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Patient Safety Learning

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  1. Patient Safety Learning
    NHS guidance ‘too long to read,’ say hospital staff as safety watchdog exposes systemic risks to patients.
    The Healthcare Safety Investigation Branch (HSIB) revealed some NHS staff had admitted not reading official guidance on how to avoid the ‘never event’ error as part of a new report identifying deeper systemic problems that it said left patients at an increased risk.
    The independent body warned patients across the NHS remained vulnerable to being injured or even killed by the error that keeps happening in hospitals despite warnings and safety alerts over the last 15 years.
    HSIB launched a national investigation into the problem of misplaced nasogastric (NG) tubes after a 26-year-old man had 1,450ml of liquid feed fed into his lungs in December 2018 after a bike accident.
    The patient recovered but the error was not spotted, even after an X-ray.
    Read full story
    Source: The Independent, 17 December 2020
  2. Patient Safety Learning
    One of England’s largest hospital trusts has been forced to divert ambulances and cancel operations, after seeing a very steep increase in covid-19 admissions over the past week.
    Whipps Cross Hospital in north east London, part of Barts Health Trust, declared a critical incident over the weekend, the trust has confirmed. The trust has also declared a “high pressure phase” of covid response.
    A well placed source said Whipps Cross had been forced to divert ambulances in recent days, because of pressure on its emergency services, while a message to staff said it was deferring some planned operations, along with other steps aimed at protecting safety.
    It is also understood to be attempting to further speed up discharges from hospital.
    Read full story (paywalled)
    Source: HSJ, 16 December 2020
  3. Patient Safety Learning
    Patients needing complex dental work might have to wait longer under new NHS targets, dentists warn.
    The British Dental Association (BDA) fears NHS England will impose penalties on practices that fail to reach 45% of their normal activity level, after negotiations broke down.
    And practices may have to prioritise routine check-ups over more time-consuming treatments.
    An NHS official said: "The NHS and the government are working to determine a safe and reasonable contractual arrangement with dentists, which recognises the constraints on practices and the need to maximise access for patients to see their dentist."
    The waiting list for NHS dentistry could reach eight million by New Year's Eve, according to the Association of Dental Groups.
    Dave Cottam, who chairs the BDA's General Dental Practice Committee, said: "This move will actively undermine patient care.
    "Ministers are instructing dentists to churn through routine appointments against the clock, rather than deal with a huge backlog of urgent cases. Dentists wanting to do the right thing by their patients will now be punished for it."
    Read full story
    Source: BBC News, 16 December 2020
  4. Patient Safety Learning
    A lack of face-to-face appointments during the coronavirus pandemic has significantly worsened the palliative care being provided to people at the end of their life, according to a survey of specialists.
    The research, which the Association of Palliative Medicine and end of life charity Marie Curie shared exclusively with HSJ, found 95% of respondents said their ability to provide good quality end-of-life care had been affected because patients had not received their “usual contact” such as visits from GPs or social care staff. Three-quarters said this had a “great” or “massive” impact.
    Significantly higher numbers of people have died at home since the start of the coronavirus pandemic, compared to previous years.
    Two-thirds of respondents said health professionals had missed opportunities to refer patients into palliative care and, once they had done, four fifths thought they had not done so in a “timely manner.”
    Dr Iain Lawrie, president of APM, said a lack of face-to-face appointments meant “red flags” about patients’ conditions were missed, as these clues are easier to gather in person.
    Read full story (paywalled)
    Source: HSJ, 16 December 2020
  5. Patient Safety Learning
    Pregnant women should be allowed to have one person alongside them during scans, appointments, labour and birth, under new NHS guidance sent to trusts in England.
    The chosen person should be regarded as "an integral part of both the woman and baby's care" - not just a visitor.
    Previously, individual hospitals could draw up their own rules on partners being present.
    This meant many women were left to give birth alone.
    The guidance says pregnant women "value the support from a partner, relative, friend or other person through pregnancy and childbirth, as it facilitates emotional wellbeing".
    Women should therefore have access to support "at all times during their maternity journey".
    And trusts should make it easy for this to happen, while keeping the risk of coronavirus transmission within NHS maternity services as low as possible.
    Read full story
    Source: BBC News, 16 December 2020
  6. Patient Safety Learning
    The waiting list for cancer patients has almost doubled over the last seven months, according to internal NHS data which has never been made public.
    A slide set seen by HSJ suggests the total number of patients waiting for cancer treatment on the 62-day pathway has increased from around 90,000 in mid-May, to around 160,000 at the start of December.
    However, the data suggests the NHS has made good progress in treating patients waiting the longest.
    Read full story (paywalled)
    Source: HSJ, 15 December 2020
  7. Patient Safety Learning
    The government’s plan to allow up to three households to mix at Christmas is a “major error that will cost many lives” and should be stopped, the editors of two leading medical journals have said.
    In a rare joint editorial, the editors of the British Medical Journal and Health Service Journal have said the government’s plan to relax coronavirus restrictions for five days between 23 and 27 December is a serious “blunder” that will put more pressure on the NHS and cause thousands of operations to be cancelled.
    The article published jointly on Tuesday says: “The government was too slow to introduce restrictions in the spring and again in the autumn. It should now reverse its rash decision to allow household mixing and instead extend the tiers over the five-day Christmas period in order to bring numbers down in the advance of a likely third wave.”
    Read full story
    Source: The Independent, 15 December 2020
  8. Patient Safety Learning
    England’s test and trace service is being sub-contracted to a myriad of private companies employing inexperienced contact tracers under pressure to meet targets, a Guardian investigation has found.
    Under a complex system, firms are being paid to carry out work under the government’s £22bn test and trace programme. Serco, the outsourcing firm, is being paid up to £400m for its work on test and trace, but it has subcontracted a bulk of contact tracing to 21 other companies.
    Contact tracers working for these companies told the Guardian they had received little training, with one saying they were doing sensitive work while sitting beside colleagues making sales calls for gambling websites.
    One contact-tracer, earning £8.72 an hour, said he was having to interview extremely vulnerable people in a “target driven” office that encouraged staff to make 20 calls a day, despite NHS guidance saying each call should take 45 to 60 minutes.
    Another call centre worker, who had no experience in healthcare or emotional support, said she suffered a nervous breakdown during an online tutorial about phoning the loved ones of coronavirus victims in order to trace their final movements.
    Read full story
    Source: The Guardian, 14 December 2020
  9. Patient Safety Learning
    In honor and recognition of the 20th anniversary of Lewis Blackman’s death on 6 November 2000, an award has been established with the goal of recognising outstanding leadership in patient safety by students pursuing a health profession and residents in training. Lewis Blackman was an outstanding student himself and because his mother, Helen Haskell, has dedicated her life to improving patient safety, especially through education, the Lewis Blackman Leadership Award has been created.

    You can find all the details and nomination requirements here. Application submissions will be accepted starting 15 December 15 and will close on 31 January.

    If you have any additional questions, please email contact@patientsafetymovement.org
  10. Patient Safety Learning
    There are not enough nurses to safely care for patients in the UK, according to the body that represents the profession, and many of those who are working are suffering from anxiety and burnout after a gruelling nine months treating Covid patients.
    A year after the prime minister pledged during the 2019 election campaign to add 50,000 nurses to the NHS, the Royal College of Nursing has accused Boris Johnson of being “disingenuous” for claiming the government is meeting this 2025 target.
    Johnson claimed last week that the government had “14,800 of the 50,000 nurses already” during prime minister’s questions in the Commons.
    Yet the latest NHS figures show there were 36,655 vacancies for nursing staff in England in September, with the worst shortages affecting mental health care and acute hospitals. Staff in some intensive care units (ICUs) have quit since the pandemic, with those whom the Observer spoke to choosing to work instead in supermarkets or as dog-walkers.
    Dame Donna Kinnair, the RCN’s chief executive and general secretary, said: “The simple, inescapable truth is that we do not have enough nursing staff in the UK to safely care for patients in hospitals, clinics, their own homes or anywhere else.”
    She said that even before the pandemic, “heavy demand” was rising faster than the “modest increases” in staff numbers.
    Read full story
    Source: The Guardian, 12 December 2020
  11. Patient Safety Learning
    The number of women involved in an investigation into a consultant gynaecologist who "unnecessarily harmed" patients has risen to 382.
    University Hospitals of Derby and Burton NHS Foundation Trust has written to another 110 women who were treated by Daniel Hay.
    Mr Hay is under investigation after eight women treated by him were found to have been "unnecessarily harmed". The latest women have been told there are "no concerns" for their health.
    Staff at the Royal Derby Hospital raised concerns about the consultant's care in late 2018. An initial review of 58 cases involving Mr Hay identified the eight lapses of care for which he and the trust have apologised.
    A broader investigation was launched and another 135 women, who had undergone surgery, were contacted to say their care was being reviewed.
    In September the trust wrote to a further 79 women who had received intermediate care.
    It has now said 110 more women, all outpatients at Ripley Hospital between April 2017 and July 2018, have now been contacted.
    Dr Magnus Harrison, executive medical director, said: "We have widened the review to a specific outpatient clinic... to understand the care being provided there. We are doing this proactively, rather than in response to any specific concerns, so that the review is as thorough as possible."
    "Each of the women have been informed that there are no concerns regarding their current health."
    Read full story
    Source: BBC News, 11 December 2020
  12. Patient Safety Learning
    Coronavirus vaccinations at GP practices will now take ‘twice as long’ after regulators announced new rules just days before the jabs are rolled out across primary care.
    The Medicines and Healthcare products Regulatory Agency announced patients would have to be observed for 15 minutes after they received the vaccine. This came after two people had severe allergic reactions to the Pfizer/BioNTech vaccine.
    Primary care directors told HSJ the change means they have had to overhaul plans in their primary care networks and, in some areas, the vaccine programme will be “unfeasibly challenging” to deliver.
    Sources told HSJ workforce plans are being overhauled, while vaccines risk being wasted because of the additional time constraints. There have been claims some practices may drop the vaccination programme altogether, as they lack capacity to carry out 15-minute observations for each patient.
    One primary care director, who spoke to HSJ anonymously, said: “For us, we now need additional space for an observation area. It also makes it more difficult to efficiently flow through the vaccines as the actual vaccination process might take a few minutes, but the through flow of patients will be limited by the 15-minute wait.”
    They added: “The vaccine now taking at least twice as long to do creates logistical problems. Not insurmountable but there nonetheless."
    Read full story (paywalled)
    Source: HSJ, 11 December 2020
  13. Patient Safety Learning
    The number of COVID-19 infections likely to have been acquired in hospital are rising again for the first time in three weeks and their proportion of all cases has reached record levels for the second wave, HSJ can reveal.
    NHS England data covering the week to 6 December (the latest available) shows 1,787 COVID-19 cases were acquired in-hospital – a rise of almost 14% on the week before. The number of hospital-acquired, or “nosocomial”, infections had been falling since the week to 15 November, when 1,794 were recorded.
    This week, hospital acquired covid infections amounted to 21% of the 8,337 new cases which were recorded in hospitals – the highest proportion in the second wave. On 6 December alone, 24% of infections had probably been acquired in hospital rather than the community.
    Read full story (paywalled)
    Source: HSJ, 11 December 2020
  14. Patient Safety Learning
    The NHS is under pressure to publish a delayed review into a bullying scandal at Matt Hancock’s local hospital that involved senior clinicians being asked to provide fingerprint samples in a “witch-hunt” for a whistleblower.
    The “rapid review” into West Suffolk hospital, which Hancock had to recuse himself from because of his friendship with the boss at the trust, was ordered in January and had been due for completion in April. Its publication was put back to this month because of the coronavirus pandemic. But it is now not expected until spring.
    The Doctors’ Association UK suspects the conclusions are being sat on because they make embarrassing reading for the trust’s chief executive, Steve Dunn, described by Hanock as a “brilliant leader”.
    A consultant who chairs the hospital’s medical staff committee wrote to the NHS’s regional director for the east of England, Ann Radmore, last week warning that senior medics felt the hospital could not move on until the review was published.
    The NHS East insists the review will be published as soon as possible, but a source confirmed this is likely to be “spring next year”.
  15. Patient Safety Learning
    A prominent feminist campaigner and writer has described in devastating detail how she was left feeling “humiliated and alone” as she was forced to deal with a miscarriage without her partner.
    Caroline Criado Perez, the author of Invisible Women, called on NHS trusts to allow partners to attend medical appointments, scans and emergencies in maternity services, because the refusal to do so was “traumatising an already traumatised woman”. She added: “It needs to stop, now.”
    At the start of the coronavirus crisis, the majority of NHS trusts began preventing partners from accompanying pregnant women to the majority of maternity appointments, and reports suggest this is still the case in many areas.
    In September the Guardian revealed that three-quarters of NHS trusts were not allowing birth partners to support women throughout their whole labour, despite being told by the NHS and Boris Johnson to urgently change the rules on visiting.
    According to a November survey by the campaign group Pregnant Then Screwed (PTS), 82% of respondents said their local hospital had restrictions in place (for labour or scans), while 90% said that these restrictions were having a negative impact on their mental health.
    Read full story
    Source: The Guardian, 9 December 2020
  16. Patient Safety Learning
    At least 162,000 patients are waiting more than a year for routine NHS operations, the highest number for more than 12 years.
    Latest statistics from NHS England show 162,888 people were waiting over 52 weeks for hospital treatment in October this year.
    The total NHS waiting list for routine treatments at the end of October had reached 4.4 million with more than a third of patients waiting over 18 weeks – the NHS target for waiting times from referral to treatment.
    Earlier this year health think tanks had predicted the waiting list could hit 10 million, but NHS England said this had not come to pass because of the work of hospitals and NHS staff to keel waiting lists lower than they were last year.
    The median waiting time was just over 11 weeks, NHS England said 
    Some experts have warned of hidden demand for NHS surgeries with many patients yet to be referred to treatment because of the covid pandemic.
    A spokesperson for NHS England, said: “Although Covid hospitalisations almost doubled during November, for every Covid inpatient the NHS treated, hospitals managed to treat five other inpatients for other health conditions. With cancer referrals and treatments now back above usual levels, our message remains that people should continue to come forward for care when they need it."
    Read full story
    Source: The Independent, 10 December 2020
  17. Patient Safety Learning
    A hospital has apologised after an elderly cancer patient tested positive for coronavirus, having been left in a ward with another patient suffering from COVID-19 for several days.
    The Aneurin Bevan University Health Board, which serves the Royal Gwent Hospital in Newport, Wales, has confirmed that it is dealing with an outbreak of the virus at the hospital.
    It comes after Lesley Pook accused the hospital of “locking” her father James ‘Jim’ Pook and others in a ward with a coronavirus patient and “waiting for them all to develop symptoms”.
    Read full story
    Source: The Independent, 9 December 2020
  18. Patient Safety Learning
    Coronavirus has not caused an increase in stillbirths despite fears it could do so, Government data suggests.
    The Office for National Statistics (ONS) published data on Monday showing that the stillbirth rate decreased from 4.0 stillbirths per 1,000 total births in 2019, to 3.9 in the first three quarters (January to September) of 2020, in line with the long-term trend.
    The data comes amid fears that coronavirus can impact pregnancy and the stillbirth rate.
    Read full story
    Source: The Telegraph, 8 December 2020
  19. Patient Safety Learning
    The UK’s drug regulator has warned that people with have a history of “significant” allergic reactions should not receive the Pfizer-BioNTech vaccine.
    The Medicines and Healthcare products Regulatory Agency (MHRA) issued the warning after two NHS staff members who were administered with doses on Tuesday both suffered an allergic reaction.
    NHS England said all trusts involved with the vaccination programme have been informed.
    Dr June Raine, chief executive of the MHRA, said the regulatory body was examining the cases.
    “We know from the very extensive clinical trials this wasn’t a feature," she told a parliamentary committee on Wednesday. 
    "But if we need to strengthen our advice now that we’ve had this experience in the vulnerable populations - the groups that have been selected as a priority - we get that advice to the field immediately.”
    Read full story
    Source: The Independent, 8 December 2020
  20. Patient Safety Learning
    Dialysis patients who must travel to hospital are nearly four times as likely to die of covid than those aged over 80, but so far have not been prioritised for receiving vaccination, HSJ has learned. 
    UK Renal Registry data shows that, from March to November 2020, 3.3% of all in-centre haemodialysis patients have died from covid (662 deaths out of a population of 20,000). This figure compares to a death rate of approximately 0.7% in all those aged over 80 and 1.8% in over 90s.
    Although the government classifies dialysis patients as clinically extremely vulnerable to COVID-19, not all patients are able to receive dialysis at home and those receiving inpatient treatment still need to travel to dialysis clinics, either in main hospital buildings or smaller satellite clinics, three times a week.
    At present the Joint Committee on Vaccine and Immunisation COVID-19 vaccine prioritisation list ranks all dialysis patients at priority level four, alongside all other shielding patients and those aged over 70. Priority one covers all care home residents and staff, while priority two covers all over 80s and frontline health workers.
    The Renal Association wrote to Public Health England and JCVI over the weekend to ask for a change in vaccine prioritisation but, at the time of writing, has not received a response. 
    Read full story (paywalled)
    Source: HSJ, 9 December 2020
  21. Patient Safety Learning
    All non-urgent elective operations are being postponed for at least two weeks in a health system still seeing significant and growing pressure from coronavirus.
    The four acute trusts in Kent and Medway will still carry out cancer and urgent electives, but other work is being postponed. Relatively few elective operations are usually carried out around Christmas and New Year, meaning the county is likely to see little or no elective work for the next four weeks.
    In a covid update bulletin issued last night, the Kent and Medway Clinical Commissioning Group acknowledged the pressure hospitals across its area were under but stressed cancer and other urgent operations would go ahead.
    It added: “However, we are now pausing non-urgent elective services. This will allow staff to move to support the increased number of covid-19 patients.
    “Initially this will be for a two-week period. We will keep this under weekly review and will contact individual patients where appointments need to be rescheduled.”
    Read full story (paywalled)
    Source: HSJ, 8 December 2020
  22. Patient Safety Learning
    The increase in the number of remote GP consultations during the COVID-19 pandemic has not appeared to increase A&E attendances, according to the Care Quality Commission (CQC).
    The regulatory body discussed concerns about access to GP services during its September meeting, including the suggestion that the increase in remote consultations and a perceived lack of face-to-face appointments were potentially leading to ‘increased attendance at A&E’.
    However, chief inspector Rosie Benneyworth has confirmed that – having looked into this – the organisation has ‘not seen evidence’ to suggest a link between the two.
    Despite this, she noted ‘anecdotal concern’ about people attending A&E departments if they ‘feel their needs are not being met elsewhere’.
    GPs have faced media criticism in the past few months for the perception that they have are failing to provide face-to-face appointments, with some believing that patients attend A&E as a result.
    Minutes from the September CQC board meeting said: ‘Concerns about access to GP services were… discussed, including the suggestion that digital appointments were not meeting the needs of some patients and how this could potentially lead to increased attendance at A&E. Work to quantify the extent of the problem and to monitor it was underway.’
    But Dr Benneyworth told Pulse this week: ‘While there may be some anecdotal concern about people attending Emergency Department (ED) if they feel their needs are not being met elsewhere, we have not seen evidence to suggest a link between digital appointments and ED attendance. The latest figures also show there has not been a sharp rise in online/video appointments (according to NHS Digital they are not currently at pre-COVID-19 levels).
    Read full story
    Source: Pulse, 7 December 2020
  23. Patient Safety Learning
    A 90-year-old woman has become the first patient in the world to receive the Pfizer Covid-19 vaccine after its approval in the UK, where the NHS has launched its biggest vaccine campaign.
    Margaret Keenan received the jab at about 6.45am in Coventry, marking the start of a historic mass vaccination programme.
    The vaccines will be administered at 50 hospital hubs around the country, with patients aged 80 and over who are either already attending hospital as an outpatient or are being discharged home after a hospital stay, being first in line.
    Read full story
    Source: The Guardian, 8 November 2020
  24. Patient Safety Learning
    Great Ormond Street Hospital may have broken the law by failing to share information with parents that showed its errors had contributed to their son’s death, The Independent understands.
    The care watchdog is speaking to Great Ormond Street about its handling of an expert report into five-year-old Walif Yafi in 2017.
    It showed that the hospital’s failure to share results that showed a deadly infection had played a role in Walif’s death. But the boy’s parents were only told about the findings after inquiries by The Independent – months after settling a lawsuit with Great Ormond Street in which the trust denied responsibility.
    The Care Quality Commission is looking at concerns relating to duty of candour regulations, which require hospitals to be open and honest with families about mistakes made that result in serious harm to patients. Breaching the regulations is a criminal offence and can lead to prosecution.
    Read full story
    Source: The Independent, 7 December 2020
  25. Patient Safety Learning
    The lateral flow devices used in the community testing pilot in Liverpool only picked up half the COVID-19 cases detected by polymerase chain reaction (PCR) tests and missed 3 out of 10 cases with higher viral loads, according to the government’s own policy paper.
    Given the low sensitivity of the Innova lateral flow devices when used in the field, experts are questioning how they can be used to allow care home residents to have contact with relatives over Christmas safely or for students to know for certain that they are not infected before returning home.
    The information can only be found by looking in annex B of the document, Community testing: a guide for local delivery, which was published on 30 November. This is the first publicly available information about the field evaluation of the Innova tests in Liverpool which has been criticised for its lack of transparency, accuracy of the tests used, and costs and potential harms.
    Read full story
    Source: BMJ, 4 December 2020
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