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Showing results for tags 'Blood / blood products'.
Found 137 results
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News Article
Infected blood scandal: Hancock pledges payouts if advised by inquiry
Patient Safety Learning posted a news article in News
Matt Hancock has said compensation will be paid to people people infected by contaminated blood products and their relatives if is recommended by the public inquiry into the scandal. Appearing at the inquiry on Friday, the health secretary agreed the government had a “moral responsibility” to address what had happened. As many as 30,000 people became severely ill after being given factor VIII blood products contaminated with HIV and hepatitis C imported from the US in the 1970s and 80s. Others were exposed to tainted blood through transfusions or after childbirth. On average one person is dying every four days, with approximately 3,000 haemophiliacs having died to date. The government set up a support scheme offering ex-gratia payments without any admission of liability, but has been urged to create a compensation scheme. The health secretary told the inquiry: “I respect the process of the inquiry and I will respect its recommendations, and should the inquiry’s recommendations point to compensation, then of course we will pay compensation, and Sir Robert Francis’s review on compensation is there in order that the government will be able to respond quickly to that. “But it would be wrong to pre-empt the findings of the inquiry on that basis by me giving a policy recommendation in the middle of it.” Read full story Source: The Guardian, 21 May 2021 -
News Article
Contaminated blood inquiry: Matt Hancock to give evidence
Patient Safety Learning posted a news article in News
The health secretary will face questions about compensation for victims of the contaminated blood scandal on Friday afternoon. Matt Hancock will give evidence at a public inquiry into what's been called the worst NHS treatment disaster. Around 3,000 people have died after being given blood containing HIV and hepatitis C in the 1970s and 1980s. Ministers announced a public inquiry into the scandal in 2017 after decades of campaigning by victims and their families. Nearly 5,000 people with the blood disorder haemophilia were infected with potentially fatal viruses after being given a clotting agent called Factor VIII. Much of the drug was imported from the US, where prisoners and other at-risk groups were often paid to donate the plasma used to make it. Victims included dozens of young haemophiliacs at a boarding school in Hampshire who died after contracting HIV as a result. Tens of thousands more victims may have been exposed to viral hepatitis through blood transfusions after an operation or childbirth. Read full story Source: BBC News, 21 May 2021 -
News Article
How COVID-19 has disrupted efforts to care for blood cancer patients
Patient Safety Learning posted a news article in News
Blood cancer patients are one of the most vulnerable groups of people at risk of COVID-19, according to research, being 57% more likely to suffer severe disease compared to other cancer patients. Despite the high risk these patients face, charities such as Anthony Nolan, which assist blood cancer patients with finding a stem cell match, were left out of the allocated government budget that was announced in March. The cancellation of face-to-face fundraising and events, despite the increase in demand for services, have led their gross income to be down by an estimated £5.5m for 2021. Henny Braund, chief executive of the charity, said people with blood cancer and blood disorders were “heavily impacted by the pandemic and everyone who needs treatment and support must be able to access it without delay”. Read full story Source: The Independent, 9 May 2021 -
EventSince the emergence of the disease, severe Covid infections have been associated with a risk of severe and dangerous coagulopathy. And in recent weeks two vaccines have been linked to a rare increased risk of clotting, in particular cerebral sinus venous thrombosis (CSVT) which requires urgent and specific treatment. This Royal Society of Medicine webinar will tell the story of our understanding of these coagulation disorders, looking at the causes, risks, diagnosis, and treatments. Register
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News Article
Young people more likely to suffer rare vaccine blood clots, MHRA says
Patient Safety Learning posted a news article in News
Younger adults are particularly affected by the rare blood clotting disorder linked to the Oxford-AstraZeneca vaccine, the UK's medicines regulator has said. The Medicines and Healthcare products Regulatory Agency (MHRA) said there were 209 cases in the UK of the rare combination of blood clots with low platelet counts following being vaccinated the Oxford-AstraZeneca jab, with 41 deaths, up to 21 April. This is up from 168 cases and 32 deaths the previous week. The new data also shows 24 cases of clots in people aged 18 to 29, 28 in those in their thirties, 30 in people in their forties, 59 in people in their fifties and 57 in those aged 60 and above, with the age not known in the remaining cases. The numbers appear to rise with age but that is because more older people have been vaccinated. Fewer than one in five clots was fatal. The latest NHS England data show that 5.5 million people under 45 had received a first dose by 25 April, while 22.6 million of those 45 and over had done so. MHRA chief executive June Raine said no medicine or vaccine was without risk, but that blood clots were extremely rare. She added: “The benefits of the vaccine continue to outweigh the risks for most people. It is still vitally important that people come forward for their vaccination when invited to do so." Read full story Source: The Independent, 3 May 2021 -
Content Article
Ensuring safe vascular access
PatientSafetyLearning Team posted an article in Improving patient safety
This guide, published in the Health Service Journal, looks at how greater standardisation and ultimately accreditation of specialised vascular access teams would ensure a basic level of competency and quality of care. -
Content ArticleThe purpose of this document from the Medicines and Healthcare products Regulatory Agency (MHRA) is to provide information and guidance to all involved with the purchase, management and use of non-invasive blood pressure measurement devices. It reviews the advantages and disadvantages of mercury, aneroid, electronic manual sphygmomanometers and automated blood pressure measuring devices. This should help to ensure the most appropriate technology is selected for use.
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News Article
Contaminated blood inquiry: Some patients used as 'guinea pigs'
Patient Safety Learning posted a news article in News
A public inquiry into the infected blood scandal has been told some patients were used as "guinea pigs" at Belfast's Royal Victoria Hospital. The inquiry is looking at how haemophilia patients across the UK were treated with Hepatitis C infected blood or HIV in the 1970s and 1980s. Among the correspondence presented to the inquiry this week was a letter, dated 1988, sent by Dr Elizabeth E Mayne, consultant/director at the Department of Haematology in the Royal Victoria Hospital, to Professor Ludlam at the Royal Infirmary in Scotland. The letter was part of discussions about a potential switch between an NHS product and a commercial product, Profilate Factor 8. Dr Mayne explained that "complications may arise with this product or indeed a safer product may become available". She added: "I am happy for us to try this arrangement as long as the treatment of the children here and the small number of other patients is safeguarded." She concluded "It would be interesting to see the reactions of the patients to this change over and to see if the number of units consumed is reduced." After the letter was read into the record of the inquiry, the chairman, Sir Brian Langstaff, said: "There is also the implicit suggestion there that the patients will not have been asked in advance. "It is going to be given to them and they wait to see what the reaction is." Counsel to the inquiry, Jenni Richards QC, replied "Yes, there doesn't appear to have been an element of choice." Read full story Source: The Independent, 1 April 2021 -
News ArticleA woman infected with hepatitis C from contaminated blood has launched legal action after the government denied her financial support available to other victims despite accepting she was made sick by tainted blood. Carolyn Challis told The Independent her life had been dramatically affected by the virus, which left her with debilitating fatigue and other symptoms meaning she couldn’t work and was left to look after three children. With the help of lawyers from Leigh Day, she is bringing a judicial review against the Department of Health and Social Care, challenging what she believes is an arbitrary cut-off date for victims of the contaminated blood scandal to receive financial support including payments of a £20,000 sum and ongoing help. The government has said only patients infected before September 1991 are eligible for the payments, but Ms Challis was infected at some stage between February 1992 and 1993 following three blood transfusions and a bone marrow transplant to treat Hodgkin’s Disease, a form of blood cancer. Read full story Source: The Independent, 21 March 2021
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News Article
Annual payments for contaminated blood bereaved
Patient Safety Learning posted a news article in News
People whose spouse or partner died as a result of the contaminated blood scandal are to receive financial help. Annual payments of up to £33,500 will be given to those whose loved one died after contracting HIV or hepatitis C having been given infected blood. About 5,000 people, including 99 from Northern Ireland, were infected by what has been described as "the worst scandal in the history of the NHS". The health minister said those who had been bereaved had not been forgotten. Robin Swann added: "I have listened to their experiences of how contaminated blood has impacted on their lives and the sacrifices they have had to make. "I sincerely hope this annual financial support will provide some long-term financial certainty as well as recognition for those bereaved through contaminated blood." The contaminated blood scandal resulted in people who had haemophilia being treated with blood infected with hepatitis C or HIV in the 1970s and 1980s. At the time the UK was struggling to keep up with demand for the Factor VIII blood clotting treatment, so supplies were imported from the US. But much of the human blood plasma used to make it came from donors such as prison inmates and drug-users who sold their blood. Those groups were at higher risk of blood-borne viruses. Victims have campaigned for decades, saying the risks were never explained to them and the scandal was covered up. An ongoing public inquiry has been hearing harrowing stories from people across the UK about how lives had been destroyed by the blood. Read full story Source: BBC News, 1 March 2021 -
Content ArticlePatient Safety Movement Foundation is joined in this video by Kourtney Wilson, Clinical Practice Consultant, Regional Patient Care Services, Maternal Child Health-Obstetrical Concentration, Kaiser Permanente, to discuss the need for standardised massive transfusion protocols in the context of postpartum haemorrhage (PPH) and the common barriers hospitals face in effectively establishing these protocols.
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News Article
Infected Blood Inquiry: Man 'not told of Aids diagnosis for 18 months'
Patient Safety Learning posted a news article in News
A man who was treated with imported blood products in the 1980s became the first haemophiliac in the UK to test HIV positive and die of Aids, an inquiry has heard. Kevin Slater, from Cwmbran, was 20 when he developed Aids in 1983 the Infected Blood Inquiry has been told. He was not informed that he had been diagnosed with the condition for at least 18 months and died in 1985. Records show it was recommended that the diagnosis be kept from him. The UK-wide inquiry is looking into what has been described as the worst treatment disaster in the history of the NHS. Haemophilia is a blood condition which affects the clotting of blood in those affected. In the 1980s some of the blood products used to treat the condition were infected with HIV. The inquiry heard there were about 100 haemophiliac patients in Wales at the time. Mr Slater's sister-in-law Lynda Maule said she does not believe he was ever told he had Aids. "He was treated disgustingly," she told the inquiry. "There was no care, nothing. Read full story Source: BBC News, 2 February 2021 -
Content ArticleAfter two weeks of evidence by experts in medical ethics the Infected Blood Inquiry finishes its review of Newcastle, reviews a single case from Cardiff and moves onto its first evidence from those involved with the Haemophilia Society. Professor Brian Edwards reflects on the evidence in this NHSManagers.Net article. See also the weekly updates on the inquiry from The Haemophilia Society.
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Content ArticleThe UK-wide inquiry is looking into what has been described as the worst treatment disaster in the history of the NHS. Thousands of patients across the UK were infected with HIV and hepatitis C via contaminated blood products in the 1970s and 1980s. The Haemophilia Society updates give a weekly summary of inquiry news when public hearings take place.
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Content ArticleFrequent and wide ‘swings’ in blood glucose levels are common in the hospital setting, for both diabetic and non-diabetic patients, due to factors including, but not limited to, physiologic stress, certain medications and procedures. However, these uncontrolled swings in glucose levels can be detrimental to patients and can compromise wound healing, increase risk of infection, and delay surgical procedures and discharge. Early recognition and anticipation of blood sugar swings have proven to be effective in improving outcomes but require significant infrastructural changes within the organisation. Many healthcare organisations have successfully implemented and sustained blood glucose management initiatives.These organisations have focused on projects that included education around and trigger tools for early recognition and anticipation of blood sugar “swings”. This document provides a blueprint that outlines the actionable steps organisations should take to successfully improve blood glucose management and summarises the available evidence-based practice protocols.
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News Article
Great Ormond Street Hospital admits errors led to boy’s death
Patient Safety Learning posted a news article in News
Mistakes by Great Ormond Street contributed to the death of a five-year-old boy, the children’s hospital has admitted – just months after it concluded a legal case with his family in which it denied responsibility. The world-renowned children’s hospital failed to flag results of a crucial blood test, showing that Walif Yafi had a dangerous infection, to doctors at King’s College Hospital where he had been receiving treatment. He died a few weeks later, in September 2017. In September this year, Walif’s parents agreed an out-of-court settlement with Great Ormond Street, which admitted negligence but denied liability for the boy’s death. However, this week the hospital admitted an expert had reviewed the case ahead of the settlement and concluded its actions did contribute to Walif’s death. The hospital said it had been under no duty to share these results with Walif’s parents at the time. Walif had a liver transplant in 2012 after suffering cancer shortly after his birth, and was being overseen by Great Ormond Street as an outpatient, as well as by the transplant team at King’s College Hospital, in south London. On 24 August 2017, he had a routine blood test at Great Ormond Street, which showed he had an adenovirus infection – something that is common in children whose immune system is being suppressed by drugs, as Walif’s was because of his transplant. If untreated, the infection can be deadly. But the blood test result was not communicated to the team at King’s College Hospital. Shortly afterwards, Walif’s health deteriorated and he was admitted to hospital. He was transferred to King’s College Hospital a week later, and it was not until 7 September that the infection was confirmed. By this stage, he was severely unwell and, though he began anti-viral therapy, Walif suffered multiple organ failure from the spread of the infection. On 30 September, he suffered cardiac arrest and died. It was only when approached by The Independent this week that the trust revealed its expert had, in the course of negotiating the settlement with Walif’s parents, determined the hospital did materially contribute to the child’s death. Read full story Source: The Independent, 29 November 2020 -
News ArticleA blood test designed to detect more than 50 types of cancer at an early stage will be trialled by the NHS. More than 165,000 people in England will be offered the tests from next year. If successful, the NHS hopes to expand it to 1m people from 2024. Sir Simon Stevens, NHS England chief executive, said early detection had the potential "to save many lives". While some welcomed the pilot, others cautioned the test was still untried and untested. Developing a blood test for cancer has been keeping scientists busy for many years without much success. Making one that's accurate and reliable has proved incredibly complex - the danger is that a test doesn't detect a person's cancer when they do have it, or it indicates someone has cancer when they don't. This test, developed by the Californian firm Grail, is designed to detect molecular changes in the blood caused by cancer in people with no obvious symptoms. As part of a large-scale pilot, also funded by the company, 140,000 participants aged between 50 and 79 will be asked to take the tests for the next three years. Another 25,000 people with possible cancer symptoms will also be offered testing after being referred to hospital in the normal way. Read full story Source: BBC News, 27 November 2020
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Content ArticleThe Patient Safety Movement Foundation is joined by Aryeh Shander, from Ichan School of Medicine at Mount Sinai and Englewood Hospital and Medical Center in this video. There has been a long-standing perception in medicine that blood products can be used without judicious consideration. It is important to recognise that blood is a biological product and, as such, is subject to virus, which can be transmitted from donor to recipient without detection. While there have been improvements in transfusion safety, it is important to recognise the patient's risk and benefit ratio based on their individual circumstance and thoroughly evaluate all alternatives to a transfusion.
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Content ArticleSusan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
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Content ArticleThis Annual Quality Statement provides a summary of the work of Cardiff and Vale University Health Board in 2019-2020, with a particular focus on community mental health.
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News ArticleInquest finds Susan Warby, 57, received insulin she did not need after blood test mistakes. Hospital errors contributed to her death five weeks after bowel surgery, an inquest into her death has concluded. Susan Warby, 57, who died at West Suffolk hospital in Bury St Edmunds, was incorrectly given glucose instead of saline through an arterial line that remained in place for 36 hours and resulted in inaccurate blood test readings. She was subsequently given insulin she did not need, causing bouts of extremely low blood sugar (hypoglycemia) and the development of “a brain injury of uncertain severity”, recorded Suffolk’s senior coroner, Nigel Parsley. Speaking after the inquest was adjourned in January, Susan's husband, Jon Warby, said he was “knocked sideways completely” when he received an anonymous letter two months after her death highlighting blunders in her treatment. Doctors at the hospital were reportedly asked for fingerprints as part of the hospital’s investigation into the letter, a move described by a Unison trade union official as a “witch-hunt” designed to identify the whistleblower. Following January’s adjournment, Parsley instructed an independent expert to review the care that Warby received. Warby’s medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia, pneumonia and perforated diverticular disease, affecting the bowel. Recording a narrative conclusion, Parsley wrote: “Susan Warby died as the result of the progression of a naturally occurring illness, contributed to by unnecessary insulin treatment caused by erroneous blood test results. This, in combination with her other comorbidities, reduced her physiological reserves to fight her naturally occurring illness.” Jon Warby said in a statement: “The past two years have been incredibly difficult since losing Sue, and it is still a real struggle to come to terms with her no longer being here. The inquest has been a highly distressing time for our family, having to relive how Sue died, but we are grateful that it is over and we now have some answers as to what happened." “After learning of the errors in Sue’s care, I wanted to know how these occurred and what action was being taken to prevent any similar incidents in the future. The trust has now made a number of changes which I am pleased about.” Read full story Source: The Guardian, 7 September 2020
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News Article
Patient bleeds to death in hospital run by scandal-hit trust
Clive Flashman posted a news article in News
Inspectors raise ‘serious concerns’ about medical wards and emergency care at Shropshire NHS trust A patient bled to death on a ward at Shrewsbury and Telford Hospitals Trust after a device used to access his bloodstream became inexplicably disconnected, The Independent has learnt. The incident came to light as new concerns arose about quality of care at the Shropshire trust, with the Care Quality Commission (CQC) warning of “serious concerns” about its medical wards and emergency department following an inspection last month. Although the report from the inspection has not yet been published, it is understood that the trust has been served with a legal notice by the regulator to comply with more than a dozen conditions. It remains in special measures following the inspection and is rated inadequate overall. See full article in The Independent here -
Content ArticleIn 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
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Content Article
Annual SHOT report 2019
Patient Safety Learning posted an article in Other
SHOT (Serious Hazards of Transfusion) is the UK's independent professionally led haemovigilance scheme. This year’s Annual SHOT Report looks back at trends and data for the last calendar year, but also highlights several very important messages for us in the present extraordinary times. The data in the report come from across the UK and include material from all areas of healthcare where transfusion is practised. -
Content ArticleUnknown to its hypertension specialists, a major teaching hospital changed the cuffs on its sphygmomanometers from manufacturer-validated to a uniform washable alternative, in line with ‘Health and Safety’ concerns surrounding potential cross-contamination between patients. When clinic doctors suspected serious under-reading with the new cuffs, a systematic comparison was undertaken in 54 patients using two UM-101 sphygmomanometers: one using the original, manufacturer-supplied cuff and the other with the washable replacement. The study confirmed an average under-reading of 8±10/5±5 mm Hg using the washable cuff, and a third of patients with poorly controlled hypertension were considered normotensive, after using this cuff. The UM-101 sphygmomanometers have now been re-fitted with the original cuffs. Sphygmomanometer cuffs are not interchangeable between devices and a modicum of common sense should be shown to prevent changes made in the name of Health and Safety from having the opposite effect to that intended.
