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PatientSafetyLearning Team

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Everything posted by PatientSafetyLearning Team

  1. Content Article
    This article, published by WIRED, tells the story of Linsey Marr, an aerosol scientist at Virginia Tech and one of the few in the world who also studies infectious diseases. When the new coronavirus was discovered, Linsey and colleagues were deeply concerned that it had been labelled as 'not airborne'.
  2. Content Article
    In this comment piece, published by the Lancet, authors propose that it is a scientific error to use lack of direct evidence of SARS-CoV-2 in some air samples to cast doubt on airborne transmission while overlooking the quality and strength of the overall evidence base. There is consistent, strong evidence that SARS-CoV-2 spreads by airborne transmission. Although other routes can contribute, they believe that the airborne route is likely to be dominant.
  3. Content Article
    This guideline from The Centre for Perioperative Care (CPOC) provides recommendations to support delivery of quality perioperative care for people with diabetes undergoing surgery, from time of contemplation of surgery to discharge back to the community. The recommendations are supported by a set of practical and visual resources collated from units across the NHS, who have developed perioperative services for people with diabetes undergoing surgery.
  4. Content Article
    This investigation from the Healthcare Safety Investigation Branch, focuses on the design and implementation of patient safety alerts. It follows a reference event where an 85-year old woman was connected to the piped medical air supply, instead of the oxygen supply, whilst she was receiving hospital treatment after a fall at home.
  5. Content Article
    People in prison are significantly more likely to die by suicide. Samaritans work with prison services to reduce suicide and self-harm in prisons. Follow the link below to find out how people in prison, and prison staff, can access Samaritans' services.
  6. Content Article
    More information about "My daughter's bipolar diagnosis was communicated without consideration for the psychological impact"
    In this anonymous blog, the author argues that clinicians need to consider the impact of their words when they are communicating medical findings and diagnoses to patients. Drawing on her daughter’s experience of seeking psychiatric support, she explains how a more humane approach might have prevented additional harm.  My daughter, who has bipolar disorder, received her diagnosis at the very end of a 90-minute psychiatrist consultation. After spending the entire session observing her as if she were a rare specimen, the psychiatrist pronounced her ‘bipolar’, as casually as if he were giving her a driving test result. He then quickly added: “But more interestingly is the fact that your entire body twitches and jerks constantly; I think you may have Tourette’s or some other underlying neurological issue.” He told us he would not treat the symptoms of the bipolar disorder (we had arrived at his clinic after a prolonged journey of increasing mood instability and psychosis) until her neurological issues had been thoroughly investigated. At that, he ended the consultation. I looked at him aghast and wondered if he had any concept of the impact of his words on the person sitting opposite him, and the potential for harm of not adequately considering what it is like to be the person on the receiving end of the diagnosis. We left, struggling to process what had just happened. Not surprisingly, 8 months later, still without access to pharmacological or therapeutic services, the burden became too much and my daughter took a massive overdose. She survived. Two years on, we are still no closer to an answer about her potential neurological issue and are still fighting to get psychological support to help her make sense of living with bipolar disorder. Sometimes clinicians think they are serving your needs by giving a diagnosis, but without advice on how to access appropriate support and guidance to deal with the diagnosis it risks causing additional harm. The impact of poor, unempathetic communication in such fragile circumstances, can be equally damaging. Patients are not lab rats. The psychiatrist clearly did not consider the impact of telling someone that they are a) bipolar and b) more worryingly potentially have an undiagnosed neurological condition. That’s a lot to take in, especially when the person on the receiving end of the diagnosis has been referred due to recent psychosis, after many years of struggling alone with a serious mental illness. My daughter arrived at the consultation hoping to gain some insight as to how to stabilise her mental health. She left with the bottom blown out of her world.
  7. Content Article
    If you think someone is in immediate danger, the quickest way to get help is to call an ambulance on 999. This webpage from Samaritans includes further information and resources on: What to do if someone is in immediate danger or experiencing a mental health crisis. How to offer support What does ‘being there’ for someone involve? Creating a 'safety plan' Try to create a support network How often should I check in with them? Getting additional help for someone Looking after yourself Follow the link below to find out more.
  8. Content Article
    This course, run by Samaritans, will benefit anyone whose role brings them into contact with vulnerable customers or colleagues. Conversations with vulnerable people will equip you with the skills and confidence to handle challenging conversations in a sensitive and professional way. Course objectives: Recognise vulnerable people Assess the Emotional Health Scale Use effective listening tools and techniques to acknowledge difficult feelings and circumstances Show you have listened and understood Use strategies to de-escalate difficult circumstances and emotions End conversations effectively Sign post people to support Follow the link below to find out moe or to register your interest.
  9. Content Article
    Samaritans have a confidential support line for health and social care workers and volunteers based in England and Wales.  Call: 0800 069 6222 All calls are answered by trained Samaritans volunteers, who provide confidential, non-judgmental support. Follow the link below to find out more about the service, and to download posters for your workplace.
  10. Content Article
    This research, published by PLoS ONE, highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. 
  11. Content Article
    Resuscitation Council UK’s Guidelines guarantee that health and care professionals across the UK share the same knowledge base surrounding teamwork and practice. The 2021 Guidelines contain detailed information about basic and advanced life support for adults, paediatrics and newborns, as well as information on the use of Automated External Defibrillators and other topics.  Executive summary of the main changes since the 2015 GuidelinesGuidelines ProcessEducationEpidemiology of cardiac arrestEthicsSystems saving livesAdult basic life supportAdult advanced life supportSpecial circumstancesPost-resuscitation carePaediatric basic life supportPaediatric advanced life supportNewborn resuscitation and support of transition of infants at birthContributors and Conflict of InterestReferences
  12. Content Article
    Think Aorta is a global campaign focused on the problem of misdiagnosis and delay in acute aortic dissection. It was created and is led by Aortic Dissection Awareness UK & Ireland. Think Aorta provides free, accredited learning resources for emergency medicine and radiology teams and for first responders, improving their ability to spot a time-critical, life-threatening aortic dissection and take appropriate action. Posters leaflets and screensavers Podcasts and videos Information on Aortic Dissection and heart disease in Pregnancy Teaching and learning events.
  13. Content Article
    The Aortic Dissection Charitable Trust aims to improve the diagnosis of aortic dissection and bring consistency of treatment across the whole patient pathway. They accomplish this through: Increased access to education for medical professionals and patients in the UK & Ireland Working with those responsible for Healthcare policy in the UK & Ireland to ensure that there is consistency in the provision of diagnosis for acute aortic dissection, specialised follow-up for survivors and access to clinical genetics for relatives Promoting funding for medical research into the detection, prevention, treatment and cure of aortic dissection. Follow the link below to access their resources.
  14. Content Article
    Paul Satori died as a result of a dissecting aortic aneurysm following a misdiagnosis, and being discharged from hospital. Evidence for this coroner's report raised systemic concerns about awareness of aortic dissection in emergency departments and about whether current guidance and risk scoring tools require review and revision to address the widespread misdiagnosis of thoracic aortic dissection. In 2020, The Healthcare Safety Investigation Branch published an investigation into delayed recognition of acute aortic dissection, which also made safety recommendations. Follow the link below to read the coroner's report regarding Paul's death in full.
  15. Content Article
    The national medical examiner system is being rolled out across England and Wales, initially on a non-statutory basis, and is part of the Death Certification Reform Programme for England and Wales. It also forms part of the NHS Patient Safety Strategy and the NHS Long Term Plan in England. The all-Wales Medical Examiner Service is a critical part of the long-established mortality review programme. Throughout 2020, medical examiner offices have been established at acute trusts in England and at regional hubs in Wales, initially providing scrutiny of non-coronial deaths in acute care. This remit is being expanded in 2021 and 2022 to cover non-coronial deaths that occur in other settings such as the community. A core part of the medical examiner role is to provide bereaved people with clear information about the cause of death, and an opportunity to raise any concerns they may have about the care and treatment provided to the deceased person. Medical examiners also carry out a proportionate review of patient records and discuss causes of death with the doctor completing the Medical Certificate of Cause of 5 | National Medical Examiner’s report 2020 Death (MCCD). They ensure concerns about patient care are identified promptly and referred for further investigation, to improve services and care for all patients. This report describes progress and next steps, building the foundations of a medical examiner system that will facilitate reflection, learning and improvement across the entire health system. 
  16. Content Article
    These coroner reports relate to two patients, Stephen and Peter, who both died as a result of complications from use of a nasogastric tube. The coroner notes concerns that this issue may be more widespread and has therefore highlighted the report to several relevant bodies who she advises to take action. The author of both reports, Margaret Jones HM Assistant Coroner, notes the matters of concern are as follows: The product description used by Enteral was insufficient to enable the end user to clearly identify that the tube marketed as a carefeed size 14FR feeding and drainage tube would not operate as a 14Fr tube due to the restricting en-fit connector. Enteral sales marketing staff were not trained to recognise the new restriction in the bore of the tube and were consequently unable to advise the end user of the change. The Hospital Trust did not fully evaluate the size 14FR tube prior to replacing all previous drainage tubes (Ryles) with the carefeed 14Fr feeding and drainage tube. Feedback was generally difficult to obtain. Nursing staff did not consider alternative action when the NG tubes were not adequately draining. There was no general recognition of the need to aspirate the tube. There is no compulsory training of clinicians required to undertake root cause analysis. Despite reports to the MHRA and issue of amended instructions for use and a field safety notice the product continues to be promoted as suitable to feeding and drainage. Please see link to the Nursing times. This was a joint inquest into the death of two patients who died in quick succession as a result of the Enteral 14F nasosgastric tube being used for decompression in an emergency situation. Four similar (non-fatal) incidents followed. It was not clear to the hospital that the Enteral connector reduced the bore of the size 14Fr tube. The inquest was aware that other Hospital Trusts had also needed to change the tubes. I am concerned that the product labelling problem identified during these inquests may not be limited to the University Hospital North Midlands but is in fact a much wider problem that merits wider industry investigation and changes. Read the report relating to Peter Hussey Read the report relating to Stephen Oakes
  17. Content Article
    NICE guidance on the management of chronic pain no longer recommends the initiation of many medications (e.g. NSAID’s, gabapentinoids etc) for primary chronic pain. However, there are many patients in the community who are already using these medications and it is important that when implementing this guideline, the recommendations are not used out of context.  This joint statement aims to provide information that will help doctors and patients when reviewing medications.
  18. Content Article
    Gary Day had a choroidal melanoma of the left eye. After discussing his treatment options with clinicians at Moorfields Eye Hospital, he elected to have that melanoma removed by an endoresection procedure at the hospital. Gary Day died less than 24 hours after the operation as a result of an air embolism. In the Coroner’s matters of concern, it was noted he was not advised beforehand of the potential risk of death, there was no check for an air embolism after the operation and he probably should have been kept in hospital overnight for observation. The report was sent to Moorfields Eye Hospital but has safety implications for all Trusts performing this procedure. Evidence showed that: 1. Mr Day was not informed that there was any risk of death from the surgery he elected to have, even though there is a risk of air embolus, and therefore death, from this procedure. The Consent Form he signed did not make any reference to a risk of death. 2. There was no check carried out for air embolus after the operation. 3. There was confusion between medical staff as to whether or not Mr Day was to be kept in for an over-night stay in hospital. As it turned out, he was not advised to stay in hospital over-night. 3 Mr Day was allowed to leave 3 hours after the operation had concluded. This meant that when he was taken to the Royal London Hospital on the evening of the 15th December, 2020 clinical staff in hospital did not have immediate access to any medical notes concerning his earlier procedure. The Assistant Coroner listed his concerns and recommendations as follows: (a) Any patient who elects to have an endoresection operation of an choroidal melanoma faces a risk (however small) of air embolism and therefore death. This must be made clear to all patients undergoing such a procedure. (b) There ought to be some check/investigation post operation to determine (or to try and determine as best possible) whether air may have entered the blood stream during the operative procedure. (c) Patients undergoing this operation (which normally lasts between 2-3 hours) should be advised to stay in hospital as an in-patient for at least 24 hours, which would enable careful and extended monitoring of their condition and a swift and informed transfer, if necessary, to an acute care unit of a hospital in the event of a deterioration in their condition.
  19. Content Article
    Since Claire Griffiths underwent a rectopexy operation she has suffered almost constant, debilitating pain. In this article, published by Yahoo Style, she describes her experience and the devastating impact on her life. Also quoted in the article is Sling the Mesh’s founder Kath Samson, who says:"Nobody really knows how many are suffering because the NHS and the regulatory body the MHRA has not kept a database of how many women have had the operation and how many are suffering."
  20. Content Article
    Use of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005 and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.’ Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm. Actions Who: All organisations where nasogastric or orogastric tubes are used for patients receiving NHS-funded care. Identify a named executive director who will take responsibility for the delivery of the actions required in this alert. Using the resources supplied with this alert, undertake a centrally coordinated assessment of whether your organisation has robust systems for supporting staff to deliver safety-critical requirements for initial nasogastric and orogastric tube placement checks. If the assessment identifies any concerns, use the resources supplied with this alert to develop and implement an action plan to ensure all safety-critical requirements are met. S hare this assessment and agree any related action plan within relevant commissioner assurance meetings. Share the key findings of this assessment and the main actions that have been taken in the form of a public board paper.
  21. Content Article
    This article looks at NHS safety advice on reducing the harm caused by nasogastric feeding tubes that have been wrongly inserted. The alert, from the National Patient Safety Agency, followed 11 deaths of patients in two years, including that of one child.
  22. Content Article
    Dr Frances Healey provides her personal perspective on the continuing persistence of harm caused by misplaced nasogastric tubes from her experience both as a nurse and head of patient safety insight at NHS Improvement.  
  23. Content Article
    Misplacement of nasogastric tubes can have disastrous consequences for patients and is listed as a “never event” by NHS England. When Lancashire Teaching Hospitals NHS Foundation Trust had two of these never events, the nutrition nursing team carried out a system-wide evaluation to identify problems and develop plans to address them. An e-learning package, robust standardisation in staff’s approach to patient care, re-setting “red lines” to support and empower staff, and the introduction of monitoring and reporting systems have contributed to improving patient safety.
  24. Content Article
    This position paper was prepared by the Nasogastric Tube Special Interest Group of BAPEN. Dr Trevor Smith, BAPEN President commented:  “It is essential that patient safety is at the top of the agenda of every NHS Trust and Health Board. Nobody in need of artificial nutrition should be at risk of a Never Event, so we endorse the special NGT placement training for a select group of staff in every hospital. Our mission is to ensure everybody receives optimal nutritional care, but it is also important to us to protect frontline healthcare professionals from the risk of avoidable and incredibly distressing mistakes. We hope this paper goes some way to encouraging Trusts and Health Boards to move towards far safer practices.” Key points include: Misplacement and use of nasogastric feeding tubes leads to ongoing avoidable complications and deaths classified as Never Events despite multiple NHS Alerts since 2005. The most common cause relates to use of X-rays to confirm intragastric placement, followed by poor adherence to guidance on use of gastric aspirate pH, although the vast majority of nasogastric feeding tubes in the UK are passed safely and have their position confirmed using pH checks without issue. The root cause of these problems is a failure by Hospital Trusts and Health Boards to implement guidelines through rigorous clinical governance over many years. The perception of nasogastric feeding tube insertion as a “simple” procedure must be changed to that of a “complex” and dangerous procedure and limited to properly trained and competent healthcare professionals. The ongoing incidence of nasogastric Never Events is symptomatic of a wider failure of NHS governance procedures centrally and at senior Trust level. It must be accepted that this method of feeding is associated with a risk of complications and death which requires new strategies to mitigate these risks and to place patient safety at the top of the agenda.
  25. Content Article
    This article discusses evidence that doctors-in-training and medical students are still performing pelvic exams on anesthetized women without their consent.

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