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Content Article
National ambulance data (to end May 2022)
Patient Safety Learning posted an article in Data and insight
Report from the Association of Ambulance Chief Executives on national ambulance data. -
Content ArticleThis letter in the BMJ in 2004 from Richard Thomson highlights the difficulty of accurately quantifying patient safety incidents. Thomson writes that data relevant to patient safety should not be presented alone and out of context. He highlights what was the National Patient Safety Agency and the development of a national reporting and learning system to enable healthcare staff to report incidents anonymously.
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Content ArticleThere was a national roll out of ‘COVID Virtual Wards’ (CVW) during England's second COVID-19 wave (Autumn 2020 – Spring 2021). These services used remote pulse oximetry monitoring for COVID-19 patients following discharge from hospital. A key aim was to enable rapid detection of patient deterioration. It was anticipated that the services would support early discharge, reducing pressure on beds. This study from Georghiou et al. evaluated the impact of the CVW services on hospital activity. The study found no evidence of early discharges or changes in readmissions associated with the roll out of COVID Virtual Wards across England.
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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 ArticleIn this study, Ibrahim et al. evaluated the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. They found that in general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The authors suggest that the Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.
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Content ArticleThis annual publication presents statistics of deaths reported to Coroners in England and Wales in 2021. Information is provided on the number of deaths reported to coroners, post-mortem examinations and inquests held, and conclusions recorded at inquests.
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Content ArticleNever Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers are following national guidance and safety recommendations. In this blog John Tingle, a lecturer at Birmingham Law School, raises concerns about the number of Never Events that continue to take place within health services, the lack of public awareness about Never Events and the need to develop a safety culture that allows learning from Never Events to actually take place.
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Content ArticleHuman error plays a vital role in diagnostic errors in the emergency department. A thorough analysis of these human errors, using information-rich reports of serious adverse events (SAEs), could help to better study and understand the causes of these errors and formulate more specific recommendations. Baartmans et al. studied 23 SAE reports of diagnostic events in emergency departments of Dutch general hospitals and identified human errors. They found that the combination of different instruments and information-rich SAE reports allowed for a deeper understanding of the mechanisms underlying diagnostic error. Results indicated that errors occurred most often during the assessment and the testing phase of the diagnostic process. Most often, the errors could be classified as mistakes and violations, both intended actions. These types of errors are in need of different recommendations for improvement, as mistakes are often knowledge based, whereas violations often happen because of work and time pressure. These analyses provided valuable insights for more overarching recommendations to improve diagnostic safety and would be recommended to use in future research and analysis of (serious) adverse events.
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News Article
Covid vaccines cut global death toll by 20m in first year, study finds
Patient Safety Learning posted a news article in News
Covid vaccines cut the global death toll by 20 million in the first year after they were available, according to the first major analysis. The study, which modelled the spread of the disease in 185 countries and territories between December 2020 and December 2021, found that without Covid vaccines 31.4 million people would have died, and that 19.8 million of these deaths were avoided. The study is the first attempt to quantify the number of deaths prevented directly and indirectly as a result of Covid-19 vaccinations. “We knew it was going to be a large number, but I did not think it would be as high as 20 million deaths during just the first year,” said Oliver Watson, of Imperial College London, who is a co-first author on the study carried out by scientists at the university. Many more deaths could have been prevented if access to vaccines had been more equal worldwide. Nearly 600,000 additional deaths – one in five of the Covid deaths in low-income countries – could have been prevented if the World Health Organization’s global goal of vaccinating 40% of each country’s population by the end of 2021 had been met, the research found. “Our findings show that millions of lives have likely been saved by making vaccines available to people everywhere, regardless of their wealth,” said Watson. “However, more could have been done.” Read full story Source: The Guardian, 24 June 2022 -
Content ArticleThe first COVID-19 vaccine outside a clinical trial setting was administered on 8 December 2020. To ensure global vaccine equity, vaccine targets were set by the COVID-19 Vaccines Global Access (COVAX) Facility and WHO. However, due to vaccine shortfalls, these targets were not achieved by the end of 2021. Watson et al. aimed to quantify the global impact of the first year of COVID-19 vaccination programmes. The study found that COVID-19 vaccination has substantially altered the course of the pandemic, saving tens of millions of lives globally. However, inadequate access to vaccines in low-income countries has limited the impact in these settings, reinforcing the need for global vaccine equity and coverage.
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News Article
Covid-positive hospital patients rise a quarter in one week
Patient Safety Learning posted a news article in News
The number of patients in English hospitals who have tested positive for Covid has increased 28% in a week, the steepest rise since mid-March The third Covid wave of 2022 has now seen Covid occupation levels rise from 3,835 on 4 June to 6,401 yesterday. The sharpest rise in the number of Covid positive patients came in the North West region, where the total rose by 43% in a week. There are now over 1,000 Covid positive hospital patients in the North West, North East and Yorkshire, Midlands and London regions for the first time since 11 May. Some 38% of Covid hospital patients are being treated primarily for the condition. Read full story (paywalled) Source: HSJ, 24 June 2022 -
Content ArticleThis study in the journal Medical Devices: Evidence and Research aimed to assess health system experiences of implementing Unique Device Identifier (UDI) systems for medical devices. Although the US Food and Drug Administration (FDA formalised the Unique Device Identification System Rule in 2013, parallel regulatory requirement for US health systems to use UDIs is lacking. Through semi-structured interviews, the authors identified barriers to implementing UDI systems and strategies to overcome them.
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News Article
Huge variation in referrals to flagship ‘urgent response’ service
Patient Safety Learning posted a news article in News
Ground breaking new data on community services appears to show enormous variation between areas in the number of referrals for a “two-hour urgent response” being recorded. NHS England has published new provisional data on the performance of urgent community response services against a key NHS long-term plan target of reaching at least 70% of patients referred to them within two hours by December 2022. It is the first time performance data has been published for community health services. It also includes the number of referrals made which are reported as “in scope” of the target, and the total number of service contacts. There is huge variation in both referrals and contacts, not accounted for by the size of areas or population need. The publication of the first national performance data for community services was described as “an important moment for community providers” by Siobhan Melia, chair of the Community Network, which is part of NHS Providers and the NHS Confederation. She added it would “raise the profile of community services, and shine a light on the important work taking place in the sector”. Read full story (paywalled) Source: HSJ, 21 June 2022 -
News Article
Hundreds of stillbirths wrongly certified as 'unexplained'
Patient Safety Learning posted a news article in News
More than 80% of UK medical certificates recording stillbirths contain errors, research reveals. More than half the inaccurate certificates contained a significant error that could cause medical staff to misinterpret what had happened. The study, published in the International Journal of Epidemiology, also shows that three out of four stillbirths certified as having an "unknown cause of death" could, in fact, be explained. A team from the Universities of Edinburgh and Manchester examined more than 1,120 medical certificates of stillbirths, which were issued at 76 UK obstetric units in 2018. Of the 421 which were resolved, 195 were re-designated as foetal growth restriction (FGR), and 184 as placental insufficiency. Dr Michael Rimmer, clinical research fellow at Edinburgh University’s MRC Centre for Reproductive Health, said: “This study shows some medical certificates of stillbirths contain significant errors. "Reducing these errors and accurately recording contributing factors to a stillbirth is important in shaping research and health policies aimed at reducing the number of stillbirths. Read full story Source: The Herald, 21 June 2022 -
Content ArticleThe Medical Certificate of Stillbirth (MCS) records data about a baby’s death after 24 weeks of gestation but before birth. Major errors that could alter interpretation of the MCS were widespread in two UK-based regional studies. A multicentre evaluation was conducted, examining MCS issued 1 January 2018 to 31 December 2018 in 76 UK obstetric units. A systematic case-note review of stillbirths was conducted by Obstetric and Gynaecology trainees, generating individual ‘ideal MCSs’ and comparing these to the actual MCS issued. Anonymized central data analysis described rates and types of error, agreement and factors associated with major errors. The study demonstrates widespread major errors in MCS completion across the UK. MCS should only be completed following structured case-note review, with particular attention on the fetal growth trajectory. Correct stillbirth cause classification is crucial for families and society; when ‘unexplained’, conditions’ true perinatal mortality contributions are uncounted and preventative strategies cannot be appropriately targeted.
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Content ArticleThis book is a resource for the coaches who provide health IT-related assistance for primary care practices to support their QI and practice transformation efforts. The audience for this handbook includes both the health IT-focused coaches who support QI work as well as the practice facilitators/coaches who have the necessary background, interest, and skills to provide clinical health IT support. Although the handbook is primarily intended for external coaches working with primary care practices, the content could also be useful for practice-based staff responsible for addressing health IT needs related to QI. The handbook assumes readers already have a basic level of comfort with EHR use and with extracting and using electronic data for QI.
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News ArticleThere’s little question that US hospitals—up against COVID, patient surges, and labor and supply shortages—have become less safe for patients during the pandemic, as preventable events and complications have become more common. Leaders with the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) said as much, earlier this year, in an article for the New England Journal of Medicine: “Many indicators make it clear that health care safety has declined,” they wrote, noting, “the fact that the pandemic degraded patient safety so quickly and severely suggests that our health care system lacks a sufficiently resilient safety culture and infrastructure.” Despite such frank assessments, CMS is now at odds with public safety advocates about whether to make some of the hospital-specific data behind those trends publicly available. Read full story (paywalled) Source: Fortune, 14 June 2022
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Content ArticleCovid-19 may be receding, but it’s leaving a quiet menace lurking in hospitals in its wake. In a Perspective essay in The New England Journal of Medicine, four senior physicians with the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention warned of a “severe” post-Covid decline in patient safety. The Association for Professionals in Infection Control and Epidemiology reached a similar conclusion, warning of a rise in “common, often-deadly” infections. To help reverse this troubling trend, the federal physician leaders called for “promoting radical transparency.” In this article, Michael L. Millenson and J. Matthew Austin discuss how adapting the psychological principles of 'Maslow’s Hierarchy of Needs' as an organising framework, paired with the principles of information design, can significantly boost both the use and impact of safety and quality information.
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Content ArticleThe National Institute for Health and Care Research (NIHR) is funding a portfolio of research to improve our understanding of, and find treatments for, Long Covid. The NIHR’s 19 studies are trying to answer some of the most urgent questions.
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Content ArticleThis strategy sets out the Secretary of State for Health and Social Care’s vision for how data will be used to improve the health and care of the population in a safe, trusted and transparent way. It: provides an overarching narrative and action plan to address the current cultural, behavioural and structural barriers in the system, with the ultimate goal of having a health and care system that is underpinned by high-quality and readily available data marks the next steps of the discussion about how we can best utilise data for the benefit of patients, service users, and the health and care system This strategy applies to England only. The strategy shows how data will be used to bring benefits to all parts of health and social care – from patients and care users to staff on the frontline and pioneers driving the most cutting-edge research. It is backed by a series of concrete commitments, including: investing in secure data environments to power life-saving research and treatments using technology to allow staff to spend more quality time with patients giving people better access to their own data through shared care records and the NHS App.
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News ArticleMore than 380,000 patients waited more than 12 hours in A&E last year, new figures show, amid claims ‘misleading’ public data masks the true scale of the problem. A Royal College of Emergency Medicine report shows 381,991 people across 74 NHS trusts waited half a day or longer from the time they arrived at hospital in 2021. The figures are 14 times higher than the official numbers published by the NHS – which say 25,553 people waited more than 12 hours during the same period at the same trusts – due to the different ways waiting times are measured. While NHS England publishes data every month, it only shows how long patients have waited after a decision by doctors to admit them. Experts claim this is misleading and have called for the NHS to publish the figures from point of arrival instead. It comes after The Independent revealed leaked data in May, showing that more than 3,000 patients a day were regularly facing 12-hour waits in the first four months of 2022. Dr Adrian Boyle, RCEM vice president, said the new figures were “staggering” and “make clear that measuring 12-hour waits from decision to admit masks the reality facing patients and staff. Read full story Source: The Independent, 14 June 2022
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Content Article
The dangerous practice of sending people with a mental illness hundreds of miles away from home for weeks at a time continues in England, according to new analysis published by the Royal College of Psychiatrists. Despite Government pledges to end the shameful practice, known as inappropriate out of area placements, by March 2021, almost 206,000 days have been spent by patients out of area in the 12 months since the deadline passed. Being far away from home, with friends and family not being able to visit, can leave patients feeling extremely isolated and emotionally distressed with devastating, long-lasting consequences for their mental health. Not only that, but it comes at a huge cost to the NHS. The health service spent £102 million on inappropriate out of area placements last year – the equivalent to the cost of the annual salary of over 900 consultant psychiatrists. The Royal College of Psychiatrists is calling on the NHS to adopt a ‘zero tolerance’ approach to inappropriate out of area placements and to take urgent action to ensure all patients get the care they need from properly staffed, specialist services in their local area. -
Content ArticleUpdatable estimates of COVID-19 onset, progression, and trajectories underpin pandemic mitigation efforts. To identify and characterise disease trajectories, Thygesen et al. aimed to define and validate ten COVID-19 phenotypes from nationwide linked electronic health records (EHR) using an extensible framework. Their analyses illustrate the wide spectrum of disease trajectories as shown by differences in incidence, survival, and clinical pathways. The authors have provided a modular analytical framework that can be used to monitor the impact of the pandemic and generate evidence of clinical and policy relevance using multiple EHR sources.
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Content ArticleThe variety of alarms from all types of medical devices has increased from 6 to 40 in the last three decades, with today’s most critically ill patients experiencing as many as 45 alarms per hour. Alarm fatigue has been identified as a critical safety issue for clinical staff that can lead to potentially dangerous delays or non-response to actionable alarms, resulting in serious patient injury and death. To date, most research on medical device alarms has focused on the nonactionable alarms of physiological monitoring devices. While there have been some reports in the literature related to drug library alerts during the infusion pump programming sequence, research related to the types and frequencies of actionable infusion pump alarms remains largely unexplored.
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News Article
Experts predict increase in Covid hospital admissions and another wave
Patient Safety Learning posted a news article in News
Admissions of people to hospital with Covid in England have begun to grow again, new data from the NHS shows, as fears were raised over a new wave. Analysis by John Roberts of the Covid Actuaries group, set up in response to the pandemic, showed hospital admissions had stopped falling after a period of decline. Figures on Tuesday showed weekly admissions increased by 4% across England as of 5 June and were up by 33% in the North East and Yorkshire. When asked if the UK was heading into another wave, Mr Roberts told The Independent: “Yes we could be but...how big that wave and how serious it will be in terms of admissions and deaths is very, very difficult to judge at this stage.” His comments come after experts in Europe warned there will be a new wave driven by the growth of the BA.5 and BA.4 Covid variants. The figures, which cover hospitals in England only, show the weekly average of admissions for patients in hospital with Covid stood at 531 as of 5 June. Read full story Source: The Independent, 9 June 2022
