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  1. Content Article
    Coroner's concerns Substantial evidence was heard at the inquest with regard to observations which were not carried out in respect of Eliot Harris in accordance with NSFT’s Policy and with regard to staff not undergoing training and assessment of their competency to carry out observations correctly. Quality audits undertaken following Eliot Harris’s death, show that observations are still not being carried out and recorded in accordance with NSFT’s most recent policy – more than two years following Eliot’s death. Not all staff have completed training with regard to carrying out of observations or have undergone and assessment of their competency to carry out observations. On the night of Eliot’s death, a Nurse in Charge had not been allocated and members of staff were not allocated specific tasks – they were told to “muck in”, as a result there was some confusion as to who was responsible for specific jobs. The evidence at the inquest was not clear as to whether specific tasks are allocated to specific members of staff on Night Duty and whether and how a Nurse in Charge is appointed for each night’s rota. Multi Team Meetings were not fully and properly recorded in the clinical records. At the inquest, evidence was heard there “is still some way to go” with regard to improving record keeping and for ensuring important matters such as rationale for decisions is fully recorded. Eliot’s Care Plan was not up to date at the time of his death. At the inquest evidence was heard that although audits show there has been an improvement in completion of Care Plans, there “is still some way to go” and staff still need to be prompted to complete these. Staff were reluctant to enter Eliot’s room following concern for his wellbeing. The evidence did not reveal what is now in place to ensure staff enter a patient’s room immediately if there are concerns for a patient’s welfare (having considered their (staff’s) own safety). It is not clear from the evidence what is now in place to ensure that relevant and requested physical health checks are carried out. The process of ensuring health checks are carried out has not changed since Eliot’s death and remains a retrospective process.
  2. Content Article
    Surgical mesh is a medical device implanted to support organs in various procedures. Thousands of women in the UK had mesh surgically implanted to treat pelvic organ prolapse and stress urinary incontinence, until its use was suspended due to safety concerns in 2018.[1] Surgical mesh has been linked to a wide range of serious health issues including chronic pain, incontinence, painful sex, recurrent infections, loss of mobility and autoimmune diseases. Prior to the suspension, women injured by mesh had been raising concerns about the safety of the procedure for years and campaigning for change through patient groups including Sling the Mesh. In 2020, the Independent Medicines and Medical Devices Safety (IMDDS) Review’s report, ‘First Do No Harm’, highlighted the lack of research evidence about safety aspects of pelvic mesh, the failure of the health system to listen to women injured by mesh and a lack of awareness among healthcare professionals about mesh complications.[2] One of the key recommendations of the report was that the Government should establish specialist mesh centres to offer comprehensive treatment, care and advice, including removal surgery, to women harmed by pelvic mesh implants. In response, the NHS has now established ten specialist mesh centres across the UK—nine in England and one in Scotland.[3] However, these specialist centres are beset with problems, preventing women harmed by mesh from receiving desperately needed treatment. Specialist mesh centres - what are the patient safety issues? 1. Long waiting lists The mesh specialist centres have unacceptably long waiting lists, with many women being told they won’t have an initial consultation for at least a year. Kath Sansom, founder of Sling the Mesh, said, “So many women on our Sling the Mesh Facebook page are reporting really long waiting lists to be seen for a first consultation—they feel hopeless about ever getting appropriate support and treatment for their complications.” 2. Lack of awareness among healthcare professionals Many healthcare professionals are simply not aware that mesh specialist centres exist. This is leading to women being told that nothing can be done for them, and that they are “too complicated” to deal with.[4] Addressing MPs in a Westminster Hall debate in February 2022, Alec Shelbrooke MP, co-chair of the Surgical Mesh All-Party Parliamentary Group, stated that “GPs are unaware of mesh complication centres and the referral process.”[5] 3. Surgical training inconsistencies In a previous blog, Patient Safety Learning and Sling the Mesh outlined concerns around inconsistencies in training for surgeons performing mesh removal which is undermining women’s confidence in the specialist centres.[6] One woman also told us, “[a surgeon] did offer to remove the mesh, but I just didn’t feel confident in his care as he had only done 15 mesh removals before, and not on a regular basis.”[7] 4. Centres being run by surgeons who implanted mesh Many women are reluctant to be treated by surgeons who spent years inserting the devices that have caused them so much suffering. Many members of the Sling the Mesh Facebook group have reported that surgeons who originally implanted their mesh did not take their concerns seriously. However, when women requested a second opinion, the mesh was often found to be causing obvious, visible damage, including slicing through nerves, the bladder and the vaginal wall, causing infections and pulling organs out of position. This breakdown in trust between surgeons and their patients undermines women’s confidence in the centres set up to treat their complications. 5. Lack of understanding about autoimmune complications A large number of women with surgical mesh implants report developing symptoms of autoimmune conditions such as lupus and Sjögren's syndrome following the surgery. In addition, around 50% of members on the Sling the Mesh Facebook group report suffering from fibromyalgia symptoms—although fibromyalgia isn’t currently officially recognised as a autoimmune condition, emerging studies are beginning to recognise a connection.[8] There have been small studies into the link between mesh and autoimmunity,[9] but much more research is needed to understand the issue and ensure women with these symptoms can receive appropriate treatment. Many women report that when they tell healthcare professionals about their symptoms, the link between mesh and autoimmune conditions is not acknowledged and little support is offered. This lack of understanding is present in specialties that deal with autoimmune conditions, such as rheumatology and immunology, as well as mesh specialist centres. Autoimmune conditions can have a major impact on health and quality of life, and this is another area where women feel that the specialist mesh centres are failing to deal with the devastating effects of surgical mesh. 6. Lack of appropriate after-care There is no guarantee for women who receive mesh removal surgery that it will improve their symptoms, and many feel that mesh centres are not offering enough post-operative support. Kath Sansom told The BMJ, “There is either very little or no aftercare, leaving some women having to go to their local [emergency department] with dangerous issues like pelvic blood clots or sepsis.”[5] How will specialist mesh centres overcome these issues? The Government and NHS leadership must recognise these issues and find ways to address both the shortage of provision and the lack of trust many women have in specialist centres. This will certainly involve bigger investments in training for surgeons, awareness raising amongst healthcare professionals and measures to address the damaged relationship between women and the healthcare system. There also needs to be consistent, joined up logging of women’s outcomes following removals. This would establish a trusted database that highlights which surgeons and centres are performing well, and who needs additional training. Another way to offer more timely care is to look beyond the NHS and give women more choice in where they have removal surgery and who assesses their case. The Scottish Government announced in July 2022 that NHS patients in Scotland would be eligible for funding to travel to a clinic in Missouri, USA for transvaginal mesh removal surgery.[10] The Scottish Government also has an existing deal with a Spire Healthcare facility in Bristol that allows Scottish women to access mesh removal surgery. The message from Scottish Health and Social Care Secretary Humza Yousaf MSP to women seeking removal surgery was that “we won’t put up any unnecessary barriers in your way.”[10] However, this option is not yet available in other parts of the UK, and some women have expressed concerns about travelling on a long haul flight after major, complex surgery. There are also worries about how aftercare would work if there were complications from a surgery performed outside of the UK. Establishing specialist mesh centres was only the first step in addressing the issues women face in getting the support they need. It is vital that the Government and NHS increase their efforts to ensure all women have fast and equitable access to mesh removal surgery. References 1 Devlin H. Government halts vaginal mesh surgery in NHS hospitals. The Guardian, 9 July 2018 2 First Do No Harm. The report of the Independent Medicines and Medical Devices Safety Review. Independent Medicines and Medical Devices Safety Review, 8 July 2020 3 Vaginal Mesh Complications. The British Association of Urological Surgeons website, last accessed 3 August 2022 4 Community post: Doctors shocking comments to women harmed by mesh. Patient Safety Learning , 22 June 2022 5 Wise, J. Specialist surgical mesh centres are not working, MPs are told. BMJ, 4 February 2022 6 Mesh Complications Training Pathway: Patient experiences must be recognised. Patient Safety Learning & Sling the Mesh, 17 February 2022 7 “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery. Patient Safety Learning, 1 May 2022 8 New study shows Fibromyalgia likely the result of autoimmune problems. Kings College London website, last accessed 1 September 2022 9 Cohen Tervaert, J. Autoinflammatory/autoimmunity syndrome induced by adjuvants in patients after a polypropylene mesh implantation. Best Practice & Research Clinical Rheumatology. 2018:32:4;511-520. 10 Dewar, C. Mesh patients to be able to travel to US for removal surgery. STV News, 12 July 2022 Related reading Doctors’ shocking comments reveal institutional misogyny towards women harmed by pelvic mesh - a Patient Safety Learning blog “There’s no problem with the mesh”: A personal account of the struggle to get vaginal mesh removal surgery ‘Mesh removal surgery is a postcode lottery’ - patients harmed by surgical mesh need accessible, consistent treatment
  3. News Article
    Nearly 38,000 vital follow-up appointments with mental health patients were missed at the time when they were most at risk of suicide, the Royal College of Psychiatrists has said. The medical body has called for “urgent action” to ensure more people are seen for follow-ups within 72 hours of their discharge from inpatient care, to prevent them from falling “through the cracks when they are so vulnerable”. The risk of suicide is highest on the second and third days after leaving a mental health ward, but 37,999 follow-up appointments with patients were not made within this timeframe in England between April 2020 and May 2022. According to NHS data, of the 160,430 instances when patients were eligible for follow-up care within 72 hours after discharge from acute adult mental health care, only three-quarters (76%) took place within that period. The Royal College of Psychiatrists is calling for more trained specialists to check on those perceived to be at risk, which they say requires more staffing and funding. The president of the Royal College of Psychiatrists, Dr Adrian James, said: “We simply can’t afford to let people fall through the cracks at a time when they are so vulnerable. It’s vital that our mental health services are properly staffed and funded to offer proper follow-up care and help prevent suicides. “Staff are working as hard as they can to provide high-quality care, but it’s clear that current resources are not enough to meet these targets. We need urgent action to tackle the workforce crisis and achieve the suicide prevention goals set out in the NHS long-term plan.” Read full story Source: The Guardian, 22 August 2022
  4. Content Article
    This article sets out six ways hospitals can ensure patient safety during treatment: Provide Patient Centric Quality Care Design Purpose-Built Hospital Adopt a Health Management System Formulate and Revise Staffing Policies Enforce Safety Protocols Educate the Staff and Patients about Safety Policies
  5. Content Article
    Arterial lines are routinely fitted for severely ill patients in critical care and are flushed with a solution to maintain patency, and ensure that blood does not clot in the line. Saline is recommended as the flush solution for arterial lines. There is a known patient safety risk in connection with this where glucose solutions being inadvertently and incorrectly used to flush arterial lines. This has led to inaccuracies in blood glucose measurements, which resulted in unnecessary administration of insulin and subsequent cases of hypoglycaemia, some of which have been fatal. Findings The key findings from the investigation include: The physical layout and design of the clinical and storage areas will influence how reliably staff are able to select and collect similar-looking equipment and medication. The labelling of bags of fluids, similar looking medications and manufacturers’ packaging reduce the reliability of selecting the correct flush fluid in the context of a critical care unit with time pressures and high workloads. The procurement and design of arterial transducer line equipment, the pressure infusion bags and transducer, do not assist in the identification of the incorrect flush fluid or prevent contamination from the flush fluid of a blood sample taken from the arterial line. Alternative equipment, for example transparent pressure infusion bags and closed arterial transducer lines, are currently available to the NHS. These may reduce the risk but are not routinely in use. Challenges in the provision of a consistent suitable workforce and high workloads have a detrimental effect on the safety controls currently relied upon to avoid or identify the risk of using the wrong flush fluid. Safety checks and training lack resilience to organisational pressures regularly experienced within critical care units. There can be a delay in identifying the contamination with glucose of an arterial line blood sample due to a normalisation and acceptance that critically ill patients may have altered blood glucose levels and require insulin treatment, and a perceived low risk associated with the use of a flush fluid. The design of systems to record and monitor information relevant to the arterial transducer line system and blood glucose levels do not easily alert staff to the potential use of the wrong flush fluid. Recommendations issued over the last 14 years by national safety bodies and professional healthcare organisations to address the safety of blood sampling associated with arterial lines have not been effectively implemented. Safety recommendations The report makes the following safety recommendations: HSIB recommends that the Medicines and Healthcare products Regulatory Agency [Head of Metabolic Disorders and Renal Systems] engages with other national regulators and relevant stakeholders to develop design guidance on labelling and packaging specific to fluids to reduce selection errors. HSIB recommends that the Medicines and Healthcare products Regulatory Agency [Head of Metabolic Disorders and Renal Systems] reviews and acts on the available evidence to regulate for the use of pressure infusion bags that allow fluid labels to be read when inflated. HSIB recommends that the Medicines and Healthcare products Regulatory Agency [Head of Metabolic Disorders and Renal Systems] communicates to all relevant stakeholders and acts on the available evidence concerning the management of the risks associated with arterial transducer line sets. HSIB recommends that the Department of Health and Social Care [Director of Medical Technology], once post-market surveillance data is available, involves relevant stakeholders including the Association of Anaesthetists’ review and determine appropriate actions that could be taken to further mitigate the risk of blood sample contamination by the flush fluid when using arterial transducer line systems. HSIB recommends that the Association of Anaesthetists [President] works with relevant professional organisations to revise existing national guidance to manage the risks of contamination by the flush fluid when using an arterial line to take a blood sample. HSIB recommends that the Care Quality Commission [Chief Executive] reviews the recommendations from the Association of Anaesthetists on how to manage the risks of contamination by the flush fluid when using an arterial transducer line and determines any appropriate actions for the oversight of governance and assurance arrangements within NHS providers following.
  6. News Article
    The quality and performance of services will suffer if medical training is not ‘prioritised and funded’ by trusts, Health Education England (HEE) has warned. HEE has set out actions in its “Covid training recovery interim report” that must be done alongside NHS England, the Department of Health and Social Care and others to protect post-covid workforce recovery. At the beginning of the pandemic, junior doctors’ training was severely disrupted because thousands of staff were redeployed to covid wards, while most routine elective operations and diagnostic procedures were stopped. HEE says training has still not returned to pre-covid levels, and fears there could be further disruptions over winter if significant volumes of elective care are cancelled. According to its report, if medical training is not “prioritised and funded”, the “long-term costs to service are significantly greater”. “If delivery recovery is prioritised over training recovery there will be an initial increase in service delivery time and value, but this will be followed swiftly by a reduction in service delivery time and value,” it warned. Read full story Source: HSJ, 13 October 2021
  7. Content Article
    For people with diabetes (PWD), hospitals can feel like unsafe places. As a result, many are afraid of having to access emergency care or stay in hospital as an inpatient. This is partly because PWD are experts at self-management, with intricate knowledge of their own bodies. I have personal experience of this, having had type 1 diabetes myself for nearly two decades. As PWD, although we can't always predict how our diabetes will behave, our decisions on how to react to every situation become instinctive. When control is taken from our hands it feels terrifying; how could anyone else make a safe decision on our behalf? It feels like handing your baby over to a stranger! Harm in hospital - a reality for people with diabetes Sadly, all too often these fears are based in reality. When appropriately trained, healthcare professionals can make safe medication decisions for PWD, but research reveals a shockingly high prevalence of harm due to diabetes-related medication and treatment errors.[2] A recent blog on the hub looked at safety concerns raised by the Healthcare Safety Investigation Branch (HSIB) about insulin administration errors in hospitals. In HSIB’s reference case, the husband of the patient in question (who was in hospital for reasons other than diabetes) had raised concerns about the potential for a dosing error on two separate occasions, but he had not been listened to by staff. As a result, the patient was given five times her prescribed dose of insulin, in what could have been a fatal incident. These concerns go back years, with various organisations including Diabetes UK highlighting the need for action to make hospitals safer for people with diabetes.[1] The Getting It Right First Time (GIRFT) report on Diabetes published in November 2020 outlined some serious patient safety issues, including the fact that many hospitals have no effective system to identify patients with diabetes and have not trained ward staff in the safe use of insulin.[2] It also highlighted inconsistent timings and content of hospital food as an issue for PWD. According to GIRFT, the risk of developing diabetic ketoacidosis (DKA)—a life-threatening complication of type 1 diabetes—is between 40-60 times higher in hospital than the background incidence rate of the type 1 population. Most people with diabetes who have stayed in hospital will have their own tale to tell about issues with the care they received. My own experience bears out this concern that many healthcare professionals simply don’t know enough about the condition to look after people with diabetes safely and respectfully. Six years ago I had a planned caesarean section and my diabetes team warned me, “Whatever happens, don’t let them take your insulin pump. They’ll try, but you keep hold of it!” As diabetes specialists, they knew that as long as I was able to, I was the best person to administer my insulin and monitor my blood sugar levels. Type 1 diabetes is a balancing act, and being put unnecessarily on a sliding scale (a glucose and insulin drip often given to PWD when they are in hospital) can damage the equilibrium we work so hard to achieve, and can cause many issues. Of course, sometimes your medical situation may mean that the best course of action is being put on a sliding scale or someone else taking over your diabetes control. But there is a tendency for doctors to see it as the safe option, when it can be unnecessary and less safe than letting an inpatient look after their own insulin needs. Unfortunately, my diabetes team was right—as soon as the anaesthetist saw my pump he was insistent he should take it from me, and I had to be incredibly assertive to be allowed to keep it on. In the end, I did keep it connected and managed excellent control throughout my three days in hospital. Despite the excellent care I received from many other healthcare professionals, the incident left me feeling on edge and like I couldn’t fully trust the staff. What people with diabetes fear most about staying in hospital It’s wrong that the very setting supposedly designed to bring us back to health is a place that seems unsafe to many people with diabetes. Wanting to better understand the issues, I recently asked the diabetes online community on Twitter why going to hospital was scary—and their responses were horrifying. I received Tweets from people in different countries, demonstrating that the problem is not confined to the NHS—people from around the world all told similar stories and raised similar concerns to people in the UK. Here are some of the issues they raised: Lack of healthcare professional knowledge about diabetes A number of people reported nurses not understanding the difference between type 1 and type 2 diabetes, with sometimes dangerous consequences. There were numerous reports of people with type 1 diabetes being denied insulin. One person said they had been denied insulin because they were over 50 and it was assumed they “must have type 2.” Another person described how an A&E consultant did not realise they needed insulin all the time, and refused to administer any more once they were out of DKA. This resulted in them going back into DKA and needing further treatment which could have been avoided with the right knowledge. Many PWD talked about the fact that healthcare professionals in inpatient settings did not know anything about how insulin pumps and continuous glucose monitors (CGM) worked. Some had never even seen them before. With these devices becoming more and more common in the UK, it seems important that all healthcare professionals are trained to understand what they are, and the basics of how they work. No one would expect an intricate knowledge of how they work, but being able to recognise them, knowing where to look for more information and seeking to facilitate their use in inpatient settings would be a good start. Treating hypoglycaemia (low blood sugar) in hospital was also described by many as being very difficult. One person said, “I told them on a few occasions I felt ‘low’. Finally Lucozade got wheeled out but it was almost an inconvenience.” Having diabetes technology and equipment taken away Many PWD reported a fear of devices amongst medical professionals, describing how their monitors and pumps were taken and “locked away.” In one particularly worrying account, someone described being sedated when they protested against having their pump taken away. Many people described intense fear and the feeling of having all power taken away from them as a patient when their devices were removed. Healthcare professionals not listening to or trusting people with diabetes Most people were understanding that healthcare professionals can’t be expected to know everything about diabetes. However, the most commonly expressed frustration was about not being listened to when sharing information about their diabetes. This is the issue that was raised in the HSIB investigation. There was a perception that some healthcare professionals are “arrogant” and assume their knowledge is superior to that of their patient. Some people reported receiving sarcastic and disparaging remarks from healthcare professionals, which heightened their sense of being unsafe. One person said, “It’s dead hard to have to fight your corner while feeling so unwell.” Another person who had type 1 for many years reported being ‘diagnosed with type 1’ while in hospital, despite repeatedly telling staff she already had the condition. Lack of systems to support safety There were numerous reports of insulin drips running out and people being left without any insulin for hours. The reason often given for this was that no doctor was available to sign off the prescription. People also reported a lack of checks in places, for example, in nurse administration of insulin via a sliding scale. One person said, “The nurse left the glucose drip on but turned off the insulin. It terrifies me to think how bad this could have been.” One person reported a fellow patient having to fetch a nurse from the nurses station because no one was responding to their call button when they needed hypo treatment. This kind of scenario is doubtless linked to NHS staffing shortages that are currently causing many safety issues for staff and patients. Alongside these horror stories, I did come across examples of good practice which left PWD feeling confident that the care they were receiving was safe. One Twitter user described being able to keep her pump and continuous glucose monitor on during brain surgery, and was told by the medical team looking after her, “You are the expert on your condition, you advise us.” Another said, “In recent years [I have] been really impressed with how all staff just leave me to my own devices.” Another said that, “most HCP listened to me as T1 myself and welcomed my input.” However, most of these positive experiences were qualified with a ‘but’ followed by a story of a negative or dangerous experience of emergency or inpatient care. You can read more of the comments I received from PWD in this community thread on the hub. Improving safety: policy, training and staff attitudes This lack of consistency across services is a major problem—we can never plan where or when we will need hospital treatment, so it is important that issues are addressed across all trusts and settings. The GIRFT report highlights this issue, recognising that “there is still a large degree of variation in the quality and availability of targeted inpatient services, and in the frequency of hospital-acquired harm resulting from poor diabetes care.”[2] The National Diabetes Inpatient Audit (NaDIA) has been carried out across 81% hospitals over the past few years and is a useful tool in providing data to help specialities and trusts identify and overcome diabetes-related safety issues. For example, its 2021 report highlighted an increased prevalence of DKA among patients in surgical specialties and recommended “the establishment of processes to ensure that insulin is not stopped in people with type 1 diabetes.”[3] The information provided by NaDIA and the GIRFT recommendations are good steps forward, but whether services will have the resources and capacity to take action, is another question. People with diabetes tend to be great educators on the condition they live with, and some reported using their hospital stay as an opportunity to educate healthcare professionals looking after them about diabetes. But it shouldn’t be down to them. Diabetes is a complex condition that requires attention to detail and accurate knowledge to manage safely. Not everyone can be an expert, but helping staff identify when to ask for help from someone who is—and having the humility to do it—should be a priority. The GIRFT report observed that having an increased presence of diabetes specialists in inpatient settings can hugely reduce the number of diabetes medication errors. It recommends the presence of a seven-day multidisciplinary diabetes inpatient team in every hospital to ensure appropriate planning and support for patients with diabetes, whatever they are in hospital for.[2] Perhaps most importantly, hospital staff need to be trained to ask people with diabetes about their management and have a degree of trust in their judgement. Only then will PWD feel confident about going to hospital, whether in an emergency or for elective treatment—shared decision making shouldn’t stop at the hospital door. References 1 Making hospitals safe for people with diabetes. Diabetes UK, 2017 2 Rayman G, Kar, P. Diabetes GIRFT Programme National Specialty Report. NHS England & NHS Improvement. November 2020 3 National Diabetes Inpatient Audit (NaDIA) Harms 2020, England. Healthcare Quality Improvement Partnership. 2021
  8. Content Article
    A new investigation report has been published by HSIB with the aim of helping to improve patient safety in relation to administering high-strength insulin from a pen device to patients with diabetes in a hospital setting.[1] The investigation focuses on the case of Kathleen who has type 2 diabetes and was using a high-strength insulin administered from an insulin pen device to manage her condition. The insulin in her pen device was Humulin R U-500 insulin, which is five times the strength of most insulins. On being admitted to hospital (for a reason unrelated to her diabetes) a nurse administered her insulin as measured by an insulin syringe, rather than the pen device. However, the syringe was intended for use with standard strength insulin and as a result Kathleen was given five times the dose of insulin that she had been prescribed. She received two overdoses of insulin in this way and on both occasions becoming hypoglycaemic (a condition where a person’s blood glucose level becomes too low, which can be dangerous if not treated quickly) and requiring medical treatment. Findings of the investigation Key findings from this investigation included: Variation among trusts in their use of high-strength insulin and the number of patients on these medications. Staff not always being familiar with the different range of high-strength insulins and associated pen devices, with significant variation in training and competency with respect of administering insulin. National safeguards were found to be inadequate to support the safe use of high-strength insulin by healthcare professionals. Inconsistent numbers of diabetes specialist nurses employed across trusts to supporting upskilling staff in relation to diabetes management. A “wholly preventable” incident? The patient safety incident described in this investigation is classed by NHS England and NHS Improvement as a Never Event. These are defined as: “Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers”.[2] A National Patient Safety Alert in 2016 highlighted the risks associated with this specific type of incident and actions required by NHS organisations.[3] This included ensuring staff are made aware of the risks of extracting insulin from pen devices and that they have appropriate training to use these devices. However, in a report published last year, citing the specific case from this investigation, HSIB stated that in their view the barriers to prevent this type of incident “were neither strong nor systemic”.[4] They suggested that this event did not fit the definition of being “wholly preventable” and should be removed from the Never Event list, with new work needed to develop systemic safety barriers to prevent this reoccurring. In response, NHS England and NHS Improvement noted they reviewed the list of Never Events on an ongoing basis and would welcome any suggestions for implementing stronger safety barriers but made no specific commitments for action regarding this insulin safety incident. The findings of this investigation indicate that the barriers that are supposed to be in place tp ensure that this type of incident is “wholly preventable” may not be present amongst all healthcare providers. Patient Safety Learning is concerned that this reference case is unlikely to be a one-off and that there remains a significant risk of avoidable harm from this incident occurring again elsewhere in the NHS. Patient and family engagement Patient engagement is key to improving patient safety. In our report, A Blueprint for Action, we identify this as one of the six foundations of safer care.[5] We believe that patients should be engaged for safety at the point of care, if things go wrong, in improving services, advocating for changes and in holding the system to account. This investigation serves to underline the important role that a patient’s family members can play in highlighting patient safety issues. It was Kathleen’s husband who highlighted concerns with the Nurse Practitioner about her two hypoglycaemic events and querying the dosage she received. This intervention subsequently resulted in the awareness that she had been receiving the incorrect doses because the insulin had been administered by using a syringe rather than a pen device. This case raises concerns about how a patient’s family member’s expertise is used by healthcare professionals. The report states that Kathleen’s husband had initially told staff on the surgical ward about her medication, including that her insulin was five times stronger than standard insulin. However, we know from the investigation that despite providing this information, this wrong dosage was still given. The report notes that: “Kathleen’s family had concerns that the nurse administering Kathleen’s insulin in hospital might not be the staff member they had spoken with." Because of this, her Husband felt that "…it puts the responsibility on me' to ensure that Kathleen was given the correct dose.” Patients must be listened to, and their information, insights and concern must be taken seriously and responded to. In this case, Kathleen was prevented from coming to further harm by the timely action of her husband but unfortunately the opportunity to prevent the two overdoses not prevented. Importance of training The report highlights specific concerns about insulin safety training for staff, noting that at the Trust involved the national ‘Safe Use of Insulin’ e-learning programme had not been among the mandatory training requirements for staff (though it has now subsequently been included in this category). HSIB states that they were told by representatives from the NHS England and NHS Improvement National Diabetes Programme that training, appropriate to the person’s level of responsibility, should be provided to all healthcare staff involved with insulin. However, they also note that: “The investigation engaged with national leaders to consider how training and support for healthcare professionals could be enhanced to increase the knowledge around insulin use relative to each clinical role. The investigation was told that this would require support from a range of national stakeholders and would need to be co-ordinated by a central NHS body to ensure it was effective.” As a result of this, HSIB made the following Safety Observation: “It may be beneficial for insulin training to be competency based and specific to the healthcare practitioner’s role, in line with the ‘Diabetes: getting it right first time’ national specialty report.” However, there is no specific organisation who is identified as being responsible for the ownership and coordination of this task. Observations not recommendations HSIB Recommendations are directed at specific organisations who are asked to respond in 90 days of publication of the report. Their Safety Observations may or may not be directed at a specific organisation and require no formal response. This report makes no recommendations, but four observations. Patient Safety Learning is concerned that as these patient safety improvement points are only observations, with no specific organisation/s responsible for their delivery and assessment of effectiveness, these are unlikely to reduce the risk of a similar incident occurring in another trust. As noted in our recent report Mind the implementation gap, for HSIB Safety Observations there “appears to be no system to disseminate or act on these, beyond them being published towards the end of numerous patient safety reports”.[6] We believe that the impact of HSIB investigations on learning and improvement would be significantly strengthened with formal recommendations, which are then implemented in a timely and rigorous manner along with transparent performance monitoring and reporting. Considering the findings of this report, we think there may also be value in a specific assessment by NHS England and NHS Improvement of the rollout and implementation of training for healthcare professionals who dispense, prescribe and/or administer insulin (as recommended in the report Diabetes: getting it right first time.[7] References HSIB, Administering high-strength insulin from a pen device in hospital, 7 July 2022. NHS England and NHS Improvement, Never Events policy and framework, January 2018. NHS Improvement, Patient Safety Alert: Risk of severe harm and death due to withdrawing insulin from pen devices, 16 November 2016. HSIB, Never Events: analysis of HSIB’s national investigations, January 2021. Patient Safety Learning, The Patient-Safe Future: A Blueprint For Action, 2019. Patient Safety Learning, Mind the implementation gap: The persistence of avoidable harm in the NHS, 7 April 2022. Getting It Right First Time, Diabetes: GIRFT Programme National Specialty Report, November 2020. Related reading Improving safety for diabetic inpatients: 4 key steps (14 June 2021) Top picks: 5 key resources about diabetes (13 June 2021)
  9. Content Article
    Kathleen, who has type 2 diabetes and was using a high-strength insulin administered from an insulin pen device to manage her condition. The insulin in her pen device was Humulin R U-500 insulin, which is five times the strength of most insulins. On being admitted to hospital (for a reason unrelated to her diabetes) a nurse administered her insulin as measured by an insulin syringe, rather than the pen device. However, the syringe was intended for use with standard strength insulin and as a result Kathleen was given five times the dose of insulin that she had been prescribed. She received two overdoses of insulin in this way, on both occasions becoming hypoglycaemic (a condition where a person’s blood glucose level becomes too low, which can be dangerous if not treated quickly) and requiring medical treatment. Findings Trusts vary in their use of high-strength insulin and the number of patients on these medications. Healthcare staff in any speciality may be required to care for hospital patients prescribed high-strength insulin. Restrictions on promoting the use of an unlicensed medication have made it difficult to communicate the risks associated with the ‘semi-routine’ use of Humulin R U-500 insulin. Nursing staff were not always familiar with the range of different high-strength insulins and associated pen devices. Variation was seen in the training and competency assessment of healthcare professionals with respect to the administration of insulin. National safeguards are inadequate to support the safe use of high-strength insulin by healthcare professionals. There is a lack of standardisation in the role and training of diabetes specialist nurses. Inconsistent numbers of diabetes specialist nurses are employed across trusts to support the upskilling of ward staff in relation to diabetes management, including on the use of high-strength insulin. Administering insulin via a pen device is a complex task that requires coordination across and between different departments to ensure that the insulin and associated equipment required are readily available in the clinical area when they are needed. The consequences of not using the insulin pen administration device as intended can be significant, particularly with high-strength insulins. Contract changes meant that a safety needle in widespread use across England disappeared from the catalogue. Safety observations HSIB made the following safety observations: It may be beneficial for insulin training to be competency based and specific to the healthcare practitioner’s role, in line with the ‘Diabetes: getting it right first time’ national specialty report. It may be beneficial if national work was undertaken to review the robustness of the strategies to prevent administration errors with high-strength insulin and update accordingly. It may be beneficial for systems to support regulators in identifying when large volumes of unlicensed medication are regularly being prescribed to patients. Regulators can then engage in dialogue with the manufacturer about applying for a UK product licence. It may be beneficial to conduct work to standardise the role, qualifications, training and competency of diabetes nurse specialists, as recommended in the Diabetes UK Position Statement.
  10. Content Article
    Here is the FRAS tool I implemented: Fire risk assessment tool.pdf Other useful resources I found: Scoring_Fire_Risk-2.pdf Surgical Site Fire Triangle.pdf Surgical_Fire_Poster (1).pdf Video: Fire hazard demo by Zaamin Hussain and Mike Reed Demonstration: "Burning Bruce" drives home the reality of surgical fires - article in Outpatient Surgery
  11. Content Article
    Findings Participants’ perceptions regarding their engagement as a patient safety strategy were expressed through three overarching themes: the word 'patient' obscures the message safety is a shared responsibility involvement in safety is a right. Themes were further defined by eight subthemes. Conclusions Using direct messaging, such as 'your safety' as opposed to 'patient safety' and teaching patients specific behaviours to maintain their safety appeared to facilitate patient engagement and increase awareness of safety issues. Patients may be willing to accept some responsibility for ensuring their safety by engaging in behaviours that are intuitive or that they are clearly instructed to do. However, they described their involvement in their safety as a right, not an obligation. Interpretation Clear, inviting communication appears to have the greatest potential to enhance patients’ engagement in their safety. Nurses’ ongoing assessment of patients’ ability to engage is critical insofar as it provides the opportunity to encourage engagement without placing undue burden on them. By employing communication techniques that consider patients’ perspectives, nurses can support patient engagement.
  12. Content Article
    e-PAIN uniquely distills the knowledge of a range of professionals into 12 Modules made up of interactive sessions to meet the needs of a multidisciplinary audience. e-PAIN is current, up to date and presented in an interactive way to make both basic and specialist knowledge accessible. Any module can be completed stand alone and you can download a certificate upon completion of each module. Sessions take on average 30 minutes to complete and modules have on average 5 sessions. e-PAIN is a collaboration between the Faculty of Pain Medicine, the British Pain Society and e-Learning for Healthcare. It is provided by Health Education England.
  13. Community Post
    These comments were made by people with diabetes in response to a Twitter thread asking "Why is a hospital stay scary if you have diabetes?" If you have diabetes, or care for someone who does, please share your experience with us by adding a comment to this community thread, “I was in ICU after a car accident—none of the staff knew how to work my CGM and/or my insulin pump. I had to manage my own care” “For me it was when I went into hospital for surgery and the nurse said 'Type 1... so do you take insulin for that?'... that's not a reassuring thing to hear minutes before you're taken into the theatre!” “Lucky to get out alive.” “DKA 10 years ago, once back in normal range the consultant insisted I didn't need anymore insulin & refused to let me have any. Obvs within 3 hours I was back in DKA, he wouldn't come see me but had a convo with my husband on the ward phone where hubs explained how T1 works.” “I've been given a full day's bolus, through my iv and then told I was wrong when I said that I only bolused when I ate. Massive hypo followed quickly. I was then told it was my fault and I should have said something.” “After being admitted as an emergency, my own insulin ran out. I was given 2 (2!) of the wrong types of insulin and told that 'it would be okay'.” “They were often confused about T2 versus T1 - lots of emphasis about low fat foods and only being allowed a low fat yoghurt for puddings even though I was on a pump! I had a bag of snacks though as it was a planned hospital stay” “After a major medical issue I was denied insulin in the ICU for over 24 hours but was told I could have some pills to treat my type 1 diabetes” “Last time I went to the hospital, they took my pump (forcefully) and refused to give it back. When I protested, they sedated me. I was in and out of sedation having a panic attack bc I couldn’t breathe. They sedated me again and put me on DKA protocol, even tho I wasn’t in DKA.” “it’s so scary right like you know that you’re the expert on your condition and your needs but that power gets totally taken away” “Handing over your care over to a group of nurses who have no idea what they are doing. It’s super scary. I hate it when they lock it all away and you can’t get to it.” “I didn’t feel safe either. Told them on a few occasions I felt ‘low’. Finally Lucozade got wheeled out but it was almost an inconvenience” “Totally understand why they don’t know much about it if it’s not their specialism BUT some are so arrogant that what they were told one afternoon 10yrs ago is the absolutely way to deal with, and that the person living with it doesn’t know what they’re talking about!” Sarcastic responses “You seem to know a lot about it!” “The neurologist told me I am a terrible diabetic.” “I never feel safe because they don’t allow me to dose my own insulin and last time dropped me from 600 to 40 in three hours and then shot me back up so fast when i specifically told them that i would go low and high from that much insulin” Report of being diagnosed with type 1 diabetes while in hospital, despite telling every healthcare professional she had T1. “I smuggled in my own tester and meds and took care of myself.” “I think the biggest thing for me is them not understanding insulin dose when they’re writing up your chart and how you don’t really have a “typical” insulin dose that fits neatly into their charts because of carb counting or correction doses/reduction dose. It’s strange, when I’ve had DKA admissions and I’m on the sliding scale IV it’s fine because there’s clear guidelines but for just day to day injection management it’s soooo difficult.” "Daughter had food and insulin withheld in a mental hospital." “the ward nurses didn’t even know I had T1 until the more mobile lady opposite me went and fetched a nurse who had been ignoring my call button. I was hypo and couldn’t reach my treatment.” "Taken off insulin for two days as no doctor to prescribe." “Particularly bad experience when a nurse left the glucose drip on but turned off the insulin. It terrifies me to think how bad this could have been.”
  14. Content Article
    The Royal College of Physicians calls for the NHS to take the opportunity to address the consultant shortage as the UK begins to recover from the Covid-19 pandemic. Key findings of the census Only 52% of posts advertised were filled. For the past eight years, barely half of advertised consultant posts were filled, mostly due to a lack of suitable applicants. 36% of consultants described being in control of their workload only ‘sometimes’ or ‘almost never’. 38% said that they worked excessive hours or had an excessive workload ‘almost always’ or ‘most of the time’. 35% of consultants had experienced being undermined and 35% had witnessed a colleague being undermined, usually by managers or fellow consultants. This was more common among women and consultants from an ethnic minority. Consultants estimate that they work 11% more than they are contracted to work, mainly due to their clinical workload. 55% of consultants reported that their morale was worse during the pandemic and only 5% reported that it was better; 69% reported that morale was worse in their department and only 4% reported that it was better. The ratio of population size to number of consultant physicians varies widely. Regions with comparatively fewer consultants have the highest rates of unfilled advertised posts and locum consultants.