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Patient Safety Learning

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  1. Patient Safety Learning
    The government removed a key section from Public Health England’s review (published Tuesday) of the relative risk of COVID-19 to specific groups, HSJ has discovered.
    The review reveals the virus poses a greater risk to those who are older, male and overweight. The risk is also described as “disproportionate” for those with Asian, Caribbean and black ethnicities. It makes no attempt to explain why the risk to BAME groups should be higher.
    An earlier draft of the review which was circulated within government last week contained a section which included responses from the 1,000-plus organisations and individuals who supplied evidence to the review. Many of these suggested that discrimination and poorer life chances were playing a part in the increased risk of COVID-19 to those with BAME backgrounds. HSJ understands this section was an annex to the report but could also stand alone.
    Typical was the following recommendation from the response by the Muslim Council of Britain, which stated: “With high levels of deaths of BAME healthcare workers, and extensive research showing evidence and feelings of structural racism and discrimination in the NHS, PHE should consider exploring this in more detail, and looking into specific measures to tackle the culture of discrimination and racism. It may also be of value to issue a clear statement from the NHS that this is not acceptable, committing to introducing change.”
    One source with knowledge of the review said the section “did not survive contact with Matt Hancock’s office” over the weekend.
    Read full story
    Source: HSJ, 2 June 2020
  2. Patient Safety Learning
    Factors such as racism and social inequality may have contributed to increased risks of black, Asian and minority communities catching and dying from COVID-19, a leaked report says.
    Historic racism may mean that people are less likely to seek care or to demand better personal protective equipment, says the Public Health England (PHE) draft, seen by the BBC. Other possible factors include risks linked to occupation and inequalities in conditions such as diabetes may increase disease severity.
    The report, the second by PHE on the subject, pointed to racism and discrimination as a root cause affecting health and the risk of both exposure to the virus and becoming seriously ill.
    It said stakeholders expressed "deep dismay, anger, loss and fear in their communities" as data emerged suggesting COVID-19 was "exacerbating existing inequalities".
    And it found "historic racism and poorer experiences of healthcare or at work" meant individuals in BAME groups were less likely to seek care when needed or to speak up when they had concerns about personal protective equipment or risk.
    The report concluded: "The unequal impact of COVID-19 on BAME communities may be explained by a number of factors ranging from social and economic inequalities, racism, discrimination and stigma, occupational risk, inequalities in the prevalence of conditions that increase the severity of disease including obesity, diabetes, hypertension and asthma."
    Read full story
    Source: BBC News, 13 June 2020
  3. Patient Safety Learning
    More than two-thirds of black, Asian and minority ethnic pharmacists have not had workplace risk assessments for coronavirus, a survey suggests.
    Of the 380 hospital and community-based pharmacists surveyed by the Royal Pharmaceutical Society and the UK Black Pharmacists Association, 236 were from a BAME background.
    Of those, 166 (70%) said they had not been approached by their employer to have a risk assessment.
    The RPS called the results "shocking". It has called on employers to take urgent action to ensure ethnic minority pharmacists are risk assessed.
    Read full story
    Source: BBC News, 26 June 2020
  4. Patient Safety Learning
    After new analysis showed pregnant black women were eight times more likely and Asian women four times as likely to be admitted to hospital with COVID-19, the NHS is rolling out additional support for pregnant women of a Black, Asian and Ethnic Minority (BAME) background.
    Given evidence of the heightened risk to BAME expectant mums, urgent action is being taken in England including increasing uptake of Vitamin D and undertaking outreach in neighbourhoods and communities in their area.
    Research carried out by Oxford University has shown 55% of pregnant women admitted to hospital with coronavirus are from a BAME background, even though they represent only a quarter of the births in England and Wales.
    In response, England’s most senior midwife, Jacqueline Dunkley-Bent, has written to all maternity units in the country calling on them to take four specific actions to minimise avoidable COVID-19 risk for BAME women and their babies.
    The steps include:
    Increasing support of at-risk pregnant women – e.g. making sure clinicians have a lower threshold to review, admit and consider multidisciplinary escalation in women from a BAME background. Reaching out and reassuring pregnant BAME women with tailored communications. Ensuring hospitals discuss vitamins, supplements and nutrition in pregnancy with all women. Women low in vitamin D may be more vulnerable to coronavirus so women with darker skin or those who always cover their skin when outside may be at particular risk of vitamin D insufficiency and should consider taking a daily supplement of vitamin D all year. Ensuring all providers record on maternity information systems the ethnicity of every woman, as well as other risk factors, such as living in a deprived area (postcode), co-morbidities, BMI and aged 35 years or over, to identify those most at risk of poor outcomes. Read full story
    Source: NHE, 29 June 2020
  5. Patient Safety Learning
    A report containing measures to protect ethnic minority groups from coronavirus has been drawn up for government, BBC News has learned.
    Public Health England (PHE) published a review last week confirming coronavirus kills people from ethnic minorities at disproportionately high rates. But a senior academic told BBC News a second report, containing safeguarding proposals to tackle this, also existed.
    And PHE now says this report will be published next week.
    Labour described the decision not to immediately publish the second report as "scandalous and a tragedy".
    Read full story
    Source: BBC News, 11 June 2020
  6. Patient Safety Learning
    Doctors who have been shielding during the covid-19 pandemic have said they are worried for their safety when they return to work.
    From 1 August those who are at high risk of serious illness if they contract covid-19 will no longer be advised to shield in England, Scotland, and Northern Ireland.123 But doctors who have been shielding during the pandemic have expressed concerns about their safety when they return to work, and say they feel forgotten by their employers.
    Read full story (paywalled)
    Source: BMJ, 21 July 2020
  7. Patient Safety Learning
    About 3,500 people in England may die within the next five years of one of the four main cancers – breast, lung, oesophageal or bowel – as a result of delays in being diagnosed because of COVID-19, say the researchers in the Lancet Oncology journal.
    “Our findings demonstrate the impact of the national Covid-19 response, which may cut short the lives of thousands of people with cancer in England over the next five years,” said Dr Ajay Aggarwal from the London School of Hygiene & Tropical Medicine, who led the research.
    Routine cancer screening was suspended during the lockdown, the authors said. So was the routine referral to hospital outpatient departments of people with symptoms that could be something else but also might possibly be cancer. Only those deemed to need emergency care by the GP or those who go to A&E are being picked up. Inevitably, those are people with more advanced cancers. If cancer is picked up at an earlier stage, successful treatment and survival are much more likely.
    “Whilst currently attention is being focused on diagnostic pathways where cancer is suspected, the issue is that a significant number of cancers are diagnosed in patients awaiting investigation for symptoms not considered related to be cancer. Therefore we need a whole system approach to avoid the predicted excess deaths,” said Aggarwal.
    Read full story
    Source: The Guardian, 20 July 2020
  8. Patient Safety Learning
    A low secure unit for people with learning disabilities and autism has been put into special measures after inspectors found the use of restraint and segregation affected the quality of life for some patients.
    Cedar House, in Barham near Canterbury, houses up to 39 people and had been rated “good” by the Care Quality Commission early last year.
    But at an inspection in February this year inspectors rated the service – run by the Huntercombe Group — “inadequate,” saying it was not able to meet the needs of many of the patients at the unit. It was issued with three requirement notices.
    One patient had been subject to prolonged restraint 65 times between September and February. Each time he was restrained by between two and 19 staff, for an average of nearly two hours. On one occasion, this restraint lasted for eight hours.
    But the inspectors were told that in the six months before the inspection 29 staff had been injured during these restraints, and the hospital had been trying to refer the patients to a more secure environment.
    “The impact of this inappropriately placed patient was considerable for both the patients and the hospital,” the report said. “The staff who were regularly involved in restraining the patient were tired and concerned about the welfare and dignity of the patient.”
    Read full story (paywalled)
    Source: HSJ, 21 July 2020
  9. Patient Safety Learning
    The Parliament and Health Service Ombudsman (PHSO) been working with the NHS and other public service organisations, members of the public and advocacy groups to develop a shared vision for NHS complaint handling. We've called this the Complaint Standards Framework. 
    Now they want to hear from you.
    Have your say in shaping the future of NHS complaint handling by taking part in their survey. 
    Read the Complaint Standards Framework: Summary of core expectations for NHS organisations and staff
  10. Patient Safety Learning
    The coronavirus vaccine candidate being developed by AstraZeneca and Oxford University induces a strong immune response and appears to be safe, according to preliminary trial results.
    The early stage trial, which involved 1,077 people, has found that the vaccine trains the immune system to produce antibodies and white blood cells capable of fighting the virus. It also causes few side effects.
    Professor Sarah Gilbert, co-author of the Oxford University study, described the findings as promising but said there “is still much work to be done before we can confirm if our vaccine will help manage the Covid-19 pandemic”.
    The results came as the UK secured 90 million doses of other promising Covid-19 vaccines, while clinical trials of a new inhaled coronavirus treatment showed it significantly reduced the number of hospitalised patients needing intensive care.
    Read full story
    Source: The Independent, 21 July 2020
  11. Patient Safety Learning
    Frontline NHS staff will be given specialist ‘air accident investigation’ style training to help improve the way the health service learns from patient safety incidents.
    Cranfield University, which has been training air, maritime and rail safety investigators for more than 40 years, is to launch the first intensive course for NHS staff responsible for investigating safety incidents in hospitals.
    It is part of a growing effort to install a safety science approach to avoidable harm in the NHS, with the service increasingly looking to other industries to adopt new approaches based on the science of human factors and just culture.
    Traditionally the NHS has focused on simpler investigations that too often miss systemic causes of mistakes and instead target individual nurses and doctors for blame.
    The new one week intensive course, run in partnership with the charity Baby Lifeline, will start in January and will give students a basic grounding in the science of investigation and using real-life actors and a maternity based scenario, show participants how to get to the real causes of what went wrong.
    Read full story
    Source: The Independent, 20 July 2020
  12. Patient Safety Learning
    A GP practice serving one of Greater Manchester’s most deprived communities has been banned from operating for four months after regulators uncovered a catalogue of basic failures - including failing to follow up on a child reporting breathing difficulties for three days.
    Jarvis Medical Practice in Glodwick has had its registration with the Care Quality Commission (CQC) suspended after ‘serious concerns’ passed to the body led to a snap inspection last month.
    Inspectors found the practice, based at Glodwick Primary Care Centre, was failing 20 separate standards, many of them relating to patient safety.
    It noted ‘poor quality’ and conflicting records that were sometimes impossible to properly understand and urgent home visits delayed or not carried out at all.
    In one case a patient with a lump apparently received no physical examination and was not referred for tests or scans ‘due to Covid-19’.
    Inspectors also found examples of patients with breathing difficulties, including a child, who were not dealt with for days after they got in touch. In one case no further contact was made for 11 working days, with no explanation provided in the patient's notes.
    The practice, which serves more than 5,000 patients in the Oldham neighbourhood of Glodwick, has now been suspended by the CQC until October 11.
    Read full story
    Source: Manchester Evening News, 17 July 2020
  13. Patient Safety Learning
    Babies are at risk of dying from common treatable infections because NHS staff on maternity wards are not following national guidance and are short-staffed and overworked, an investigation has revealed.
    The Healthcare Safety Investigation Branch (HSIB), a national safety watchdog, has warned that NHS staff on maternity wards face sometimes conflicting advice on treating women who are positive for a group B streptococcus (GBS) infection.
    They are also making errors in women’s care because of the pressure of work and a lack of staff, with antibiotics not being administered when they should be.
    HSIB’s specialist investigators examined 39 safety incidents in which GSB had been identified, and found that the infection had contributed to six baby deaths, six stillbirths and three cases of babies being left with severe brain damage.
    In its report, the watchdog warned that the problems on maternity wards meant that even in cases where mothers were known to be positive for GBS infection, this wasn’t shared with the mother or noted in the record, resulting in the standard care and antibiotics not being provided.
    It added: “The identification and escalation of care for babies who show signs of GBS infection after birth was missed. This has resulted in severe brain injury and death for some of the affected babies.”
    Read full story
    Source: The Independent, 19 July 2020
  14. Patient Safety Learning
    Dentists are warning of a looming dental and mouth cancer crisis after months of delays and patients being unable to get check-ups and repair work.
    It comes as surgeries begin to reopen more widely but dentists are still facing significant restrictions on how they can operate, with rooms having to be vacated for an hour after any treatment is done using a drill.
    For Maezama Malik, who is the principal dentist of her surgery in Croydon, south London, this has caused a big backlog of patients.
    She said the biggest worry is that a patient might have "something minor that could progress in a few months" without them seeing a dentist.
    Read full story
    Source: Sky News, 18 July 2020
  15. Patient Safety Learning
    Matt Hancock has ordered an urgent review into how Public Health England (PHE) calculates daily COVID-19 death figures.
    It comes after scientists said they believed PHE was “over-exaggerating” the daily coronavirus death toll, by counting people if they die of any cause at any time after testing positive for the disease.
    Professor Yoon K Loke, of the University of East Anglia, and Carl Heneghan, professor of evidence-based medicine at the Nuffield Department of Primary Care, said on Thursday night that a “statistical flaw” in the way PHE compiles data on deaths created a disparity in figures published by the different UK nations.
    “It seems that PHE regularly looks for people on the NHS database who have ever tested positive, and simply checks to see if they are still alive or not,” they wrote. “PHE does not appear to consider how long ago the Covid test result was, nor whether the person has been successfully treated in hospital and discharged to the community. Anyone who has tested Covid-positive but subsequently died at a later date of any cause will be included on the PHE Covid death figures.”
    Read full story
    Source: The Independent, 17 July 2020
  16. Patient Safety Learning
    There are "deep concerns" for brain injury survivors after many reported losing rehabilitation services during the COVID-19 lockdown.
    A survey by the charity Headway found 57% of people, injured since 2018, had seen face-to-face services stopped. The first two years of recovery are crucial in regaining skills, such as talking, with fears this could affect future independence.
    The government acknowledged it had been "a challenging time".
    Headway conducted its survey across all brain injury rehab services, with 1,140 respondents. It found about 60% of those were frustrated by the situation, their anxiety and depression had increased and they felt more socially isolated.
    Read full story
    Source: BBC News, 17 July 2020
  17. Patient Safety Learning
    The list is a dismal and shameful one - Mid-Staffordshire, Morecambe Bay, the rogue surgeon Ian Paterson, maternity care at the Shrewsbury and Telford.
    All are patient safety scandals involving tragic stories of life-changing mistreatment of patients and, in some cases, the loss of loved ones.
    Pledges have been made that patient safety will be put front and centre of health policy. New regulators have been put in place. But now yet another review has found the health system in England to be "disjointed, siloised and defensive" and that the culture needs a shake-up.
    It has called for a new patient safety champion with legal powers to be put in place.
    The plan is to have an individual with "real standing" outside and independent of the system, accountable to the parliamentary Health and Social Care Select Committee.
    The Commissioner would be expected to take up and investigate patient complaints where appropriate, and hold organisations to account - the review had stated that the failure of health authorities to respond to concerns was a recurrent theme.
    Read full story
    Source: BBC News, 8 July 2020
  18. Patient Safety Learning
    The hospital trust which has been recording the largest number of covid deaths for several weeks has asked NHS England and NHS Improvement for help with infection control.
    East Kent Hospitals University Foundation Trust is also getting help from the Kent and Medway Clinical Commissioning Group, including a senior infection control and prevention nurse who is now working with the trust.
    It has seen persistently high numbers of covid deaths at a time when most other trusts have seen them dwindle to nothing or almost nothing. In the week to 10 July, it had 18 deaths – 9.5% of the national total. 
    In a statement to HSJ yesterday the trust said it had “recently asked for support from NHS England and NHS Improvement to strengthen our infection prevention and control resource”. 
    It said it had also introduced “a strict ‘front door’ policy, limiting the number of people on site, taking temperature checks before people enter the building, providing face masks and hand washing facilities”; begun testing asymptomatic staff; and regularly testing asymptomatic patients.
    Read full story (paywalled)
    Source: HSJ, 16 July 2020
  19. Patient Safety Learning
    RLDatix, the leading provider of intelligent patient safety solutions, have announced a new framework—Applied Safety Intelligence™—that will tighten the relationship between patient safety and risk management by moving the industry from a retrospective review of adverse events toward a future of proactive prevention. This profound shift will usher in a new era of future-forward patient safety.
    Traditionally, patient safety and risk management efforts have been driven by a retrospective capture of harmful events, often resulting in long wait times to reach resolutions for patients and families, hefty litigation and punitive damages to health systems, and a profound negative impact on the care teams involved. With Applied Safety Intelligence, healthcare organisations will be able to reduce preventable harm and, in many cases, avoid it altogether.
    "As the global leader in patient safety, RLDatix is unmatched in its ability to drive innovation that leads to safer care," said Jeff Surges, CEO of RLDatix. "With Applied Safety Intelligence, we are putting patient and caregiver safety at the center of value-based care as we continue challenging traditional conventions around inevitable harm, provider burnout and enterprise risk. Together with our customers, we are catalysing a future where the human and financial impact of unsafe care is significantly reduced. "
    Read full story
    Source: CISION PR Newswire, 15 July 2020
  20. Patient Safety Learning
    Every child in Scotland will need additional mental health support as a consequence of measures taken to tackle the coronavirus crisis, according to the country’s children and young people’s commissioner.
    Speaking exclusively to the Guardian as he publishes Scotland’s comprehensive assessment of the impact of the pandemic on children’s rights – the first such review undertaken anywhere in the world – Bruce Adamson said the pandemic had sent a “very negative” message about how decision-makers value young people’s voices.
    He said Scotland has been viewed as a children’s rights champion but that efforts to involve young people in the dramatic changes being made to their education and support “went out the window as soon as lockdown came along”.
    There have been escalating concerns across the UK about children’s mental health after support structures were stripped away at the start of lockdown. Earlier this week, the Guardian revealed that five children with special educational needs have killed themselves in the space of five months in Kent, amidst warnings over the impact of school closures on pupils.
    Read full story
    Source: The Guardian, 16 July 2020
  21. Patient Safety Learning
    A hospital trust at the centre of Britain’s largest ever maternity scandal has widespread failings across departments and is getting worse, the care regulator has warned as it calls for NHS bosses to take urgent action.
    Ted Baker, chief inspector of hospitals, urged NHS England to intervene over the “worsening picture” at Shrewsbury and Telford Hospital Trust, which is already facing a criminal investigation.
    There are as many as 1,500 cases being examined after mothers and babies died and were left with serious disabilities due to poor care going back decades in the trust’s maternity units.
    Now, in a leaked letter seen by The Independent, Prof Baker has warned national health chiefs that issues are still present today across wards at the trust – with inspectors uncovering poor care in recent visits that led to “continued and unnecessary harm” for patients.
    He raised the prospect that the Care Quality Commission (CQC) could recommend the trust be placed into special administration for safety reasons, which has only been done once in the history of the NHS – at the former Mid Staffordshire NHS Trust, where a public inquiry found hundreds of patients suffered avoidable harm and neglect because of widespread systemic poor care.
    In a rarely seen intervention, Prof Baker’s letter to NHS England’s chief operating officer, Amanda Pritchard, warned there were “ongoing and escalating concerns regarding patient safety” and that poor care was becoming “normalised” at the trust, which serves half a million people with its two hospitals – the Royal Shrewsbury and Telford’s Princess Royal.
    Read full story
    Source: The Independent, 16 July 2020
  22. Patient Safety Learning
    The initial data on a trial of the coronavirus vaccine being developed by Oxford University will be released in the coming week, The Lancet medical journal has announced amid reports its findings have been promising.
    The development of a vaccine to fight against the virus has been touted as pivotal in returning the world to life as it was before the pandemic by protecting vulnerable people and building up immunity among populations.
    Now Oxford University’s contribution - one of the world’s leading candidates for a viable vaccine – is understood to have made promising results in initial testing.
    Read full story
    Source: The Independent, 16 July 2020
  23. Patient Safety Learning
    Around 5000 fewer people were admitted to hospitals in England for acute coronary syndrome than expected from January to the end of May this year, an analysis has shown. The results, published in the Lancet, indicate that many patients have missed out on lifesaving treatments during the COVID-19 outbreak.
    This decline started before the UK lockdown began on 23 March and “was qualitatively similar throughout the country, with only minor variations … in different demographic groups,” the authors wrote.
    Among patients admitted to hospital with acute myocardial infarction there was a “sustained increase in the proportion ... receiving [a percutaneous coronary intervention (PCI) for acute myocardial infarction] on the day of admission and a continued reduction in the median length of stay,” they added.
    “The reduced number of admissions … is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease,” they concluded.
    Read full story
    Source: BMJ, 15 July 2020
  24. Patient Safety Learning
    Trials of new systems to prevent overcrowding in emergency departments ahead of a potential second wave of COVID-19 in the winter are taking place at hospitals in Portsmouth and Cornwall and are due to shortly be expanded to other areas, with Dorset and Newcastle likely sites, HSJ can reveal.
    London is also experimenting with introducing the system, having pulled back from an earlier proposal to roll it out it rapidly, shortly after the COVID-19 peak.
    In the trials, NHS 111 has acted as a “triage point” enabling patients not facing medical emergencies but needing urgent treatment to book access to primary care, urgent treatment centres or same-day emergency “hot clinics” staffed by specialists. 
    Patients are discouraged from attending without an appointment, but they are able to do so; and sources said performance targets would continue to apply to them, although these were already subject to review pre-covid.
    Both the Royal College of Emergency Medicine and NHSE are now hopeful a new triage system for emergency care can be in place by the winter.
    Read full story (paywalled)
    Source: 15 July 2020
  25. Patient Safety Learning
    The NHS is losing more than 3.5 million days of work because of staff sickness linked to mental health problems, it has emerged.
    New data from NHS England shows the problem is getting worse with an increasing number of days and proportion of staff off sick for mental health reasons.
    The data runs from March 2019 to February 2020, before the coronavirus crisis. It is feared the pandemic could lead to lasting mental health issues for some NHS workers.
    Layla Moran, a Liberal Democrat MP who obtained the data through a parliamentary question, said: “These incredibly worrying figures show the mental health of NHS workers was already at a tipping point before the pandemic struck."
    Read full story
    Source: The Independent, 14 July 2020
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