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Content ArticleEffective incident investigation is an integral part of the provision of a safe blood transfusion service, with the aim to prevent recurrence of adverse events and harm to patients. Determining how an incident has taken place allows understanding of the gaps or failures within the system and identification of effective corrective and preventive measures that can be implemented to reduce risk of recurrence. Consideration of human factors supports a more sophisticated understanding of the factors that cause incidents, optimising human performance through better understanding of human behaviour and the factors that influence this behaviour, thus improving patient safety.
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Content ArticleThe National Infusion and Vascular Access Society (NIVAS) is a multidisciplinary organisation made up of healthcare professionals with a special interest in vascular access and IV therapy. This white paper by NIVAS lays out evidence that having a nursing-led vascular access team in every hospital in the UK will improve patient safety, reduce workload pressures for other staff, and save the NHS money. Vascular access involves the use of devices such as catheters to deliver or remove fluids, blood or medication from a patient’s bloodstream. The paper examines the arguments advocating for Vascular Access Services Team (VAST) across the NHS, acknowledging the current pressures of restarting the NHS following the pandemic and the roadmap to reduce the elective waiting lists. It also outlines how integrating a standardised model of VAST into the healthcare systems of the NHS will benefit patients, the new Integrated Care Systems (ICS) and the wider objectives of the NHS.
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Content ArticleRates of blood testing in primary care are rising. Communicating blood test results generates significant workload for patients, GPs, and practice staff. This study from Watson et al. explored GPs’ and patients’ experience of systems of blood test communication. The study found that methods of test result communication varied between doctors and were based on habits, unwritten heuristics, and personal preferences rather than protocols. Doctors expected patients to know how to access their test results. In contrast, patients were often uncertain and used guesswork to decide when and how to access their tests. Patients and doctors generally assumed that the other party would make contact, with potential implications for patient safety. Text messaging and online methods of communication have benefits, but were perceived by some patients as ‘flippant’ or ‘confusing’. Delays and difficulties obtaining and interpreting test results can lead to anxiety and frustration for patients and has important implications for patient-centred care and patient safety.
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News Article
High covid rates spark blood supply ‘crisis’
Patient Safety Learning posted a news article in News
NHS Blood and Transplant (NHSBT) which supplies blood to hospitals is reporting severe supply shortages for the first time since 2018, HSJ has learned. Well-placed senior sources said it is close to issuing a formal “amber alert”, which would mean it could not guarantee blood supplies to hospitals, they said. NHSBT acknowledged to HSJ that it was “expecting a difficult few months”. NHS trusts would have to start cancelling elective operations if they cannot ensure that necessary bloods are available. NHSBT has already written to trusts asking them not to over-order supplies, and to ensure management plans are in place should the situation escalate. Supplies of the common O blood types are thought to be down to less than three days’ worth. If they were to drop to two days, this would trigger an amber alert. Read full story (paywalled) Source: HSJ, 5 July 2022 -
News Article
Trust boards instructed to ‘scrutinise’ sepsis data by NHSE
Patient Safety Learning posted a news article in News
Trust boards should start scrutinising performance against new indicators set out by NHS England this month as part of a national push to iron out unwarranted variation in performance on key sepsis blood tests, according to an NHSE report. Blood cultures are the primary test for detecting blood stream infections, determining what causes them, and directing the best antimicrobial treatment to deal with them. However, it is too often seen as part of a box-ticking exercise, according to a report published by NHSE yesterday. Improving performance on this important pathway should be integrated into existing trust governance structures for sepsis, antimicrobial stewardship, and infection control “to help secure a ‘board to ward’ focus on improvement,” the report says. It says there is too much variation in how blood cultures are taken prior to analysis and sets out two targets for trusts to use to standardise their collection. The first is ensuring clinicians collect two bottles of blood, each containing at least 20ml for culturing. The more blood collected, the higher the rate of detecting bloodstream infections. Blood culture bottles “are frequently underfilled”. The second is ensuring blood cultures are loaded into an analyser as fast as possible, within a maximum of four hours, because delaying analysis reduces the volume of viable microorganisms that can be detected. Read full story (paywalled) Source: HSJ, 1 July 2022 -
Content ArticleNHS England’s report into blood culture practices outlines key improvement steps in the pre-analytical phase of the blood culture pathway. Through targeted recommendations to trust chief executives, clinical and pathology staff, we have an opportunity to improve the blood culture pathway, antimicrobial stewardship and patient outcomes from sepsis. This document sets out proposals to improve and standardise the pre-analytical phase of the blood culture pathway. It details the outputs of the antimicrobial resistance (AMR) diagnostics improvement workstream at NHS England and NHS Improvement, and examines the required changes to improve existing processes within the blood culture pathway. It concludes with a set of recommendations for best practice.
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News Article
Former prime minister calls contaminated blood scandal 'incredibly bad luck'
Patient Safety Learning posted a news article in News
Former prime minister Sir John Major has described the contaminated blood scandal as "incredibly bad luck", drawing gasps from families watching him give evidence under oath to the public inquiry into the disaster. Up to 30,000 people contracted HIV and hepatitis C in the 1970s and 80s after being given blood treatments or transfusions on the NHS. Thousands have since died. Sir John later apologised for his choice of language. He said: "I obviously caused offence inadvertently this morning when I referred to the fact that it was awful that people had been fed infected blood and I referred to it as sheer bad luck. "I can only say to people it wasn't intended to be offensive. I was seeking to express the fact that I was concerned about what happened. "It was intended simply to say that it was a random matter and I perhaps expressed it injudiciously." The UK-wide inquiry was launched after years of campaigning by victims, who claim the risks were never explained and that the scandal was covered up. Campaigners say those infected decades ago are now dying at the rate of one every four days as a result. Read full story Source: BBC News, 27 June 2022 -
News Article
Possible link between blood clots and Covid symptoms investigated
Patient Safety Learning posted a news article in News
A possible link between blood clots and ongoing symptoms of Covid is under scrutiny by researchers in the UK. While Covid can cause a period of acute illness, it can also lead to longer-term problems. Research has suggested fewer than a third of patients who have ongoing Covid symptoms after being hospitalised with the disease feel fully recovered a year later. Now researchers are due to begin a number of trials to explore whether blood thinners may help those who have had the disease. Prof Ami Banerjee, of University College London, who is leading a study called Stimulate-ICP, said it was known that a Covid infection increases the risk of blood clots, and that people who have had the disease have a greater risk of related conditions including stroke, heart attacks and deep vein thrombosis. In addition, Banerjee said research from scientists in South Africa had suggested that people with long Covid have microclots in their blood, while studies in the UK suggested almost a third of long Covid patients have clotting abnormalities. But he said it was not clear if the findings were generalisable, and while there had been calls on social media for anticoagulants to be made available on the basis of such findings, further research was needed, not least as blood thinners can lead to an increased risk of bleeds. Read full story Source: The Guardian, 27 June 2022 -
News Article
Major trust records fifth never event at troubled department
Patient Safety Learning posted a news article in News
A fifth patient has been given the wrong blood at a major teaching hospital’s haematology department where patient safety concerns were raised by clinicians last year. The incident, at University Hospitals Birmingham Foundation Trust, is the fifth never event involving patients being transfused with the wrong blood at the trust since April 2020. Only 15 such never events have been recorded in England in the last two financial years, which means UHB accounted for a third of the total in 2020-21 and 2021-22. HSJ revealed last year that several clinicians had raised safety concerns at the trust’s haematology specialty after most of its services at Heartlands Hospital were moved to Queen Elizabeth Hospital as part of the trust’s pandemic response. The latest never event, which occurred in March, saw a patient being given an “unintentional transfusion of ABO-incompatible blood components” – according to papers provided to the trust’s council of governors. Read full story (paywalled) Source: HSJ, 14 June 2022 -
Content ArticleThis study by Sir Robert Francis QC looks at options for a framework for compensation for the victims of the infected blood tragedy. Sir Robert will give evidence about his work to the Infected Blood Inquiry in July. Before then, it is important that the Inquiry, and recognised legal representatives of its infected and affected core participants, have an opportunity to consider his work.
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News ArticleA compensation scheme for thousands of people affected by the infected blood scandal, described as the biggest treatment disaster in the history of the NHS, will reportedly be announced within weeks. Ministers will set up an arm’s-length body to administer the funds, which could run into hundreds of millions of pounds, and recognise culpability for the scandal for the first time, according to the Sunday Times. As many as 30,000 people became severely ill after being given factor VIII blood products that were contaminated with HIV and hepatitis C imported from the US in the 1970s and 80s, or after being exposed to tainted blood through transfusions or after childbirth. On average, one person affected is dying every four days, with approximately 3,000 having died to date. Last year, before the then health secretary Matt Hancock’s appearance at the public inquiry into the scandal, the paymaster general, Penny Mordaunt, announced the appointment of Sir Robert Francis QC to examine options for a framework for compensation before the inquiry reports its findings. A Cabinet Office spokesperson confirmed the review would be published shortly. “The government intends to publish the study by Sir Robert Francis QC in time for the inquiry and its core participants to consider it before Sir Robert gives evidence to the inquiry in July,” they said. “Government will give full consideration to Sir Robert’s recommendations and evidence to the inquiry.” Read full story Source: The Guardian, 29 May 2022
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News Article
Basildon Hospital blood tests contaminated in 'major failure'
Patient Safety Learning posted a news article in News
THE majority of blood tests taken at Basildon Hospital to identify life-threatening illnesses have been contaminated in a “major failure”. An investigation has been launched by health bosses, with staff shortages allegedly causing the issue with “blood cultures”. Blood cultures, which look for germs or fungi in the blood and more deadly bacteria are routinely carried out ahead of operations. However, latest figures show that 70% of tests taken in the year up to January 2022 were found to be contaminated, leading to treatment being delayed as patients are re-tested. The normal limit of contaminated tests would be below 3%. The issue was raised at a joint board meeting of the clinical commissioning groups, which oversee local healthcare, on 24 March. Katherine Kirk, chairman of quality and governance committee at the Basildon and Brentwood group, said: “If I’m understanding this right and it’s about the effectiveness of blood tests, what’s going on? It’s clearly a major failure.” Read full story Source: The Echo, 4 April 2022 -
News Article
GP practices training receptionists to do blood tests
Patient Safety Learning posted a news article in News
A number of London GP practices are training their receptionists to do blood tests, Pulse has learned. Professor Sir Sam Everington, a GP and chair of Tower Hamlets CCG, told Pulse that ‘lots of practices’ in the area have taken the step, including his own. Training a receptionist to carry out blood tests – which can be done in just six weeks – provides much-needed support to pressured practices, he said. Dr Everington told Pulse: ‘A lot of our receptionists have signed up to be phlebotomists and they love it because actually, phlebotomy is not just about taking blood. "You get to know all the patients with long-term conditions and so our phlebotomists know all these patients." He added that reception teams are a ‘fertile recruitment ground’ for a phlebotomist. They can ‘manage even the most terrified patients’ and have ‘amazing’ clinical skills. Dr Everington suggested that training receptionists as phlebotomists can help build trust with patients who are suspicious about having to describe their symptoms for triage by reception staff. But he said that the extra role just ‘acknowledges’ that all members of practice staff are ‘part of the clinical team’. He told Pulse: "In our practice, we all train together. We have meetings together, the whole team, and it’s acknowledging in this modern world that actually every member of your staff is a clinician – part of the clinical team – because there are always things they will do or can do that will have an impact clinically." "There isn’t a hidden supply of GPs out there in the next few years. It takes 10 years to train GPs so actually help is going to come from a wider team base." Read full story Source: Pulse, 31 March 2022 -
Content Article
In this blog, Lotty Tizzard, Patient Safety Learning’s Content and Engagement Manager, looks at the difficulties people experience in disposing of needles and injection devices safely at home. Variation in services across the UK can lead individuals to dispose of sharps incorrectly, posing a risk to refuse workers and the wider public. -
Content ArticleHospital-acquired venous thromboembolism (VTE) continues to be a significant source of preventable patient harm. This study from Richie et al. retrospectively examined patients admitted with VTE and found that only 15% received correct risk stratification and appropriate management and treatment. The case review found that patients were commonly incorrectly stratified, received incorrect pharmaceutical treatment, or inadequate application of mechanical prophylaxis (e.g., intermittent compression).
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Content ArticleThis investigation by the Healthcare Safety Investigation Branch (HSIB) looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain. As its ‘reference case’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit. Baby Aria sadly died when she was two days old.
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Content ArticleThis article in the Journal of Diabetes Science and Technology reviews the literature from various geopolitical regions and describes how a substantial number of patients with diabetes improperly discard their sharps. Data support the need to develop multifaceted and innovative approaches to reduce the risks associated with improper disposal of medical sharps into local communities.
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Content ArticleThe National Comparative Audit of Blood Transfusion (NCABT) is a programme of clinical audits which looks at the use and administration of blood and blood components in NHS and independent hospitals in England. Blood services in Northern Ireland, Scotland and Wales are also invited to take part. The audit aims to provide evidence that blood is being ordered and used appropriately and administered safely, and to highlight where practice is deviating from guidelines and may cause patients harm. The latest audit took place in 2021, and previous audits are also available to download on this page.
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Content ArticleThe Safer Healthcare and Biosafety Network (SHBN) is seeking input from occupational health managers based in the UK to support the establishment of a new annual UK national database of blood and body fluid exposures in healthcare workers.
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EventThe National Comparative Audit of Blood Transfusion is the largest programme of clinical audits of blood transfusion in the world and is funded by NHS Blood and Transplant. It began in 2002 and audits the administration of blood and blood components as well as assessing appropriate use of blood in various clinical settings. It is concluding its work on three National Comparative Audits: 2018 audit of the use of fresh frozen plasma, cryoprecipitate and transfusions for bleeding in neonates and other children 2019 Re-audit of the medical use of red cells 2021 audit of NICE Quality Standard 138 This webinar includes a 40 minute presentation by experts from NCA and SHOT teams. Register
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Content ArticleThis study in Scientific Reports aimed to understand the current situation of occupational exposure to blood-borne pathogens in a women's and children's hospital in China. The authors analysed the causes of exposure to provide a scientific basis for improving occupational exposure prevention and control measures.
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Content ArticleBlood transfusion is considered one of the safer aspects of healthcare, however potentially avoidable patient-safety incidents led to 14 deaths in the UK in 2017. Improvement initiatives often focus on staff compliance with standard operating procedures. This fails to understand adaptations made in a complex, dynamic environment, so the aim of this study from Watt et al. is to examine the extent and nature of adaptations at all stages of the vein to vein transfusion process.
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News ArticleNearly half of patients with blood cancer are insufficiently protected against the Omicron variant after three vaccine doses, according to a new study. Experts from the Francis Crick Institute and the Royal Marsden NHS Foundation Trust said their research highlights the need for a fourth jab among these vulnerable people. As part of the ongoing Capture study, scientists have been monitoring the antibody response of hundreds of patients with different types of cancer, after one, two and three vaccine doses. Specifically, the researchers measured levels of neutralising antibodies which identify, attack and block the Omicron variant from infecting the body’s cells. Patients with solid tumours appeared to generate antibody responses similar to people without cancer. But among patients with blood cancer who had three doses of a Covid-19 vaccine, only 56 per cent generated neutralising antibodies, according to the study, which has been published as a research letter in The Lancet. This means that 44% of patients with blood cancer did not generate a sufficient antibody response. The study supports the need for four jabs among these immunocompromised groups of people. “We found that a third vaccine dose boosted the neutralising response against Omicron in patients with cancer, but the effect was blunted in patients with blood cancer compared to those with solid cancer,” the authors wrote. Read full story Source: The Independent, 25 January 2022
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News Article
Infected blood scandal: ex-pupils and relatives sue Hampshire school
Patient Safety Learning posted a news article in News
A group of survivors and relatives of people who died in the infected blood scandal are suing a school where they contracted hepatitis and HIV after being given experimental treatment without informed consent. A proposed group action lodged by Collins Solicitors in the high court on Friday alleges that Treloar College, a boarding school in Hampshire that specialised in teaching haemophiliacs, failed in its duty of care to these pupils in the 1970s and 80s. The claim could result in a payout running into millions of pounds, and is based on new testimony given by former staff at the school to the ongoing infected blood inquiry. Gary Webster, 56, a former pupil who was infected with hepatitis C and HIV after being treated with contaminated blood at the school in the early 80s and gave evidence to the inquiry last year, is the lead claimant of the 22 survivors in the group. Speaking to the Guardian, he said: “We were lab rats or guinea pigs. We always thought that we may have been experimented on for research purposes, but we had no proof until the evidence given in the inquiry.” Last year in testimony to the inquiry, the former headteacher of Treloars, Alec Macpherson, confirmed that doctors at the school were “experimenting with the use of factor VIII”, an imported pooled plasma that was later discovered to be contaminated with HIV and hepatitis. He said he and other teaching staff did not question doctors about the trials. He told the inquiry: “We didn’t have any authority or reason to interfere. You can’t – doctors are god, aren’t they?” Macpherson said he consented to the treatment because he trusted the doctors, and he could not recall if parents were informed and consulted. Read full story Source: The Guardian, 23 January 2022 -
Content ArticleSerious Hazards Of Transfusion (SHOT) is the UK's independent, professionally-led haemovigilance scheme. This guidance replaces previous versions and provides information for healthcare professionals on reporting serious adverse reactions and serious adverse events to SHOT.
