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Patient Safety Learning

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  1. Patient Safety Learning
    An NHS hospital which has faced repeated criticism by regulators for poor standards of care has been fined £4,000 for failing to assess A&E patients quickly enough.
    The Shrewsbury and Telford Hospitals Trust has been fined by the Care Quality Commission (CQC) after patients were not triaged within 15 mimutes of arrival in A&E – in breach of conditions set by the regulator last year and a national target.
    The care of emergency patients at the hospital trust, which is also facing an inquiry into poor maternity care, has been a long running concern for the watchdog which has rated the trust inadequate and put it in special measures in 2018.
    Earlier this year the CQC’s chief inspector of hospitals, Professor Ted Baker, wrote to NHS England warning of a “worsening picture" at the Midlands hospital and demanding action be taken.
    The CQC said it had issued the fixed penalty notice to the trust because it failed to comply with national clinical guidance that all children and adults must be assessed within 15 minutes of arrival. It also failed to implement a system that ensured all children who left the emergency department without being seen were followed up.
    After inspections in April 2019 and November 29 the CQC imposed seven conditions on the hospital over emergency care. The regulator said it was now clear the trust had not stuck to the conditions and had breached them both at Royal Shrewsbury Hospital and Princess Royal Hospital.
    Professor Baker said: "The trust has not responded satisfactorily to previous enforcement action regarding how quickly patients are assessed upon entering the urgent and emergency department."
    “We have issued a penalty notice due to the severity of the situation and to ensure the necessary, urgent improvements are made. It is essential that patients are seen in a timely way when they arrive at an emergency department; failure to do so could result in deteriorating health, harm, or even death, which is why national guidelines exist and must be followed."
    Read full story
    Source: The Independent, 12 October 2020
  2. Patient Safety Learning
    East Cheshire faces a serious issue with head and neck cancer, with missed target times and inefficient practices leading to worsening outcomes for patients.
    That’s prompted officials from the NHS Cheshire Clinical Commissioning Group (CCG) to come up with a plan of action to tackle the problem — but as Cheshire East councillors heard this week, it’s hit a snag.
    Since 2014, the East Cheshire NHS Trust and Manchester Foundational Trust (MFT) have co-delivered the head and neck cancer pathway. This means that patients are seen by staff at Macclesfield Hospital for diagnostic tests — and if malignant cells are detected, then the patient will be referred on to Wythenshawe for surgery or, if sadly needed, East Cheshire’s own palliative care team for supportive care.
    In a presentation to CEC’s health scrutiny committee, the CCG said just 10% of patients in the borough were seen at Macclesfield within the 62-day target time in Q3 of 2019/20 — against a desired level of 85%.
    Simon Goff, chief operating officer of East Cheshire NHS Trust, told the committee: “There is no one stop service - which is where a patient gets diagnostics all on the same day. Biopsies are not always up to the standards required so patients need to have it again. This is a key weakness in the existing service.”
    The lack of a ‘one stop service’ means there are no on-site pathology services — so samples are taken off-site for testing, and with biopsies needing to be analysed within 24 hours of collection, it results in 39% of all patients having to undergo the procedure again.
    So what did East Cheshire do about it?
    The first step was to launch a consultation, with 64 former patients out of roughly 300 eligible providing feedback to the Trust over the summer. The ‘robust’ consultation, saw patients express their desire to ‘know what is going on as soon as possible’, with the ‘issue of travel being outweighed by [the desire for] a quick diagnosis’.
    Fortunately for health chiefs in Cheshire, there are ‘outstanding’ hospitals surrounding the county — with the Care Quality Commission giving top marks to hospitals in Salford, St Helens, and The Christie in Didsbury.
    So with East Cheshire’s patients happy to travel a distance in order to gain a quick and accurate diagnosis, and the existing partnership with Manchester’s trust, officials are proposing moving some patients experiencing positive diagnoses and ‘bad news’ cases to MFT sites, such as The Christie or Wythenshawe Hospital.
    The idea is that ‘neck lump’ patients will be immediately sent to Wythenshawe, with all other patients undergoing initial tests in Macclesfield first before being either sent home with the all clear, or referred on.
    Biopsies will be done in Wythenshawe, as will ‘breaking bad news’ appointments — where patients are told of a positive cancer diagnosis.
    Officials say this solution ‘would start to address some of the clinical and performance concerns’ by cutting the average diagnosis wait time from four weeks down to one, reducing the amount of appointments patients need to attend, and allowing for continuity of care throughout treatment.
    Read full story
    Source: Knutsford Guardian, 10 October 2020
  3. Patient Safety Learning
    Saskatchewan's highest court has ruled in favour of a nurse who was disciplined after she complained on Facebook about the care her grandfather had received in a long-term care facility.
    In a decision delivered Tuesday, the Saskatchewan Court of Appeal set aside a decision by the province's Registered Nurses Association that found Carolyn Strom guilty of unprofessional conduct. 
    Strom was off-duty when she aired her concerns on Facebook in 2015, a few weeks after her grandfather's death. In her Facebook post, she said staff at St. Joseph's Integrated Health Centre in the town of Macklin, about 225 kilometres west of Saskatoon, needed to do a better job of looking after elderly patients.
    The lawyer for the Saskatchewan Registered Nurses Association argued that Strom personally attacked an identifiable group without attempting to get all the facts about her grandfather's care. In 2016, she was found guilty of professional misconduct by the Saskatchewan Registered Nurses Association and ordered to pay a $1,000 fine and $25,000 to cover the cost of the tribunal.
    After the association's decision, she received support from the Saskatchewan Union of Nurses, as well as nurses and civil liberties groups across the country.
    "Once I understood what this case meant ... once it was past being just about me, I didn't want someone else to have to go through the same thing. Because it's been rough," Strom said. 
    Strom says she continued to fight the decision because she wanted nurses to be able to talk about, and advocate for, better care for family members publicly and in a respectful manner.
    "You should be able to properly advocate for family members, regardless of whether you're a health-care member."
    "And I felt that if this decision went wrong, it would actually hurt people who have healthcare members as family members. because they would have to be a little more careful and not express concerns for fear of punishment."
    Appeal court Justice Brian Barrington-Foote wrote in his decision that Strom's freedom of expression was unjustifiably infringed, and she had a right to criticise the care her grandfather received.
    The judge ruled that criticism of the healthcare system is in the public interest, and when it comes from front-line workers it can bring positive change.
    Read full story
    Source: CBC News, 6 October 2020
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  4. Patient Safety Learning
    Less than half of the UK population will get a Covid vaccine with the elderly being top priority - a top advisor has warned.
    Kate Bingham, who was appointed as the chair of the Vaccine Taskforce back in May has claimed that the public has been “misguided” when it comes to availability of a vaccine.
    In an interview with the Financial Times, she said the government “needs to vaccinate everyone at risk”.
    She said: “People keep talking about ‘time to vaccinate the whole population’, but that is misguided."
    “There’s going to be no vaccination of people under 18. It’s an adult-only vaccine, for people over 50, focusing on health workers and carehome workers and the vulnerable.”
    Read full story
    Source: Financial Times, 4 October 2020
  5. Patient Safety Learning
    A pair of Conservative former ministers have announced they are to lead a rapid, cross-party investigation into the UK’s handling of the coronavirus crisis, amid worries a government inquiry will take too long for lessons to be learned in time.
    In a rare set of joint hearings, the Commons health committee, led by ex-health secretary Jeremy Hunt, and the science committee, chaired by Greg Clark, who was business secretary, are to hear from witnesses in the hope of producing a report by the spring.
    Announcing the plan, Hunt and Clark said the inquiry would aim to produce interim recommendations along the way. It will hold weekly joint sessions, with early witnesses set to include Chris Whitty, the chief medical officer for England, and Patrick Vallance, the government’s top scientific adviser.
    Hunt said he would expect the inquiry to cover the need for regular, large-scale coronavirus testing, an issue he has repeatedly raised in parliament, and whether this could help people visit loved ones in care homes.
    The hearings begin next Tuesday with a session on social care. Other promised areas of examination include the efficacy of lockdown measures; how well modelling and statistics have been used; the efficacy of government messaging; wider preparedness for a pandemic; and the impact on BAME communities.
    Read full story
    Source: The Guardian, 8 October 2020
  6. Patient Safety Learning
    Doctors are being told to "think carefully" before ordering any tests for their patients, amid shortages caused by a supply chain failure at a major diagnostics company.
    Swiss pharmaceutical firm Roche said problems with a move to a new warehouse had led to a "very significant" drop in its processing capacity.
    A spokesman said COVID-19 tests would be prioritised, but the backlog could affect tests including for cancer and heart disease.
    One NHS trust in the south west has already advised its GPs to stop all non-urgent blood tests.
    A memo seen by the BBC, sent to clinicians within a large hospital trust in London, said leaders were "preparing for a sustained disruption".
    "We urgently need all clinical teams to only send tests that are absolutely essential for immediate patient care, delaying testing where possible," it said.
    Thyroid and cortisol tests were unavailable, while certain cholesterol, liver function and inflammation tests were "severely restricted".
    Read full story
    Source: BBC News, 7 October 2020
  7. Patient Safety Learning
    A baby died during birth because of systemic errors in one of Britain's largest NHS hospitals, months after staff had warned hospital chiefs that the maternity unit was “unsafe”, an inquest has found.
    A coroner ruled that neglect by staff at Nottingham University Hospitals Trust contributed to the death of baby Wynter Andrews last year.
    She was delivered by caesarean section on 15 September after significant delays. Her umbilical cord was wrapped around her neck and leg, resulting in her being starved of oxygen.
    In a verdict on Wednesday, assistant coroner Laurinda Bower said Wynter would have survived if action had been taken sooner, criticising the units “unsafe culture” and warning that her death was not an isolated incident.
    Wynter’s mother, Sarah Andrews, called on the health secretary, Matt Hancock, to investigate the trust’s maternity unit.
    She said: “We know Wynter isn’t an isolated incident; there have been other baby deaths arising because of the trust’s systemic failings.  She was a victim of the trust’s unsafe culture and practices.”
    Read full story
    Source: The Independent, 7 October 2020
  8. Patient Safety Learning
    NHS England will spend £10m on new clinics for ‘long covid’ sufferers, it was announced yesterday.
    Sir Simon Stevens, NHSE chief executive, told the NHS Providers annual conference the clinics would offer support to the “probably hundreds of thousands” of people suffering persisting symptoms such as fatigue, breathlessness and ‘brain fog’ months after being infected with COVID-19.
    It comes amid growing calls for wider services to support people with ‘long covid,’ as hospital follow-up clinics are generally only open to those who were previously admitted with the virus.
    HSJ was last month only able to identify one genuine “long covid clinic”, despite claims by health secretary Matt Hancock they had “announced them in July”. It appears that comment was a mistake.
    Speaking about long covid, he said: “The NHS has got to be just as responsive and agile in respect of… new needs, including long covid, as we were in repurposing critical care, and ventilators, and acute capacity in the first phase in March, April and May."
    “Today we are going to be allocating £10m to establish a network of designated long covid clinics across the country, which, in line with new NICE guidelines on effective treatment pathways, will offer support for the tens of thousands, probably hundreds of thousands, of patients who have got long covid.”
    Sir Simon also told the conference today that NHSE was “enthusiastic” about introducing regular asymptomatic covid testing for NHS staff “if and when” it is recommended by the government chief medical officer, and when Test and Trace has enough capacity. 
    There are growing calls for regular testing of asymptomatic NHS staff, especially in hotspot areas, including from former health secretary Jeremy Hunt.
    Sir Simon said it was “something the chief medical officer and the test and trace programme are continuing to review”.
    He said: “We would be enthusiastic about doing that if and when that is the clinical recommendation and if and when the Test and Trace programme has got the testing capacity to do that. The plan was always that it would largely have to be sourced out of the total testing capacity available to the nation, not just the NHS labs.”
    Read full story
    Source: HSJ, 7 October 2020
    Read Patient Safety Learning's response to this news
    Please share your thoughts with us on the support that is needed on our patient safety platform, the hub.
  9. Patient Safety Learning
    People suffering 'Long Covid’ symptoms will be offered specialist help at clinics across England, the head of the NHS announced today.
    Respiratory consultants, physiotherapists, other specialists and GPs will all help assess, diagnose and treat thousands of sufferers who have reported symptoms ranging from breathlessness, chronic fatigue, 'brain fog', anxiety and stress.
    Speaking at the NHS Providers conference today (Wednesday), NHS chief executive Sir Simon Stevens will announce that £10 million is be invested this year in additional local funding to help kick start and designate Long Covid clinics in every area across England, to complement existing primary, community and rehabilitation care.
    Sir Simon said new network will be a core element of a five-part package of measures to boost NHS support for Long Covid patients:
    New guidance commissioned by NHS England from NICE by the end of October on the medical ‘case definition’ of Long Covid. This will include patients who have had covid who may not have had a hospital admission or a previous positive test. It will be followed by evidence-based NICE clinical guidelines in November on the support that Long Covid patients should receive, enabling NHS doctors, therapists and staff to provide a clear and personalised treatment plan. This will include education materials for GPs and other health professionals to help them refer and signpost patients to the right support. The ‘Your Covid Recovery’ – an online rehab service to provide personalised support to patients. Over 100,000 people have used the online hub since it launched in July, which gives people general information and advice on living with Long Covid. Phase 2 of the digital platform will see people able to access a tailored rehabilitation plan. This service will be available to anyone suffering symptoms that are likely due to COVID-19, regardless of location or whether they have spent time in hospital.  Designated Long Covid clinics, as announced today. This will involve each part of the country designating expert one-stop services in line with an agreed national specification. Post-covid services will provide joined up care for physical and mental health, with patients having access to a physical assessment, a cognitive assessment and a psychological assessment. Patients could also then be referred from designated clinics into specialist lung disease services, sleep clinics, cardiac services, rehabilitation services, or signposted into IAPT and other mental health services. NIHR- funded research on Long Covid which is working with 10,000 patients to better understand the condition and refine appropriate treatment. The NHS’s support will be overseen by a new NHS England Long Covid taskforce which will include Long Covid patients, medical specialists and researchers. Read full story
    Source: NHS England, 7 October 2020
    Read Patient Safety Learning's response to this news
    Please share your thoughts with us on the support that is needed on our patient safety platform, the hub.
  10. Patient Safety Learning
    The care model run by independent sector mental health and learning disability hospitals is ‘inherently risky’, a Care Quality Commission (CQC) chief inspector has warned.
    Speaking at the NHS Providers conference, Ted Baker, chief inspector of hospitals for the Care Quality Commission, unveiled the regulator’s plans to change how it inspects health and care services.
    When asked by HSJ how its new “streamlined” approach would be applied to inpatient units run by the independent sector for people with mental health and learning disability, Professor Baker said: ”One of the things we’ve been doing during the pandemic, and will continue in our transitional approach, is target risk. And one of the risks we have been targeting is exactly this, patients with learning disability and/or autism in some of these small units that have got closed cultures."
    “I think we do recognise that model of care is an inherently risky model of care and so we have been inspecting many of those under this risk driven model and taking action against many of them.
    But there is ongoing concern about that model of care and in a few weeks’ time we will be publishing a report on our assessment of that model of care and the importance of it being changed for the benefit of the people being looked after. The model of care needs to be improved but we need to make sure we are tackling the risk.”
    The chief’s comments come ahead of the regulator’s state of care report, which is due to be published next week.
    In its report published last year the CQC highlighted a concern regarding the quality and safety of independent learning disability and autism units. In particular it warned these were at a higher risk of developing closed cultures. 
    Read full story (paywalled)
    Source: HSJ, 7 October 2020)
  11. Patient Safety Learning
    Patients who saw a pain medicine specialist via telemedicine saved time and money and were highly satisfied with their experience, even before the COVID-19 pandemic, according to a study presented at the ANESTHESIOLOGY® 2020 annual meeting.
    Results of the study confirm many chronic pain patients are confident they will receive good care via telemedicine, while avoiding lengthy commutes and time spent in traffic.
    "This era of contactless interactions and social distancing has really accelerated the adoption of telemedicine, but even before the pandemic, patient satisfaction was consistently high," said Laleh Jalilian, M.D., lead author of the study and clinical assistant professor at the University of California, Los Angeles (UCLA).
    "Patients who are being evaluated for new conditions may be better off having office visits initially. But once patients establish a relationship with providers, follow-up visits can occur efficiently with telemedicine, while maintaining patient rapport and quality outcomes. We believe 50% of our visits could be conducted via telemedicine."
    "Now that telemedicine is more widespread, it may become a valued part of care delivery in chronic pain practices," said Dr. Jalilian. "Clearly many patients benefitted from remote consultations and follow-up appointments using telemedicine. We hope it will encourage policymakers and insurance providers to continue to support these platforms and inspire more innovation in this developing field of research and patient care."
    Read full story
    Source: EurekAlert, 5 October 2020
  12. Patient Safety Learning
    Almost half of NHS Trusts in England have reported risks classified as “significant” or “extreme”, with issues facing funding, buildings and failing equipment, according to an analysis by Labour.
    Highlighting warnings of staff shortages and patient safety, the party demanded urgent action from the government to prepare the health service for the winter months as cases of COVID-19 accelerate across the country.
    Labour said its study of 114 NHS Trusts’ risks registers showed that over three quarters of trusts logged a workforce risk. 
    The analysis also revealed that 66% reported a financial risk, 82% highlighted risks directly related to COVID-19 and 84% recorded a risk to patient safety. Almost half of Trusts (54), the party said, had outlined risks described as “significant” or “extreme”.
    One hospital trust reported it was “not financially stable” beyond the current financial year while another recorded a potential risk to patient safety due to “structural deficiencies” in roof structure.
    NHS hospitals are expected to consider risks to their operations and processes and when risks are identified, it is likely they will have been considered at board level and mitigations put in place.
    Describing the registers – compiled between March and August - as “worrying” in a normal winter, Jonathan Ashworth, the shadow health secretary, said: “In the coming winter, with the incompetent handling of the test and trace system leaving the NHS wide open and poorly supported, they take on a whole new meaning."
    "We urgently need a commitment from ministers to fix the problems with test and trace and a timetable by which these issues will finally be sorted. On top of this it is vital that ministers confirm that the NHS will get the additional support it needs to address these risks."
    Read full story
    Source: The Independent, 6 October 2020
  13. Patient Safety Learning
    The Prime Minister has confirmed a £3.7bn funding package to facilitate the construction of 40 new hospitals around the England by 2030, with a further eight schemes invited to bid for future funding.
    Talked about over the coming months, the funding announcement comes as the first official confirmation to deliver on the Government’s manifesto commitment.
    New standards are set to be developed over the coming months to help standardise the design of new hospitals and make use of modular construction methods to speed up the build process.
    Originally launched last September with a £2.8bn investment which provided six new hospitals with the funding to go ahead, alongside seed funding for trusts to work up business cases, the health infrastructure plan (HIP) represents the largest hospital building programme in the UK for a generation.
    The trusts which received seed funding will now all be fully funded to deliver 25 new hospitals. An additional site – a new hospital in Shotley Bridge – has also been added to the programme.
    The new Shotley Bridge hospital represents a commitment from the Government to ensure much of the funding also goes to rebuilding across the North of England, as part of its levelling up agenda.
    As part of welcoming new schemes to bid for funding for the eight further new hospitals down the line, the Government also committed that a proportion of these would be new mental health hospitals.
    Prime Minister Boris Johnson said: “The dedication and tireless efforts of our nurses, doctors and all healthcare workers have kept the NHS open throughout this pandemic. But no matter what this virus throws at us, we are determined to build back better and deliver the biggest hospital building programme in a generation."
    Read full story
    Source: NHE, 5 October 2020
    40hospitals.pdf
  14. Patient Safety Learning
    NHS Payouts linked to medication blunders have doubled in six years, fuelling record spending, official figures show.
    The NHS figures show that in 2019/20, the health service spent £24.3 million on negligence claims relating to medication errors - up from £12.8 million in 2013/14. The statistics show that in the past 15 years, almost £220 million has been spent on claims relating to the blunders.
    Previous research has suggested that medication errors may be killing up to 22,000 patients in England every year. Errors occur when patients are given the wrong drugs, doses which are too high or low, or medicines which cause dangerous reactions.
    In some cases, patients have been given medication which was intended for another person entirely, sometimes with fatal consequences. Other studies suggest that 1 in 12 prescriptions dispensed by the NHS involve a mistake in medication, dose or length of course. 
    In some cases, patients have died after being given a dose of morphine ten times that which should have been administered, with other fatalities involving fatal reactions. Confusion often occurs when drugs are not labelled clearly, or when packaging of different medications looks similar.
    Jeremy Hunt, now chairman of the Commons Health and Social Care Committee, said the NHS needed to make far more progress preventing harms, instead of seeing an ever increasing negligence bill.
    He said: “It is nothing short of immoral that we often spend more cleaning up the mess of numerous tragedies in the courts, than we actually do on the doctors and nurses who could prevent them."
    Read full story (paywalled)
    Source: The Telegraph, 3 October 2020
  15. Patient Safety Learning
    A further £8.7million is to be dished out to seven NHS hospital trusts to introduce digital records and e-prescribing. The money is part of a £78million investment which was announced in February 2018 and aims to accelerate the roll out of electronic prescribing systems across the NHS.
    The latest funding is part of the third wave of the investment, which will be handed out over three years. In 2018/ 19, £16.2 million was awarded, £29.4 million was given in 2019/20 and another £12 million will be invested later this year.
    The seven trusts which will benefit from this latest round of finding are:
    Portsmouth Hospitals NHS Trust (£1.7m) Solent NHS Trust (£988,000) Sussex Community NHS Foundation Trust (£637,000) United Lincolnshire Hospitals NHS Trust (£1.26m) North Cumbria Integrated Care NHS Trust (£2m) East Lancashire Hospitals NHS Trust (£1.6m) Birmingham Community NHS Trust (£531,000) National director of patient safety, Dr Aidan Fowler, said: “Patient safety is of paramount importance and is something we are continuously looking at ways to improve, whether through new technology, such as the introduction of electronic prescribing, or by building a safety culture where all NHS staff feel supported and safe to speak up.”
    Read full story
    Source: Digital Health, 1 October 2020
  16. Patient Safety Learning
    Melissa Vanier, a 52-year-old postal worker from Vancouver, had just returned from holiday in Cuba when she fell seriously ill with COVID-19. “For the entire month of March I felt like I had broken glass in my throat,” she says, describing a range of symptoms that included fever, migraines, extreme fatigue, memory loss and brain fog. “I had to sleep on my stomach because otherwise it felt like someone was strangling me.”
    By the third week of March, Vanier had tested negative for Sars-CoV-2 – the virus that causes Covid-19. But although the virus had left her body, this would prove to be just the beginning of her problems. In May, she noticed from her Fitbit that her heart rate appeared to be highly abnormal. When cardiologists conducted a nuclear stress test – a diagnostic tool that measures the blood flow to the heart – it showed she had ischaemic heart disease, meaning that the heart was not getting sufficient blood and oxygen.
    Similar stories illustrate a wider trend – that the coronavirus can leave patients with lasting heart damage long after the initial symptoms have dissipated.
    Cardiologists are still trying to find out exactly why some people are left with enduring heart problems despite having had an apparently mild bout of COVID-19. The underlying mechanisms are thought to be slow and subtle changes that are quite different to those that put strain on the heart during the acute illness, especially in patients who have been hospitalised with the disease.
    Some cardiologists have suggested that treatments such as cholesterol-lowering drugs, aspirin or beta blockers may help patients with lingering cardiovascular effects many weeks or months after the initial infection, but the evidence remains limited.
    “It is too early to share data on this,” says Mitrani. “But these therapies have proven efficacy in other inflammatory heart muscle diseases. They have anti-inflammatory effects and we believe may help counter some of the lingering pro-inflammatory effects from Covid-19.”
    But for patients such as Vanier, there remains a long and uncertain road to see whether her heart does fully recover from the impact of the virus. “Psychologically this has been brutal,” she says. “I haven’t been back to work since I went on holiday in February. The heart hasn’t improved, and I now have to wait for more tests to see if they can find out more.”
    Read full story
    Source: The Guardian, 4 October 2020
  17. Patient Safety Learning
    Omnicell UK & Ireland, a leading provider of automated healthcare and medication adherence solutions, hosted a health summit on the eve of World Patient Safety Day, to discuss the impact of medication errors on patients and the NHS. The session focussed on the role technology can play in preventing such issues.
    The summit, this year held via webinar, comes off the backdrop of the Department of Health and Social Care disclosing that in England 237 million mistakes occur every year at some point in the medication process.  These errors cause serious issues for patient safety, but also place a significant cost burden on an already stretched NHS. The 2019 Patient Safety Strategy published by NHS England and NHS Improvement also found the NHS failed to save 11,000 lives a year due to safety concerns with the cost of extra treatment needed following incidents being over £1bn.
    A number of high-profile panel members answered a series of questions from the audience on solutions and best practice to improve patient safety with the aim of debating and sharing ideas on how to meet challenges and the impact of COVID-19.
    One of the panelists, Patient Safety Learning's Chief Digital Office Clive Flashman, agreed with the other panel members that the NHS had become more collaborative and familiar with technology since Covid: “We’ve seen a definite increase in telehealth and telemeds. Covid has forced cultural blockers that were there before to be removed out of necessity. There has been a growth in robotic pharmacy automation to free up staff time from high volume administration tasks to do more complex work that adds value for patients.”
    But with the second-wave of COVID-19 still a very real threat he advised: “We don’t want to wait until the next wave to learn a lesson – we need to learn lessons now. Quality Improvement Leads should be focussed on what went right and what went wrong over that period between March and May. They need to be looking at what we can learn from that now and what we can do differently next time. If we don’t do that, we won’t succeed in the second wave where we might fail.”
    Ed Platt, Automation Director, Omnicell UK & Ireland, added: “Challenges within the NHS throughout Covid has forced them to embrace technology and drive innovation."
    "It’s important that when things go back to normal, we don’t go back to the same status quo. We need to invest in the right infrastructure in hospitals so unnecessary demands and stress are not put on pharmacy, supply managers and nurses so they are free to focus on patient care not administration tasks."
    Read full story
    Source: NHE, 17 September 2020
    You can watch the webinar on demand here
  18. Patient Safety Learning
    A 33-year-old woman says she's been suffering awful coronavirus symptoms for six months and says it's "ruined her life".
    Stephanie, from London, says her symptoms began in mid-March when she started experiencing loss of taste and smell, body aches, headaches, a fever, shivering, hot and cold sweats, and sickness. But six months later she still has had no sense of taste and smell, she suffers brain fog and chronic fatigue and says just walking across her flat leaves her chest feeling tight.
    The photographer, who lives alone, says she sleeps for 10-12 hours but is still always tired. "I'm only 33," she said.
    Stephanie wants to raise awareness of 'long Covid' and says more research needs to be done on how to treat the long-term effects of the disease.
    She said she's scared she'll 'never be the same again'.
    Stephanie says she has a hospital appointment on Friday to have tests on her lungs and heart as doctors are concerned she has lung damage.
    She added: "I think some people don't believe in long Covid, so I want to raise awareness of what people are going through. We need more research of how to treat people with long Covid because there isn't much available, it's so awful."
    Read full story
    Source: Mirror, 1 October 2020
  19. Patient Safety Learning
    From the moment coronavirus reached UK shores, public health advice stressed the importance of washing hands and deep-cleaning surfaces to reduce the risk of becoming infected.
    The advice was informed by mountains of research into the transmission of other respiratory viruses: it was the best scientists could do with such a new pathogen. But as the pandemic spread and data rolled in, some scientists began to question whether the focus on hand hygiene was as crucial as it seemed.
    The issue has resurfaced after Monica Gandhi, a professor of medicine at the University of California, San Francisco, told the US science magazine Nautilus that the easiest way to catch the virus was through droplets and aerosols sprayed from an infected person’s mouth or nose.
    “It’s not through surfaces,” she said. “We now know the root of the spread is not from touching surfaces and touching your eye. It’s from being close to someone spewing virus from their nose and mouth, without in most cases knowing they are doing so.”
    Gandhi’s is not a lone voice. Her comments follow a prominent paper in the Lancet from Emanuel Goldman, a professor of microbiology at Rutgers University in New Jersey. He was sceptical about the relevance of scientific studies that showed the virus could survive on surfaces for days at a time.
    “In my opinion,” he wrote, “the chance of transmission through inanimate surfaces is very small, and only in instances where an infected person coughs or sneezes on the surface, and someone else touches that surface soon after the cough or sneeze.” He defined soon as within one to two hours.
    Dr Julian Tang, an honorary associate professor of respiratory sciences at the University of Leicester, thinks hand washing should stay but agrees the risk from contaminated surfaces has been overplayed.
    He points to documents from the UK government’s Scientific Advisory Group for Emergencies (Sage) that estimate hand washing can reduce acute respiratory infections by only 16%. Meanwhile, he adds, the World Health Organization has warned about surfaces being a likely route of transmission while conceding there are no reports demonstrating infection this way.
    Tang believes that a preoccupation with contaminated surfaces distracted countries from taking airborne transmission seriously and played down the necessity of wearing masks. “What we’ve always said is that the virus transmits by all routes. There might be some transmission by hand and fomites and we’re not opposed to hand washing, but the emphasis is wrong,” he told the Guardian.
    Read full story
    Source: 5 October 2020
  20. Patient Safety Learning
    The Care Quality Commission (CQC) is to target poorly performing NHS maternity units after a series of maternity scandals. It is drawing up plans to spot high-risk maternity units and will use data on their patient outcomes and culture to draw up a list of facilities for targeted inspection.
    The watchdog has voiced concerns over the wider safety of maternity units in the NHS after a number of high-profile maternity scandals in the past year.
    Almost two-fifths of maternity units, 38%, are rated as “requires improvement” by the CQC for their safety.
    The Independent has joined with charity Baby Lifeline to call on the government to reinstate a national maternity safety training fund for doctors and midwives. The fund was found to be successful but axed after just one year.
    On Tuesday, the CQC’s chief inspector of hospitals, Professor Ted Baker, told MPs on the Commons Health and Social Care Committee that he was concerned about the safety of mothers and babies in some maternity units which had persistent problems.
    “Those problems are of dysfunction, poor leadership, of poor culture, of parts of the services not working well together,” he said. “This is not just a few units; this is a significant cultural issue across maternity services.”
    Now the CQC has confirmed it is planning to draw up a list of poor-performing units or hospitals where it suspects there could be safety issues. The new inspection programme will specifically look at issues around outcomes and teamworking culture although the full methodology has yet to be decided.
    Read full story
    Source: The Independent, 4 October 2020
     
  21. Patient Safety Learning
    A Dublin teenager has told of his harrowing battle with COVID-19 and is urging other young people to take the disease seriously.
    Jack Edge, 17, from Rathfarnham, had no underlying health conditions when he contracted the virus in April. Five months on and three hospital admissions later, the Leaving Cert student is still suffering from the "destruction" the virus wreaked on his body.
    Jack first displayed symptoms of COVID-19 on 15 April and five days later was admitted to Tallaght University Hospital. Within hours of being hospitalised, he was fighting for his life. Jack had to be put on a ventilator to help him breathe for 12 days. As his condition stabilised, he was transferred to a high dependency unit.
    Jack said: "I couldn't sleep for three days. Every time I closed my eyes, there was just dizziness and loads of colours. "I literally stayed in the bed for 72 hours, just staring at the wall. I had a lot of dark times in the hospital, since I do struggle with anxiety too."
    "But the care I received was absolutely amazing. They came in and talked to me if I needed to talk, as I would often get lonely, as it was mainly just me in an isolation room."
    However, surviving COVID-19 was just the first step for Jack. On 28 May, he was readmitted to hospital in excruciating pain. Doctors told him he may have suffered nerve damage associated with the virus.
    "I’m currently taking 18-20 tablets a day. Tablets for the nerve damage, for pain and for my anxiety. "
    "I basically have to learn to walk again. I do two to two-and-a-half hours of physio every day, depending on how much energy I have. I wake up some days and I get really upset. I still don’t know why this happened to me or how I got it."
    Jack hopes that by sharing his story he can raise awareness of the dangers and debilitating long-term effects of COVID-19 for young people.
    Read full story
    Source: RTE News, 2 October 2020
  22. Patient Safety Learning
    Next Thursday we’ll see more waiting list data released.
    What is contained in it is probably why Sir David Sloman’s office has taken nearly a month to not answer this question: Your letter to system leaders said you would “eliminate” 52-week waits, by when?
    The regional director’s office could not answer, nor could it reveal which hospitals were going to be the high-volume centre to burn through the lists in the six major specialities.
    There are a couple of likely reasons for their not being able to say when the long waiters would be eliminated.
    NHSI/E’s phase three letter set “mad” targets that don’t feel very real to many on the ground. I/E central will know this and have their own reasons for setting stretching-to-the-point-of-snapping targets, but trusts don’t really want to be held to submitting impossible commitments then being chastised for missing them (management teams have been moved on for this kind of thing in less fraught times).
    The second reason is that the picture is likely to be scary and also to have an impact on the ongoing three-way negotiation between the NHS, the independent sector - which will be hosting a lot of this work - and the workforce that will actually do it in both places.
    There is even less transparency than usual from the regional director’s office and I/E generally when asked anything at all about how effectively private sector facilities are being used, or how much it is costing.
    Much more surprising is the fact that Sir David’s office cannot yet name where each of the ICS’s six high-volume centres will be.
    Read full story (paywalled)
    Source: HSJ, 1 October 2020
  23. Patient Safety Learning
    October is Speak Up Month – a chance to raise awareness of Freedom to Speak Up and the work which is going on in organisations to make speaking up business as usual. 
    2020 has been an extraordinary year, and all NHS workers, whatever their role, have been under increased pressure from the COVID-19 crisis.
    Throughout October the National Guardian Freedom to Speak Up will be sharing their Alphabet of Speak Up – from Anonymity to Zero Tolerance. 26 days to explore the issues, the people, the values, the challenges – everything which goes into what Freedom to Speak Up means in health.
    #SpeakUpABC
    National Guardian Freedom to Speak Up
  24. Patient Safety Learning
    As she lay dying in a Joliette, Que., hospital bed, an Atikamekw woman clicked her phone on and broadcast a Facebook Live video appearing to show her being insulted and sworn at by hospital staff.
    Joyce Echaquan's death on Monday prompted an immediate outcry from her home community of Manawan, about 250 kilometres north of Montreal, and has spurred unusually quick and decisive action on the part of the provincial government.
    The mother of seven's death will be the subject of a coroner's inquiry and an administrative probe, the Quebec government said today. A nurse who was involved in her treatment has been dismissed.
    But that dismissal doesn't ease the pain of Echaquan's husband, Carol Dubé, whose voice trembled with emotion as he told Radio-Canada his wife went to the hospital with a stomach ache on Saturday and "two days later, she died."
    Echaquan's relatives told Radio-Canada she had a history of heart problems and felt she was being given too much morphine. 
    In the video viewed by CBC News, the 37-year-old is heard screaming in distress and repeatedly calling for help. Eventually, her video picks up the voices of staff members. One hospital staff member tells her, "You're stupid as hell." Another is heard saying Echaquan made bad life choices and asking her what her children would say if they saw her in that state.
    Dubé said it's clear hospital staff were degrading his wife and he doesn't understand how something like this could happen in 2020.
    Read full story
    Source: CBC News, 29 September 2020
  25. Patient Safety Learning
    Nearly half of trust chairs fail to “effectively deal with non-performing board members” according to a major study of the role of NHS non-executive directors seen by HSJ.
    The Henley Business School conducted in-depth research over a two-year period for its report 'The Independent Director in Society: Our Current Crisis of Governance & What to Do About It' which is published later this month. The research included a survey of NHS non-executive directors, which reveals that they have a broadly positive view about their contribution but also reveals significant areas of concern.
    Only 55% of respondents agreed with the statement that NHS trust chairs “effectively deal with/remove non-performing and/or disruptive board members”. Just 47% said chairs had “positive relations with the media.”
    The survey was undertaken before the onset of the pandemic, but nearly a third of the respondents disagreed with the statement that NHS chairs were “effective in a crisis”. However, almost every survey respondent claimed trust chairs had “high moral values” which were “aligned with those of the organisation.”
    All but 2% of respondents backed the idea that non-executive directors “have a sense of duty to see things are done both ethically and morally”, while 94% claimed they were “truly independent”. However, a fifth claimed it was impossible for non-executive directors to be effective “given the mandate of the NHS”.
    Read full story (paywalled)
    Source: HSJ, 1 October 2020
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