Search the hub
Showing results for tags 'Medicine - Haematology'.
-
Content Article
Sickle cell disease can affect people of all backgrounds but is more common in African and Caribbean communities. It has become one of the fastest growing genetic conditions in England, with 250 new cases every year. People living with sickle cell disease may experience painful crises, fatigue and an increased risk of serious health complications. Despite this, the condition is often not well understood. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together 8 useful resources about sickle cell disease that have been shared on the hub. They include recommendations on tackling inequalities, recognising and managing sickle cell disease in hospital, and managing pain. 1 Sickle Cell Society: Standards for the clinical care of adults with sickle cell disease in the UK These standards for the clinical care of adults with sickle cell disease were produced by the Sickle Cell Society in collaboration with a broad multi-disciplinary group of healthcare providers, patients and support groups. 2 The King's Fund: The implicit bias of sickle cell disease Although health outcomes have improved, evidence shows that people with sickle cell still feel marginalised. Their frustrations largely stem from a perceived lack of empathy in a healthcare system that does not fully recognise their struggles. When compounded with limited treatment pathways, these poor experiences leave many feeling neglected and unsupported. This blog from CJ Nwasike discusses sickle cell health inequalities. 3 Sickle cell comparative review to inform policy report: Providing evidence-based recommendations to tackle inequalities This study analysed data across a wide range of indicators and revealed striking inequalities, which were often reflected in the experiences of patients living with sickle cell across the country. The report adds further to the urgent need to address the underlying problems affecting the quality of care for patients with sickle cell. Importantly, this comparative research shows that improvements are also needed for other severe chronic conditions, such as cystic fibrosis and haemophilia, and that lessons can be learned from successes achieved in other specialties. This report includes a set of recommendations that aim to help tackle inequalities associated with sickle cell in the UK. 4 HSSIB: Invasive procedures for patients with sickle cell disease This investigation from the Health Services Safety Investigations Body sets out to review the care of patients with sickle cell disease who need to have an invasive procedure. Invasive procedures involve accessing the inside of a patient’s body, either through an incision (cut) or one of the body’s orifices. Specifically, the investigation focused on: how haematology teams – the specialists who treat people with blood disorders – are involved and informed when a patient with sickle cell disease is treated in another area of healthcare how patients with sickle cell disease are prepared for invasive procedures how and where clinical information relevant to the patient is shared. 5 HSSIB: Management of sickle cell crisis In this investigation, HSSIB used a real patient safety incident to explore how sickle cell crises are managed within hospital settings. In particular, the investigation considered: the knowledge nursing staff may have about the care of patients in sickle cell crisis how patient-controlled analgesia (PCA) – where a patient can use a device to give themself doses of pain relief medication – is considered holistically, such as monitoring the patient and staff workload. 6 Sickle Cell Society: 'The difference between life and death' Following on from the care failures highlighted in the 2021 report, 'No one's listening', this Sickle Cell Society report takes a deeper look at sickle cell nursing care. The findings show the need for vastly more resources, training and support in this critical area of care. The report highlights that not only is no-one listening, but that lives are still being put at risk. 7 Treating chronic pain in sickle cell disease — The need for a biopsychosocial model Clinicians are often unsuccessful at addressing chronic pain in sickle cell disease. In this perspective article in the New England Journal of Medicine, Childerhose et al. discuss how a biopsychosocial model can help capture people’s experience of chronic pain by affirming that biologic, neuropsychological, and socioenvironmental elements play a role in pain-related processes. 8 Sickle cell digital discovery report: Designing better acute painful sickle cell care The report explores the range of technology that is in place for accident and emergency clinicians, red-cell specialists, and ambulance care, to aid timely support to patients with sickle cell on their emergency hospital arrival. A number of focus groups and interviews were carried out with those that have lived experience of the disease, including patients who have suffered acute, painful sickle cell episodes during NHS A&E admissions. Research found a lack of individual care plans in place and, more broadly, no clear definition of what constitutes an actual care plan. A number of recommendations are set out in the report for the NHS and the wider healthcare system. Do you have a resource on sickle cell disease to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.- Posted
-
- Sickle cell
- Top picks
- (and 3 more)
-
Content Article
After 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.- Posted
-
- Blood / blood products
- Medicine - Haematology
- (and 3 more)
-
Content Article
The 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.- Posted
-
- Blood / blood products
- Medicine - Haematology
- (and 3 more)
-
Content Article
This Patient Safety Notice has been developed by Sandwell and West Birmingham NHS Trust following a serious incident inquest of a case involving sampling from a central line. A patient, under renal physicians, required blood cultures from their central venous line (normally used for haemodialysis). Due to unfamiliarity with the correct procedure the line was not clamped prior to use. Air therefore entered the port causing an air embolus and subsequently cardiac arrest. This poster is also available to download via the attached PDF.- Posted
-
- Medicine - Renal
- Medicine - Haematology
-
(and 1 more)
Tagged with:
-
Content Article
This report, No Patient Left Behind, has been published by The APPG on Stem Cell Transplantation and Advanced Cellular Therapies, following an inquiry into barriers which patients face when accessing treatment and care. The report draws out the barriers patients may face, which broadly fit into the following five themes: Socio-economic barriers Complex health systems, health literacy and education Cultural barriers Race, ethnicity and discrimination Geographical barriers. Nine recommendations are made within the report, which are categorised under the following five themes: Personalising care Supporting patients emotionally and financially Better demographic data capture Improving outcomes through research Investment in the stem cell register. Read the report in full by following the link below to the Anthony Nolan website, or you can access it by downloading the attached PDF. no_patient_left_behind_final.pdf- Posted
-
- Racism
- Health inequalities
- (and 2 more)
-
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- Posted
-
- Medicine - Haematology
- Blood / blood products
-
(and 2 more)
Tagged with:
-
Content Article
Medicine is a mirror for the racial injustice in our society; it is a field riddled with racial disparities in everything from research funding to patient care to life expectancy. There may be no population of patients whose healthcare and outcomes are more affected by racism than those with sickle cell disease (SCD). Patients with SCD are too often marginalised and dismissed while seeking medical care when their bodies hurt and they cannot breathe. As medical leaders around the United States issue statements denouncing racial injustice and calling for us to “dismantle racism at every level,” we must ensure that these pledges translate into durable improvements for patients with SCD. Alexandra Power-Hays and Patrick T. McGann propose a number of changes to reduce the impact of racism on patients with SCD in the US. -
News Article
Landmark sickle cell disease inquiry finds evidence of racism in patient care
Patient Safety Learning posted a news article in News
A groundbreaking inquiry into sickle cell disease has found “serious care failings” in acute services and evidence of attitudes underpinned by racism. The report by the all-party parliamentary group (APPG) on Sickle Cell and Thalassaemia, led by Pat McFadden MP, found evidence of sub-standard care for sickle cell patients admitted to general wards or attending A&E departments. The inquiry also found widespread lack of adherence to national care standards, low awareness of sickle cell among healthcare professionals and clear examples of inadequate training and insufficient investment in sickle cell care. The report notes frequent disclosures of negative attitudes towards sickle cell patients, who are more likely to be people with an African or Caribbean background, and evidence to suggest that such attitudes are often underpinned by racism. The inquiry also found that these concerns have led to a fear and avoidance of hospitals for many people living with sickle cell. Care failings have led to patient deaths and “near misses” are not uncommon, leading to a cross-party call for urgent changes into care for sickle cell patients. Read full story Source: The Independent, 15 November 2021- Posted
-
- Medicine - Haematology
- Racism
- (and 5 more)
-
News Article
Doctors raise safety fears at Birmingham hospitals
Patient Safety Learning posted a news article in News
Whistleblowers at one of England's worst performing hospital trusts have said a climate of fear among staff is putting patients at risk. Former and current clinicians at University Hospitals Birmingham (UHB) NHS Trust allege they were punished by management for raising safety concerns, a BBC Newsnight investigation found. One insider said the trust was "a bit like the mafia". The trust said it took "patient safety very seriously". It said it had a "high reporting culture of incidents" to ensure accountability and learning. Staff concerns included a dangerous shortage of nurses and a lack of communication leading to some haematology patients dying without receiving treatment. The deaths of 20 patients in the haematology department of the Queen Elizabeth Hospital, which is run by the trust, led to a review in 2017 by consultant Emmanouil Nikolousis. Mr Nikolousis, who left the trust in 2020, told the BBC he was shocked by the failings he found and believes patients' lives could have been saved. A report by Mr Nikolousis criticised a lack of "ownership" of patients and a lack of communication among senior clinicians. In some cases this led to patients dying without having received treatment, he said. "Certainly there should have been different actions done," he said. "They could be saved. Certainly, when you don't have an action done, then you don't really know the outcome." Mr Nikolousis said he felt he had no option but to quit after his findings were ignored and his position was made "untenable". He left the NHS after 18 years. "They were trying, as they did with other colleagues, to completely sort of ruin your career," he said. Read full story Source: BBC News, 1 December 2022- Posted
-
- Whistleblowing
- Speaking up
- (and 6 more)
-
Content Article
This article looks at the issue of distinguishing between haemofilters and plasma filters, which are used in similar clinical settings, to reduce the risk of mis-selection that could result in patient death.- Posted
-
- Medical device
- Medicine - Haematology
-
(and 1 more)
Tagged with:
-
Content Article
This report was triggered by the Coroner’s report into the death of Evan Nathan Smith in North Middlesex hospital. Evan was a young man with his whole life in front of him. The mistakes made in his treatment leading to his early and avoidable death brought into sharp focus the lack of understanding of sickle cell, the battles patients have to go through to get proper treatment and the terrible consequences which can come about as a result. Following the publication of the Coroner’s report, the All-Party Parliamentary Group (APPG) on Sickle Cell and Thalassaemia held three evidence sessions, hearing from patients, clinicians and politicians. This report is a result of that evidence. The findings in this report reveal a pattern of many years of sub-standard care, stigmatisation and lack of prioritisation which have resulted in sickle cell patients losing trust in the healthcare system that is there to help them, feeling scared to access hospitals, expecting poor treatment from some of those who are supposed to care for them and fearing that it is only a matter of time until they encounter serious care failings. Key findings from the inquiry include: evidence of sub-standard care for sickle cell patients admitted to general wards or attending A&E departments (including a widespread lack of adherence to national care standards) low awareness of sickle cell among healthcare professionals and clear examples of inadequate training and insufficient investment in sickle cell care frequent reports of negative attitudes towards sickle cell patients and a weight of the evidence suggests that such attitudes are often underpinned by racism. The inquiry also found that these concerns have led to a fear and avoidance of hospitals for many people living with sickle cell. While the inquiry did find that specialist haemoglobinopathy services are generally felt to be of a good standard, the report shows that this is far from the case on general wards or A&E departments. Care failings have led to patient deaths and ‘near misses’ are not uncommon. The inquiry heard that awareness of sickle cell among healthcare professionals is low, with sickle cell patients regularly having to educate healthcare professionals about the basics of their condition at times of significant pain and distress and that there is routine failure to comply with national care standards around pain relief when patients attend A&E.- Posted
-
1
-
- Investigation
- Medicine - Haematology
- (and 7 more)
-
News Article
Sickle cell: NHS to investigate racial inequalities for first time
Patient Safety Learning posted a news article in News
Sickle cell patients’ experiences of barriers to treatment and racial inequalities will be investigated by an NHS body next month, The Independent has learned. The NHS Race and Health Observatory has collaborated with Public Digital, a consultancy group, to lead original research into the experiences of people with sickle cell, including listening to NHS patients’ and carers’ first-hand accounts of acute emergency hospital admissions and managing the condition at home. Research will focus on a series of interviews and ‘experience mapping’ workshops, the findings of which are anticipated to inform recommendations that will help improve emergency care and treatment pathways. “As a priority, we need to discover new measures and treatment plans that can help eradicate the often unacceptable, substandard care people with sickle cell have historically received whilst being unwell and in acute pain,” Dr Habib Naqvi, Director of the NHS Race and Health Observatory, said. This move comes after a parliamentary inquiry into avoidable sickle cell deaths called upon the Observatory to undertake work into sickle cell care in relation to race and ethnicity. The inquiry published a report, ‘No one’s listening’, in November 2021, which uncovered the bleak reality of patients grappling with racism in the NHS while attempting to access healthcare. Only half of healthcare professionals feel they have sufficient tools to manage the long-term damage that sickle cell disease brings, new research from Global Blood Therapeutics found, following extensive studies carried out across 10 countries including the UK, US and Canada. Read full story Source: The Independent, 22 September 2022- Posted
-
- Sickle cell
- Medicine - Haematology
- (and 4 more)
-
News Article
A young NHS patient suffering a sickle cell crisis called 999 from his hospital bed to request oxygen, an inquest into his death was told. Evan Nathan Smith, 21, died on 25 April 2019 at North Middlesex Hospital, in Edmonton, north London, after suffering from sepsis following a procedure to remove a gallbladder stent. The inquest heard Smith told his family he called the London Ambulance Service because he thought it was the only way to get the help he needed. Nursing staff told Smith he did not need oxygen when he requested it in the early hours of 23 April, despite a doctor telling the inquest he had “impressed” on the nurses he should have it. Smith’s sepsis is thought to have triggered the sickle cell crisis – a condition that causes acute pain as blood vessels to certain parts of the body become blocked. Barnet Coroner's Court heard Smith, from Walthamstow in east London, might have survived if he had been offered a blood transfusion sooner but the hospital’s haematology team were not told he had been admitted. Read full story Source: The Independent, 3 April 2021- Posted
-
- Accident and Emergency
- Medicine - Haematology
- (and 3 more)
-
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- Posted
-
- Blood / blood products
- Medicine - Haematology
- (and 3 more)
-
Content Article
UK Infected Blood Inquiry (2024)
Patient-Safety-Learning posted an article in Other reports and inquiries
The independent public statutory Inquiry was established to examine the circumstances in which patients in the UK were given infected blood and blood products, in particular since 1970. The Inquiry is Chaired by barrister Keith Langstaff, who has experience of health-related public inquiries.- Posted
-
- Blood / blood products
- Healthcare associated infection
- (and 4 more)
-
Content Article
SHOT: Transfusion risks
PatientSafetyLearning Team posted an article in High risk areas
SHOT is the United Kingdom independent, professionally led haemovigilance scheme. Transfusion is a vital, often life-saving intervention, but it is not without risk. A clear understanding of these risks is essential for informed decision-making, effective risk mitigation strategies and maintaining trust in the safety of transfusions. SHOT shares the key risks associated with transfusion based on the UK haemovigilance data from SHOT 2020-2024 The risks shown are for all transfusion recipients, adult and paediatric.- Posted
-
- Blood / blood products
- Medicine - Haematology
- (and 2 more)
-
Content Article
SHOT (Serious Hazards of Transfusion) is the UK's independent professionally led haemovigilance scheme. Annual SHOT Report 2024 Annual SHOT Report 2023 Annual SHOT Report 2022 Annual SHOT Report 2021 Annual SHOT Report 2020 Annual SHOT Report 2019- Posted
-
- Medicine - Haematology
- Blood / blood products
- (and 3 more)
-
Content Article
SHOT: Transfusion Safety Standards
Patient Safety Learning posted an article in High risk areas
The SHOT Transfusion Safety Standards have been produced to promote and ensure safe, effective transfusions by identifying risks, implementing strategies that create a safer environment for everyone involved, contributing to better patient outcomes, staff wellbeing and overall system safety. SHOT is the UK’s independent, professionally-led haemovigilance scheme analysing transfusion errors and reactions submitted annually since 1996 to identify areas for improvement to optimise safety. Haemovigilance reporting and learning from reports submitted contribute to improving patient safety. These reports provide a mechanism to identify risks so that all healthcare organisations can implement interventions to reduce these.- Posted
-
- Medicine - Haematology
- Blood / blood products
-
(and 1 more)
Tagged with:
-
Content Article
This national patient safety alert has been issued by the NHS England National Patient Safety team. It instructs all organisations providing emergency departments and cancer services to take steps to reduce the risk of harm from delayed administration of rasburicase for tumour lysis syndrome (TLS). All actions should be completed by 9 March 2026. TLS is a life-threatening emergency that can develop when cancer cells break down rapidly, releasing harmful substances into the bloodstream. It requires urgent treatment with rasburicase in high-risk cases, ideally within 1 hour. Patients are at risk of TLS when they have blood cancers with high tumour burden or fast-growing malignancies, particularly when starting cancer treatment that rapidly destroys cancer cells. The release of harmful cellular contents into the blood stream can overwhelm the body’s normal clearance mechanisms and lead to kidney failure, heart rhythm problems, seizures, and even death. Rasburicase is a time-critical medication that rapidly converts uric acid released from dying cancer cells into more soluble compounds that can be safely eliminated. The alert requires NHS organisations providing emergency departments and cancer services to implement specific improvements within 6 months, including updated risk assessment protocols, ensuring medication availability, and addressing operational barriers to timely treatment.- Posted
-
- Cancer
- Emergency medicine
- (and 6 more)
-
Content Article
Sickle cell disease is the name for a group of inherited red blood cell disorders that affect haemoglobin, which is a protein in red blood cells that carries oxygen through a person’s body. It mainly affects people from African or Caribbean backgrounds, though it can affect anyone. It affects approximately 15,000 people in the UK. In November 2021, the All-Party Parliamentary Group for Sickle Cell and Thalassaemia published a report detailing the issues that people with sickle cell disease experience in relation to their care. The report made 31 recommendations to organisations across the healthcare system to help address these issues. HSIB launched two investigations (see also: Management of sickle cell crisis) to find out what additional learning or knowledge could be added in this area and to provide further insights into the practical challenges that patients with sickle cell disease may face when receiving NHS care. This investigation set out to review the care of patients with sickle cell disease who need to have an invasive procedure. Invasive procedures involve accessing the inside of a patient’s body, either through an incision (cut) or one of the body’s orifices. Specifically, the investigation focused on: how haematology teams – the specialists who treat people with blood disorders – are involved and informed when a patient with sickle cell disease is treated in another area of healthcare how patients with sickle cell disease are prepared for invasive procedures how and where clinical information relevant to the patient is shared. The reference event was a patient, 45 years old at the time of the incident, who had a history of sickle cell disease that had led to her being admitted to hospital multiple times. For approximately 3 years she had been receiving regular exchange blood transfusions (transfusions that replaced her blood with donated blood) to help treat the symptoms of her sickle cell disease. Due to heavy, painful and frequent menstrual periods she was scheduled for a surgical procedure to help ease her symptoms. The haematology team were made aware of the procedure but were not told when it was occurring, the procedure was conducted 1 week before the patient was due to have her regular exchange transfusion. Her haemoglobin levels were low. The patient experienced a significant amount of pain during the procedure and was transferred to the haematology ward afterwards for treatment of a sickle cell crisis. Findings The treatment people with sickle cell disease receive varies depending on where they live and the number of patients that clinicians see. Guidance on the treatment of sickle cell disease is limited to specific circumstances, such as sickle cell crisis or blood transfusion, with limited wider guidance available on the through-life management of sickle cell disease. Compared to other conditions that affect similar numbers of people, there has been limited research into the lifelong management of sickle cell disease. This may indicate a health inequality. There is no national information system for storing and sharing clinical information for patients with sickle cell disease. Currently the main way in which haematology consultants are made aware that a patient with sickle cell disease is having treatment in another area of healthcare is when they are notified of this by the patient. It may be possible to set up healthcare IT systems so that they alert haematology consultants when one of their patients accesses another type of healthcare. However, consultants in areas with a high prevalence of sickle cell disease may then receive so many alerts that such a system would be ineffective. Recommendations HSIB recommends that NHS England identifies and implements a system for sharing clinical information about patients with sickle cell disease to improve access to this information for clinicians, and reduce the risk of a patient’s sickle cell disease not being treated consistently. HSIB recommends that the National Institute for Health and Care Research assesses the priority and feasibility of commissioning research into the management of patients with sickle cell disease, encompassing the requirements of patient-controlled-analgesia (pain relief) pumps. This will contribute towards building an evidence base for the generation of national clinical guidance and will reduce unnecessary variance in treatment for patients with sickle cell disease. Observations HSIB makes the following safety observations: It may be beneficial if trusts included a sickle cell disease notification within their electronic patient record systems, to ensure that clinicians treating patients with the disease consider it and seek advice from haematology teams about the impact of any planned treatments, such as invasive procedures. It may be beneficial if the healthcare sector explores, researches and fully understands the care provision to all patients with sickle cell disease, at all points in their life, encompassing day-to-day treatment through to sickle cell crisis.- Posted
-
- Investigation
- Sickle cell
- (and 4 more)
-
Content Article
A long-time patient and a prominent advocate for patient partnership in Quebec and abroad, Vincent Dumez grew up with haemophilia, in constant dialogue with the healthcare system. Like many of his generation, he was impacted by the tainted blood scandal, a chapter in Canada’s history that laid bare deep fractures in safety. From that collective wound, Vincent began a new path. Not to run from what happened but to seek understanding. To turn pain into knowledge and silence into dialogue. He chose to stay. To stay, and to act. Read his blog for Healthcare Excellence Canada.- Posted
-
- Patient engagement
- Person-centred care
- (and 4 more)