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Patient Safety Learning

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  1. Patient Safety Learning
    Around two-thirds of NHS providers were found to be breaking laws aimed at protecting staff from violence and aggression, when inspected by the Health and Safety Executive (HSE), information released to HSJ reveals.
    The HSE has inspected 37 NHS organisations since April 2018, looking at how they manage risks to staff from violence and aggression, and found 25 of them (67%) were in breach of the law.
    It comes amid concern about rising numbers of assaults on NHS and care staff. The HSE has identified that three staff members have been killed by patients or service users in the last five years.
    Read full story (paywalled)
    Source: HSJ, 6 January 2020
  2. Patient Safety Learning
    A hospital accused of bullying its staff is facing new claims that it failed to act on a leading doctor’s warning about a potentially fatal failure to monitor vulnerable patients, the Guardian newspaper can reveal.
    Dr Jonathan Boyle, the UK’s top vascular surgeon, had warned West Suffolk NHS trust that patients at risk of dying from burst aneurysms were not being safely monitored. An IT glitch meant that patients were not followed up to see how soon they would need potentially life-saving surgery.
    A doctor at the trust, however, says it initially repeatedly refused to take any action, raising further questions about its management.
    The trust initially suggested the problem was the result of senior doctors not keeping up with emails, but later accepted its IT systems were at fault. The hospital was forced to recognise that patients were potentially put at risk and took action only after a whistleblower alerted the NHS regulator.
    Read full story
    Source: The Guardian, 5 January 2020
  3. Patient Safety Learning
    IT systems in the NHS are so outdated that staff have to log in to up to 15 different systems to do their jobs. Doctors can find themselves using different logins for everything from ordering x-rays and getting lab results to accessing A&E records and rotas.
    The government in England said it was looking to streamline the systems as part of an IT upgrade. Around £40 million is being set aside to help hospitals and clinics introduce single-system logins in the next year.
    Alder Hey in Liverpool is one of a number of hospitals which have already done this, and found it reduced time spent logging in from one minute 45 seconds to just 10 seconds. With almost 5,000 logins per day, it saved over 130 hours of staff time a day, to focus on patient care.
    Health Secretary Matt Hancock said it was time to "get the basics right". "It is frankly ridiculous how much time our doctors and nurses waste logging on to multiple systems. Too often outdated technology slows down and frustrates staff."
    British Medical Association leader Dr Chaand Nagpaul said logging on to multiple systems did waste time. But he said on its own this move would not solve all the problems, pointing out that many of the IT systems themselves were "antiquated" and needed upgrading.
    Read full story
    Source: BBC News, 4 January 2020
  4. Patient Safety Learning
    More than 80% of patients who have signs of a deadly sepsis infection before high-risk surgery are not getting antibiotics fast enough, a major NHS report has warned.
    Sepsis kills an estimated 44,000 people in England every year and rapid access to antibiotics within the first hour after diagnosis is vital to halt the infection. However, a review of performance across 179 NHS hospitals has found a majority of patients undergoing emergency bowel surgery are not getting medication early enough. A leak of the bowel can cause sepsis and while antibiotics will help treat the infection, surgery is essential to repair any sepsis-causing leak.
    The Royal College of Anaesthetists, which carried out the study for the NHS, said although the number of patients getting surgery in time had improved over the last five years, the numbers receiving antibiotics within an hour had not.
    Read full story
    Source: The Independent, 4 January 2020
  5. Patient Safety Learning
    A residential care home failed to notify the health watchdog about the deaths of people they were providing a service to, its report has found.
    Kingdom House, in Norton Fitzwarren, run by Butterfields Home Services, was rated "requires improvement". The home cares for people with conditions such as autism. The Care Quality Commission (CQC) said the registered manager and provider lacked knowledge of regulations and how to meet them. Inspectors found the provider failed to notify the CQC about the deaths of people which occurred in the home, as required by Regulation 16 of the Health and Social Care Act 2008.
    The report also found people were at "increased risk" because the provider had not ensured staff had the qualifications, competence, skills and experience to provide people with safe care and treatment.
    Inspectors did, however, praise the "positive culture" at the home, that is "person-centred", and noted the provider was "passionate about their service and the people they cared for".
    Read full story
    Source: BBC News, 2 January 2020
  6. Patient Safety Learning
    Hundreds of people with haemophilia in England and Wales could have avoided infection from HIV and hepatitis if officials had accepted help from Scotland, newly released documents suggest.
    A letter dated January 1990 said Scotland’s blood transfusion service could have supplied the NHS in England and Wales with the blood product factor VIII, but officials rejected the offer repeatedly.
    Large volumes of factor VIII were imported from the US instead, but it was far more contaminated with the HIV and hepatitis C viruses because US supplies often came from infected prison inmates, sex workers and drug addicts who were paid to give blood but not screened.
    The death of scores of people with haemophilia and blood transfusion patients and the infection of thousands of others across the UK in the contaminated blood scandal has been described as the worst health disaster to hit the NHS.
    The latest document was released under the Freedom of Information Act to campaigner Jason Evans, whose father died in 1993 having contracted hepatitis and HIV. In it, Prof John Cash, a former director of the Scottish Blood Transfusion Service, said the decision not to use Scotland's spare capacity to produce Factor VIII for England was "a grave error of judgement".
    Read full story
    Source: The Guardian, 3 January 2020
  7. Patient Safety Learning
    An NHS hospital in Norwich has had to close four beds in its high dependency unit because it does not have enough nurses to staff them.
    Norfolk and Norwich university hospital (NNUH) decided on Monday to temporarily shut the beds in the Gissing ward of its critical care complex.
    The beds, which are used for seriously ill patients, have been shut despite flu and other viruses that circulate at this time of year leaving more patients than usual suffering from breathing problems.
    Hospital managers told doctors in an email that: “A decision has been made to temporarily close our GHDU beds and reduce to 20 bed capacity on our CCC [critical care complex] from today as the nursing staffing is insufficient to keep Gissing open.”
    The closure is another stark illustration of both the lack of staff in the NHS, which in England has around 100,000 vacancies, and the extra strain winter is putting on hospitals.
    NHS bosses warned recently that staff shortages were now so widespread that patients’ safety and quality of care are under threat.
    Read full story
    Source: The Guardian, 31 December 2019
  8. Patient Safety Learning
    A woman has died after being set on fire during surgery in Romania, the country’s health ministry has said, in a case that has cast a spotlight on the ailing Romanian health system.
    The patient, who had pancreatic cancer, died on Sunday after suffering burns to 40% of her body when surgeons used an electric scalpel despite her being treated with an alcohol-based disinfectant.
    Contact with the flammable disinfectant caused combustion and the patient “ignited like a torch”, Emanuel Ungureanu, a Romanian politician, said.
    A nurse threw a bucket of water on the 66-year-old woman to prevent the fire from spreading. The health ministry said it would investigate the “unfortunate incident”, which took place on 22 December.
    “The surgeons should have been aware that it is prohibited to use an alcohol-based disinfectant during surgical procedures performed with an electric scalpel,” the Deputy Minister, Horatiu Moldovan, said.
    Read full story
    Source: The Guardian, 30 December 2019
    the hub has a number of posts on preventing surgical fires:
    Surgical fires: nightmarish “never events” persist MHRA. Paraffin-based skin emollients on dressings or clothing: fire risk (18 April 2016) National Patient Safety Agency: Fire hazard with paraffin-based skin products (Nov 2007) How I raised awareness of fires in the operating theatre  
     
  9. Patient Safety Learning
    A woman has been awarded $10.5 million (£8m) in damages after medical staff left a sponge inside her body.
    The sponge – which measured 18-by-18 inches and was left behind during surgery – was inside the woman's body for years before she realised.
    It had been left in her body after she underwent heart surgery at a Kentucky hospital in 2011. The bypass surgery is said to have gone wrong, leaving a mess – and as nurses rushed to deal with the problems, the sponge was left inside her body. 
    It was not discovered for four years, until she had a CT scan in 2015. In the meantime, the sponge had moved around the woman's body, shifting around her intestines and causing pain as it did so. She had her leg amputated and was left with gastrointestinal issues after the sponge eroded into her intestine.
    The patient's lawyers said the case should be a reminder to hospitals to ensure that objects such as needles and other sharp objects, as well as sponges, are removed from patients after surgery.
    Read full story
    Source: The Independent, 1 January 2020
  10. Patient Safety Learning
    Hundreds of patients have been warned supply problems with the specially made IV feed they need to stay alive is likely to continue for months.
    NHS England, which declared a national emergency incident in the summer because of the delays in production of intravenous nutrition, has written to patients warning the problems are far from resolved.
    Dozens of patients have been admitted to hospital in the past six months because of the supply shortage, which was sparked in June when the main manufacturer, Calea, based in Runcorn, was hit by overnight restrictions by the Medicines and Healthcare products Regulatory Agency (MHRA).
    Since the shortages started the NHS has been forced to fly in feed from other European countries, while some patients have had to switch from their bespoke feed to so-called off-the-shelf bags which don’t contain everything they need in the right quantities. Some hospitals have admitted patients to hospital to make sure they receive what they need because of fears for their health or lack of supplies in the community.
    Initially it had been hoped the delays in production would be improved by the end of the year, but in a letter sent to some patients, seen by The Independent, NHS bosses warn patients could be facing many more months of delays.
    Read full story
    Source: The Independent, 1 January 2020
  11. Patient Safety Learning
    Artificial intelligence is more accurate than doctors in diagnosing breast cancer from mammograms, a study in the journal Nature suggests.
    An international team, including researchers from Google Health and Imperial College London, designed and trained a computer model on X-ray images from nearly 29,000 women.
    The algorithm outperformed six radiologists in reading mammograms. AI was still as good as two doctors working together.
    Unlike humans, AI is tireless. Experts say it could improve detection.
    Sara Hiom, director of cancer intelligence and early diagnosis at Cancer Research UK, told the BBC: "This is promising early research which suggests that in future it may be possible to make screening more accurate and efficient, which means less waiting and worrying for patients, and better outcomes."
    Read full story
    Source: BBC News, 2 January 2020
  12. Patient Safety Learning
    Critically ill children are being rushed from one part of England to another because NHS hospitals are running short of intensive care beds in which to treat them, the Guardian has revealed.
    An increase in severe breathing problems in children driven by winter viruses and infections, including flu, means some are having to be transferred sometimes many miles from their home area because there are not enough paediatric intensive care (PICU) beds locally.
    Specialist doctors who staff the units say the situation is “dangerous and rotten for the families” involved and that staff are firefighting to handle the number of children needing sometimes life-saving care, many of whom are on a ventilator to help them breathe.
    In the past few weeks, young patients have been sent from the Midlands to Sheffield, from London to Cambridge, and from one side of the Pennines to the other in order to get them a place in a PICU.
    One doctor at a PICU in the Midlands said: “PICU beds are always in high demand. But since winter hit this year, around six weeks ago, the situation feels like we are simply firefighting. Many days I come on shift to find there are no beds in [our] region and the patients referred to us end up in Southampton, Sheffield, Oxford and other centres far away."
    “The PICU network is overstretched. There aren’t enough beds, nurses or skilled doctors.”
    Read full story
    Source: The Guardian, 29 December 2019
  13. Patient Safety Learning
    Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed.
    Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved.
    Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospitals ignoring the deadlines.
    National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes.
    NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt.
    Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.”
    He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.”
    Read full story
    Source: The Independent, 30 December 2019
  14. Patient Safety Learning
    Cancer patients are being pushed to “breaking point” because of a lack of support from overstretched nurses and carers, a leading charity has warned.
    Almost half of specialist cancer nurses have told the Macmillan Cancer Support charity that their high workload was having a negative impact on patient care, while one in five people diagnosed with the disease say the staff responsible for their care have unmanageable demands.
    Now the charity says this is affecting patients, with thousands calling its specialist support helpline in distress and worried because they feel they can’t get answers from their health workers.
    Read full story
    Source: The Independent, 31 December 2019
  15. Patient Safety Learning
    Hospitals will be required to employ patient safety specialists from next April as part of efforts by the health service to reduce thousands of avoidable errors every year.
    NHS trusts will be told to identify staff who will be designated as the safety specialist for each organisation. These workers, who will get specific training and work as part of a network across the country, will help to tackle a fragmentation in the way safety issues are dealt with in the NHS and ensure nationwide action on key safety risks is coordinated.
    The proposals are part of a national patient safety strategy which is aiming to save 928 lives and £98.5m across the NHS, as well as reducing negligence claims by £750m by 2025.
    The specialists will be identified from existing staff, with part of the role focused on embedding a so-called “just culture” approach to safety. This means reducing blame, supporting staff who make honest errors and tackling systemic causes of mistakes.
    Read full story
    Source: The Independent, 26 December 2019
    What do you think? Join the conversation on the hub.
  16. Patient Safety Learning
    MedAware, a developer of AI-based patient safety solutions, has announced the publication of a study by The Joint Commission Journal on Quality and Patient Safety, validating both the significant clinical impact and anticipated ROI of MedAware's machine learning-enabled clinical decision support platform designed to prevent medication-related errors and risks.
    The study analysed MedAware's clinical relevance and accuracy and estimated the platform's direct cost savings for adverse events potentially prevented in Massachusetts General and Brigham and Women's Hospitals' outpatient clinics. If the system had been operational, the estimated direct cost savings of the avoidable adverse events would have been more than $1.3 million when extrapolating the study's findings to the full patient population.  
    Dr David Bates, study co-author, Professor at Harvard Medical School, and Director of the Center for Patient Safety Research & Practice at Brigham and Women's Hospital, said: "Because it is not rule-based, MedAware represents a paradigm shift in medication-related risk mitigation and an innovative approach to improving patient safety."
    Read full story
    Source: CISION PR Newswire, 16 December 2019
  17. Patient Safety Learning
    Cultivation of kindness is a valuable part of the business of healthcare, discusses Klaber and Bailey in an Editorial in the BMJ. 
    "When we reflect on the past decade, it feels as if we have made a big mistake in healthcare. We have allowed the dominant narrative to be around money, taking the focus, energy, and leadership away from our core purpose of delivering the best care possible. Balancing the books is important, especially in a tax funded system, and we have a duty to drive value for every pound we spend — but money is not the most important thing."
    Read full Editorial
    Source: BMJ, 16 December 2019
  18. Patient Safety Learning
    Nurses in Northern Ireland have announced their plans for further strike action in the new year.
    Earlier this month, more than 15,000 nurses took to the picket lines over pay and staffing levels. It was the first time in the 103-year history of the Royal College of Nursing (RCN) that its members had taken such action.
    It has announced nurses will strike on 8 January and 10 January 2020, unless a resolution is reached.
    Read full story
    Source: BBC News, 24 December 2019
  19. Patient Safety Learning
    Two people died and hundreds of others were harmed following prescription errors in North East hospitals last year, new figures reveal.
    Staff at North East health trusts reported 2,375 prescribing mistakes to an NHS watchdog in 2018, including patients being given the wrong drug, failure to prescribe medicine when needed or given the wrong dosage.
    At County Durham And Darlington NHS Foundation Trust, where 359 errors were found, 103 patients were harmed by prescription mistakes while one person died.
    City Hospitals Sunderland NHS Foundation Trust was the second worse in the region for patients coming to harm as a result of prescription errors. One person was killed while 56 were harmed.
    An NHS spokesperson said: “NHS staff dealt with over a billion patient contacts over the last three years, while serious patient safety incidents are thankfully rare, it is vital that when they do happen organisations learn from what goes wrong - building on the NHS’ reputation as one of the safest health systems in the world."
    “As part of the NHS Long Term Plan a medicines safety programme has been established, meaning more than ever before is been done to ensure safe medicine use, and nearly £80 million been invested in new technology to prescription systems.”
    Read full story
    Source: Chronicle Live, 22 December 2019
  20. Patient Safety Learning
    Only 14% of pharmacy professionals are worried about criminal prosecution when reporting a patient safety incident, compared with 40% in 2016, survey results have showed.
    The results of the 2019 ‘Patient safety culture survey’ of 917 pharmacy professionals, carried out by the Community Pharmacy Patient Safety Group (PSG) in April and May 2019 came after the introduction of a legal defence for dispensing errors in 2018.
    The survey also showed that 22% of pharmacy professionals would not report a patient safety incident inside their organisation owing to fears of criminal prosecution. This is compared with 40% of 623 respondents saying in 2016 that they would not report a patient safety incident because of the possibility of criminal prosecution.
    Janice Perkins, chair of the PSG, said the results “demonstrate that there have been significant positive improvements since 2016”.
    “Nurturing an open and honest safety culture in community pharmacies is vital. It requires everyone to feel confident in openly sharing when things go wrong to learn from errors and prevent them occurring again,” she added.
    Read full story
    Source: The Pharmaceutical Journal. 19 December 2019
  21. Patient Safety Learning
    An NHS hospital has been so overwhelmed that it told senior doctors to make “the least unsafe decision” when treating patients.
    Medical groups have voiced concern that Norfolk and Norwich hospital trust’s instruction to its consultants this week showed it was struggling so much to cope with the number of people needing care that patient safety was being put at risk.
    At the time the hospital had no spare beds, a full accident and emergency department, 35 patients waiting on trolleys to be admitted, and had declared a major internal incident.
    In its message, seen by the Guardian, it said: “We would like you to know that the trust will support you in making difficult decisions that may be the least unsafe decision, and we would appreciate your cooperation over the coming days with this.”
    The circular from the Norwich hospital added: “We are facing our most challenging situation with our trust today,” because it was so overcrowded and unable to find a bed for the 35 patients doctors had decided needed to be admitted as emergencies.
    Read full story
    Source: The Guardian, 20 December 2019
  22. Patient Safety Learning
    The Healthcare and Safety Investigation Branch (HSIB) started a new national investigation looking into a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient hospital stay.
    If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.
    The investigation was launched after HSIB identified an event where a patient was discharged from hospital on two separate occasions with a plan to follow-up in outpatient clinics. Neither of the outpatient appointments were made.
    Read full story
    Source: HSIB, 20 December 2019
  23. Patient Safety Learning
    A coroner has criticised health professionals for failing to give a young woman who died after suffering severe anorexia the support and care she needed.
    Maria Jakes, 24, died of multiple organ failure in September 2018 after struggling for years with the eating disorder.
    Coroner Sean Horstead last week concluded that the agencies involved in the Peterborough waitress’s care missed several key opportunities to monitor her illness properly. Mr Horstead said that there had been insufficient record-keeping and a failure to notify eating disorder specialists in the weeks before her death, following treatment at Addenbrooke’s and Peterborough City Hospital.
    He also criticised the lack of specialist eating disorder dieticians at Addenbrookes and Peterborough hospitals, “together with a nursing team insufficiently trained and knowledgeable of eating disorder patients”, both of which had contributed to the lack of monitoring of Maria.
    Despite the criticism the father of another anorexia victim, whose death was described in a Parliamentary and Health Service Ombudsman’s report as an “avoidable tragedy”, has said the inquest failed to properly address or challenge the “lack of care” that Maria received from the NHS.
    Nic Hart, whose daughter Averil died in 2012 at the age of 19, criticised the inquest as “a very one sided process”. He told The Telegraph: “No real challengers were made of the clinical evidence or indeed of the lack of care that poor Maria received.”
    Read full story
    Source: The Telegraph, 21 December 2019
  24. Patient Safety Learning
    Hospital wards across the country are having to look after an unsafe number of patients, with hundreds of beds closed due to an outbreak of norovirus.
    NHS England has said that on average almost 900 beds were closed each day during the week to Sunday 15 December.
    Hospitals have reported fewer empty beds with bed-occupancy rates reaching as high as 95 per cent, 10 per cent higher than the recommended safe level.
    Read full story
    Source: The Independent, 20 December 2019
  25. Patient Safety Learning
    A Dublin mental health centre has failed to comply with the code of practice on physical restraint for four consecutive years, an inspection report has found.
    The 39-bed Elm Mount Unit at St Vincent’s University Hospital said the issue was now high risk. 
    Two episodes were recorded by the Mental Health Commission (MHC) where the staff member responsible for leading the physical restraint did not monitor the person’s head or airway, and that this went undocumented. In another case, inspectors noted, the physical restraint was not reviewed by members of the multidisciplinary team and recorded correctly.
    There was also concern regarding the administration of medicine, specifically deficits in the prescription and administration record “which could potentially lead to medication errors”.
    Read full story
    Source: The Irish Times, 17 December 2019
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