to help local NHS organisations manage medicines shortages, but we do need to do more. From my perspective, I don’t see medicines shortages reducing any time soon. We need to be better at communicating with healthcare teams and patients about the causes of shortages, and what we all have to do to help ensure that the impact on patients is minimised. Now the report has been published RPS are continuing to raise the profile of medicines shortages within parliament and working collaboratively with stakeholders to take forward recommendations. The RPS also committed to review the implementation of the recommendations in the report in twelve months to establish the extent of progress made. Related reading Medication supply issues: A pharmacist’s perspective Medicines shortages: House of Commons Research Briefing Medication supply issues: Mast cell activation syndrome (MCAS)