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Content Article
Katie Hurst is a general surgery registrar based in the Thames Valley Deanery and chair of the Trainees’ Committee for the Royal College of Surgeons of Edinburgh. In this interview, we talk to Katie about the work she is doing with the Royal College of Surgeons of Edinburgh on raising awareness and protecting staff from ionising radiation. -
News Article
CEO admits ‘risk aversion’ clogging up hospitals
Patient Safety Learning posted a news article in News
Medics and managers must overcome a system-wide “aversion” to risk after their integrated care system was identified as a national outlier for low numbers of patients discharged home, according to the ICS’s chief executive. Kate Shields, CEO of Cornwall and Isles of Scilly ICS, has highlighted a discrepancy between the ICS and the rest of England, with a lower proportion of patients discharged with no new social care requirements, or discharged directly to their own home, with only intermediate additional care (known as ”pathways” 0 and 1 in national discharge guidance). Problems with delayed patient discharges – known as “no criteria to reside” patients – are a major contributor to overcrowding and long waits in the emergency department at Royal Cornwall Hospitals Trust, as well as severe delays for ambulances to handover patients. Discharge on pathways 2 and 3 – to a care home or intermediate care bed, with substantial additional care requirements – typically take a lot longer, and require more resources. Ms Shields’ comments come 18 months after an external report warned of an “over-reliance on bedded care” in Cornwall. Speaking at a meeting of Cornwall and Isles of Scilly Integrated Care Board last month, Ms Shields said the health economy needed to “look at how we get people out of hospital faster”. Read full story (paywalled) Source: HSJ, 4 March 2024 -
News Article
Maternity unit rated ‘inadequate’ after delayed Caesarean warning
Patient Safety Learning posted a news article in News
A trust’s main maternity unit has been rated “inadequate” and given a warning notice amid concerns delayed Caesarean sections are causing harm to babies. The Care Quality Commission (CQC) told Maidstone and Tunbridge Wells Trust to make significant improvements in how quickly it carries out emergency C-sections, the regulator said in a report today. The trust was also told to improve risk management, governance and oversight of services at its Tunbridge Wells Hospital. Inspectors found between April and July last year, 42% of “category 1” emergency Caesareans – defined as those posing an immediate threat to the life of the woman or foetus — at the Tunbridge Wells Hospital were delayed. The National Institute for Health and Care Excellence says these should be carried out “as soon as possible and in most situations within 30 minutes of making the decision”. The report identified “ongoing recurrent delays” to emergency Caesareans overnight, as the trusts did not have a second theatre available. This “meant an increased risk of harm, including cases reported by the service such as babies with ‘acute foetal hypoxia’ had emerged due to delayed births”, the inspection report said. It also criticised the trust for not responding to a high level of post-partum haemorrhages, some of which had caused “moderate” harm. Read full story (paywalled) Source: HSJ, 16 February 2024 -
Content ArticleThis study aimed to assess whether the risk of 90-day mortality is comparable for individuals who switch early to oral antibiotics and those who continue intravenous (IV) antibiotics in the treatment of uncomplicated gram-negative bacteremia. The results suggest that transition to oral antibiotics within four days after initial blood culture may be an effective alternative to prolonged IV antibiotic treatment for uncomplicated gram-negative bacteremia.
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News ArticleThe NHS has been accused of putting patients' lives at risk after it allowed hundreds of staff, including senior consultants and managers, to work thousands of miles from the UK. A Mail on Sunday investigation has discovered that NHS staff at every level are working remotely in places as far flung as Australia and Japan. Critics last night warned that the 'unacceptable and dangerous' arrangements could threaten patient safety. Professor Karol Sikora, a former director of the World Health Organisation cancer programme, said: "Allowing staff to work from abroad is a huge mistake that can only undermine patient safety and the efficacy of treatment." At least 335 NHS staff from 33 trusts have been allowed to work abroad in the past two years, according to data from Freedom of Information requests. Until last year, Constantine Fragkoulakis, 42, was employed as a consultant radiologist at Sherwood Forest Hospitals Foundation Trust in Nottinghamshire. The trust said its radiologists "routinely interpret images and write reports away from the hospitals where they are based". But Mr Fragkoulakis admitted there had been "a lot of IT issues, so there was no patient care involved or clinical work'. He added: 'Essentially it was just meetings that I did." Another consultant radiologist, Branimir Klasic, 50, is being allowed to work two weeks each month in Croatia by the Aneurin Bevan University Health Board in South Wales. It said recruitment was "increasingly challenging" and that it was "open to exploring ways of working that ensures we can provide the skills and expertise that our patients need". A Department of Health spokesman said: "We are clear that ways of working, which are agreed between NHS employers and its staff, should never impact on NHS patients or services." Read full story Source: Daily Mail, 10 February 2024
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Content ArticleBibliometric analysis is a research technique that allows a macroscopic study of the literature surrounding a subject, enabling a prediction of themes that will arise in future research on the subject. In this book chapter, Hülya Saray Kiliç, Assistant Professor at the Bilecik Şeyh Edebali University in Turkey outlines the approach taken in his bibliometric analysis of patient safety in the operating room. His analysis anticipates that the following subjects will be explored in the coming years in relation to patient safety in the operating room. Technology integration and digital solutions Communication and team collaboration Patient education and information Staff training and skill development Risk management and error analysis
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Content ArticleAn otherwise healthy patient is taken to the operating room for the removal of a neck mole under monitored sedation. After the patient is given two litres of oxygen through nasal cannula and administered intravenous sedation, an alcohol-based skin preparation is applied to the surgical field. As the surgeon uses electrocautery to coagulate bleeding, a flash occurs, and the surgical drapes ignite. After extinguishing the fire by pouring water on the surgical field, assessment of the patient reveals second-degree burns on the patient’s face. Oxygen from the nasal canula had accelerated the fire and caused the nasal cannula to melt and adhere to the patient’s face. The patient was transferred to the burn unit for care, and ultimately required reconstructive plastic surgery. This case illustrates one type of injury that can be sustained during a surgical fire. The Joint Commission issues this alert to help healthcare organizations recommit to surgical fire prevention.
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Content ArticleThis NICE guideline covers the recognition, diagnosis and early management of suspected sepsis. It includes recommendations on recognition and early assessment, initial treatment, escalating care, finding the source of infection, early monitoring, information and support, and training and education. In January 2024,, the evidence was reviewed and NICE has made new recommendations on risk evaluation and management of suspected sepsis for people aged 16 or over who are not and have not recently been pregnant, in mental health, ambulance and acute hospital settings. This covers the population and settings in which the national early warning score (NEWS2) applies.
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News Article
People severely ill with suspected sepsis should be given antibiotics, Nice says
Patient Safety Learning posted a news article in News
People who are severely ill with suspected sepsis should promptly be given life-saving access to antibiotics to prevent unnecessary deaths, according to updated guidance from the National Institute for Health and Care Excellence (NICE.) The guidelines state that the national early warning score should be used to assess people with suspected sepsis aged 16 and over, who are not and have not recently been pregnant, and are in an acute hospital setting or ambulance. The updated guidance also recommends that doctors are more considerate as to who is given antibiotics, in order to reduce the risk of antibiotic resistance in people being prescribed them for less severe cases of sepsis. With the update, NICE says that more people will be categorised at a lower risk level where a sepsis diagnosis should be confirmed before being given antibiotics. Prof Jonathan Benger, Nice’s chief medical officer, said: “This useful and usable guidance will help ensure antibiotics are targeted to those at the greatest risk of severe sepsis, so they get rapid and effective treatment. It also supports clinicians to make informed, balanced decisions when prescribing antibiotics. “We know that sepsis can be difficult to diagnose so it is vital there is clear guidance on the updated [national early warning score] so it can be used to identify illness, ensure people receive the right treatment in the right clinical setting and save lives." Read full story Source: The Guardian, 31 January 2024 -
Content ArticleThis study in the British Journal of General Practice aimed to assess the risk of poor respiratory outcomes for people with resolved asthma compared to those with active asthma and people without asthma. The authors used three retrospective cohorts of around 16,000 patients each, in the following groups: Active asthma cohort (patients with an asthma-specific diagnostic code at any point in their GP record, and >1 asthma medication prescription). Resolved asthma cohort (patients with >1 resolved asthma code, followed from date of first resolved asthma during the study period to the earliest data of an asthma prescription, the end of the study period, date of transfer out of practice or death). Non-asthma cohort (population-based patients without active or resolved asthma or chronic obstructive pulmonary disease). The results showed that compared to the active asthma cohort, the resolved asthma cohort had fewer GP consultations for asthma exacerbations and fewer asthma hospital admissions. However, compared with non-asthma patients, resolved asthma patients had more GP consultations, greater rates of respiratory tract infections and higher rates of antibiotic use. The authors highlighted a lack of guidance around care pathways for patients with a record of resolved asthma. They concluded that patients with resolved asthma may need a more comprehensive respiratory assessment if they present with symptoms of lower respiratory tract infection, in order to assess symptom burden, airway obstruction and the potential value of inhaled treatment.
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Content ArticleThe 2021 UK NHS Getting It Right First Time report recommended that a significant proportion of native tissue vaginal prolapse operations should be undertaken as day-case procedures. The evidence for perioperative care, options for anaesthesia and outcomes of day-case vaginal prolapse surgery is limited. This study aimed to establish current practice amongst UK gynaecologists and explore perceived barriers to implementing day-case surgery for pelvic organ prolapse.
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Content ArticleHospitalised adults whose condition deteriorates while they are on hospital wards have considerable morbidity and mortality. Early identification of patients at risk of clinical deterioration has traditionally relied on manually calculated scores, and outcomes after an automated detection of clinical deterioration have not been widely reported. The authors of this article published in The New England Journal of Medicine developed an intervention program involving remote monitoring by nurses who reviewed records of patients who had been identified as being at high risk. Results of this monitoring were then communicated to rapid-response teams at hospitals. They compared outcomes among hospitalised patients whose condition reached the alert threshold at hospitals where the system was operational, with outcomes among patients at hospitals where the system had not yet been implemented. The authors found that using an automated predictive model to identify high-risk patients, for whom interventions could then be implemented by rapid-response teams, was associated with decreased mortality.
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Content Article
Designing in risk: Measuring safety part 3
NMacLeod posted an article in Improving patient safety
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The relationship between management and the workforce, in very simplistic terms, can be considered one of reward in return for effort. The contracted effort is communicated through a roster. In organisations that have a continuous operation, blocks of effort are distributed to maintain the flow of output. The organisation of effort, then, is a legitimate function of management. Norman's previous blog looked at performance variability under normal conditions. In this blog, Norman looks at the impact of physiological states and how management’s organisation of effort degrades decision-making.- Posted
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News ArticleA new risk calculator will help to identify people with type 2 diabetes who are at high risk of developing heart and circulatory diseases with greater accuracy than ever before. By spotting high-risk individuals years in advance, doctors will be able to offer vital preventative treatment that can help save lives by warding off future heart attacks and strokes. The risk calculator is included in the new European Society of Cardiology (ESC) Guidelines advising doctors on the management of cardiovascular disease in people with type 2 diabetes, which were announced at the ESC’s annual Congress in August. There are around 4.5 million people in the UK with type 2 diabetes, and one third of adults with diabetes die from a heart or circulatory disease. The SCORE2-Diabetes risk calculator, published in the European Heart Journal, will allow doctors to estimate the risk of developing a heart or circulatory disease in the next 10 years, with much improved accuracy. Professor Sir Nilesh Samani, our Medical Director, said: “People with diabetes are overall nearly twice as likely to die of heart disease or stroke as those who do not have the condition. "This increased risk can be substantially reduced by interventions such as blood pressure control and statins, but this requires more accurate identification of those at increased risk. “SCORE2-Diabetes is a valuable advance that will allow doctors to tailor pre-emptive treatments for individuals with type 2 diabetes based on their personal risk of heart and circulatory diseases. "Such an approach is vital as clinicians in the UK and across Europe find new ways to reduce the high levels of ill health associated with diabetes.” Read full story Source: British Heart Foundation, 26 November 2023
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Content Article
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In a three-part series of blogs for the hub, Norman Macleod explores how systems behave and how the actions of humans and organisations increase risk. In part 1 of this blog series, Norman suggested that measuring safety is problematic because the inherent variability in any system is largely invisible. Unfortunately, what we call safety is largely a function of the risks arising from that variability. In this blog, Norman explores how error might offer a pointer to where we might look. -
Content ArticleThrough a data sharing agreement, the Faculty of Intensive Care Medicine can access a record of incidents reported to the National Reporting and Learning System (NRLS). Available information is limited and from a single source; all that is know about these incidents is presented in this report. The safety bulletin aims to highlight incidents that are rare or important, and those where the risk is perhaps something we just accept in our usual practice. It is hoped that the reader will approach these incidents by asking whether they could occur in their own practice or on their unit. If so, is there anything that can be done to reduce the risk?
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Content Article
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NHS England is introducing a new approach to investigating patient safety incidents, called the Patient Safety Incident Response Framework (PSIRF). To help organisations develop their plans and transition to this new way of working, Patient Safety Learning has published a template PSIRF Risk Register and Risk Management Plan.- Posted
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Content ArticleBowtie is a visual tool which effectively depicts risk, providing an opportunity to identify and assess the key safety barriers either in place or the ones lacking, between a safety event and an unsafe outcome. This guidance from the UK Civil Aviation Authority outlines how the bowtie model works and how to use it.
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News ArticleOver the counter genetic tests in the UK that assess the risk of cancer or heart problems fail to identify 89% of those in danger of getting killer diseases, a new study has found. Polygenic risk scores are so unreliable that they also wrongly tell one in 20 people who receive them they will develop a major illness, even though they do not go on to do so. That is the conclusion of an in-depth review of the performance of polygenic risk scores, which underpin tests on which consumers spend hundreds of pounds. The findings come amid a boom in the number of companies offering polygenic risk score tests which purport to tell customers how likely they are to get a particular disease. Academics at University College London (UCL) who undertook the research are warning that such tests are so flawed they should be regulated “to protect the public from unrealistic expectations” that they will correctly identify their risk of a particular disease. The authors concluded: “Polygenic risk scores performed poorly in population screening, individual risk prediction and population risk stratification. “Strong claims about the effect of polygenic risk scores on healthcare seem to be disproportionate to their performance.” Read full story Source: The Guardian, 17 October 2023
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Content ArticleThis infographic by artist Sonia Sparkles highlights ways to prevent patient falls in hospital. A wide range of graphics relating to patient safety, healthcare and quality improvement is available on the Sonia Sparkles website.
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Content ArticleDelirium is a common but underdiagnosed state of disturbed attention and cognition that afflicts one in four older hospital inpatients. It is independently associated with a longer length of hospital stay, mortality, accelerated cognitive decline and new-onset dementia. Risk stratification models enable clinicians to identify patients at high risk of an adverse event and intervene where appropriate. The advent of wearables, genomics, and dynamic datasets within electronic health records (EHRs) provides big data to which machine learning (ML) can be applied to individualise clinical risk prediction. ML is a subset of artificial intelligence that uses advanced computer programmes to learn patterns and associations within large datasets and develop models (or algorithms), which can then be applied to new data in rapidly producing predictions or classifications, including diagnoses. The objectives of this review from Strating et al. were to: (1) provide a more contemporary overview of research on all ML delirium prediction models designed for use in the inpatient setting; (2) characterise them according to their stage of development, validation and deployment; and (3) assess the extent to which their performance and utility in clinical practice have been evaluated.
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Content ArticleMost healthcare organisations (HCOs) find diagnostic errors hard to address. Singh et al. developed a checklist (the Safer Dx Checklist) of 10 high-priority safety practices HCOs can use to conduct a proactive risk assessment to address diagnostic error.
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News Article
Should Ozempic come with a warning about a risk of suicidal thoughts?
Patient_Safety_Learning posted a news article in News
In the U.S., the prescribing label of Ozempic's sister drug, Wegovy, already warns of possible suicidal ideation because of similar side effects linked to other weight loss drugs. Following reports of self-injury and suicidal thoughts among a small number of people who’ve taken Ozempic or Wegovy in Europe and the United Kingdom, health regulators there are investigating whether the drugs carry a risk of these side effects. The European Medicines Agency said last month that it was reviewing 150 such reports from people who took drugs in this class, called GLP-1 receptor agonists, which lower blood sugar and suppress appetite by mimicking a hormone in the gut. Then last week, the U.K.'s Medicines and Healthcare products Regulatory Agency told Reuters that it was reviewing safety data about the drugs following similar reports. Neither Ozempic nor Wegovy, which are both versions of a drug called semaglutide at different dosages, carry warnings about suicidal ideation in Europe or the U.K., since clinical trials have not shown evidence of an increased risk. But in the United States, the Food and Drug Administration requires that medications for weight management that work on the central nervous system carry a warning about suicidal thoughts. Because the agency approved Wegovy as a weight loss treatment, its prescribing label asks medical professionals to monitor for these symptoms and to discontinue the medication if people develop them. Ozempic, which is only FDA-approved to treat diabetes, does not come with that warning. But some patients think it should. Read full story Source: NBC 1 August 2023 -
EventThis masterclass will focus on developing your role as a SIRO (Senior Information Risk Owner) in health and social care. Key learning objectives: Understanding the role of the Senior Information Risk Owner Identifying Information Risks across the organisation Working with others to mitigate the risk to patients, staff and organization. Confidence that all reasonable technical and organisation measure are in place Giving assurance to the Board that risks have been considered, mitigated or owned Understand the requirements of external confidence that policies, procedures are in place to deal with Data Breaches. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/masterclass-developing-your-role-as-a-senior-information-risk-owner-siro or email kate@hc-uk.org.uk. hub members receive a 20% discount. Email info@pslhub.org for a discount code.
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News Article
Baby died of brain injury after midwives ‘neglected’ mum while breastfeeding
Patient Safety Learning posted a news article in News
Olly Vickers died of a brain injury in February last year just weeks after two midwives at Royal Bolton Hospital let his mother Emma Clark feed him while she was having gas and air – in breach of guidelines. Despite being well when he was born, Olly was found “pale and floppy” hours later due to his airways being obstructed. He developed a brain injury and died five months later. Coroner Peter Sigee ruled his death was a result of “neglect” and due to a “gross failure to provide basic medical care”. An inquest into his death heard a student midwife placed a pillow under his mother’s arm while she was feeding him, “contrary to accepted practice”. Another midwife then gave Ms Clark gas and air while she was feeding Olly as she was stitched up for a tear obtained during labour – which again went against guidance. No risk assessment was carried out and the coroner said Olly’s breastfeeding should have been stopped before the midwives began to suture Ms Clark. Read full story Source: The Independent, 8 July 2023
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