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Patient Safety Learning

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  1. Patient Safety Learning
    More than 2.8 million antibiotic-resistant infections occur in the U.S. every year, and more than 35,000 people die as a result of those infections, according to a newly released Centers for Disease Control and Prevention (CDC) report.

    The updated Antibiotic Resistance Threats in the United States (AR Threats Report) also estimates when antibiotic-resistant bacterium Clostridium difficile (or C. diff) is included, that number exceeds 3 million infections and 48,000 deaths. The report, which used data sources such as electronic health records not previously available, shows that there were nearly twice as many annual deaths from antibiotic-resistant infections as the CDC originally reported in 2013.
    CDC officials called the numbers in this report "more precise, though still conservative, estimates of the human costs of antibiotic resistance.
    Read full story
    Source: FierceHealthcare, 13 November 2019
  2. Patient Safety Learning
    A 99-war-old war veteran was left in agony on an A&E trolley in a hospital for almost 10 hours.
    Brian Fish, a former captain in the Royal Engineers, was left “crying out in pain” as he endured the long wait at Margate’s Queen Elizabeth Queen Mother Hospital, his daughter said. Mr Fish had been urgently admitted to hospital with gall bladder problems.
    Details of his ordeal emerged as figures showed the queues at NHS emergency departments are now the longest on record, with one in four patients at major A&Es waiting longer than four hours to be seen or treated in October.
    His daughter Hilary Casement, who witnessed her father’s hospital ordeal, said: “It was traumatic for him. He lay for hours crying out in pain on a hard trolley. Eventually, with much pleading from me, he was transferred, actually tipped, on to a slightly more comfortable hospital bed and eventually seen by the kind, but overworked, medical team".
    Read full story
    Source: The Independent, 19 November 2019
  3. Patient Safety Learning
    The NHS is relying on less qualified staff to plug workforce gaps because of a huge shortage of nurses, according to a new report.
    Support staff, such as healthcare assistants and nursing associates, have been used to shore up staffing numbers, said the Health Foundation charity.
    The NHS has relied upon overseas recruitment, but a lack of EU nurses because of Brexit means it is now taking more nurses from countries such as India and the Philippines.
    At present, there are almost 44,000 nursing vacancies across the NHS (12% of the nursing workforce), but this could hit 100,000 in a decade, the report said.
    The report said most changes to the skill mix – meaning the ratio of fully qualified to less qualified staff – are implemented well and led by evidence, but added: “It is important that quality and safety are at the forefront of any skill mix change.”
    Read full story
    Source: The Guardian, 28 November 2019
  4. Patient Safety Learning
    Hospitals are so short of doctors and nurses that patients’ safety and quality of care are under threat, senior NHS leaders have warned in a dramatic intervention in the general election campaign
    Nine out of 10 hospital bosses in England fear understaffing across the service has become so severe that patients’ health could be damaged. In addition, almost six in 10 (58%) believe this winter will be the toughest yet for the service.
    The 131 chief executives, chairs and directors of NHS trusts in England expressed their serious concern about the deteriorating state of the service in a survey conducted by the NHS Confederation. The findings came days after the latest official figures showed that hospitals’ performance against key waiting times for A&E care, cancer treatment and planned operations had fallen to its worst ever level. However, many service chiefs told the confederation that delays will get even longer when the cold weather creates extra demand for care.
    “There is real concern among NHS leaders as winter approaches and this year looks particularly challenging,” said Niall Dickson, the chief executive of the confederation, which represents most NHS bodies, including hospital trusts, in England."
     “Health leaders are deeply concerned about its ability to cope with demand, despite frontline staff treating more patients than ever."
    Read full story
    Source: 19 November 2019
  5. Patient Safety Learning
    A health board criticised for severe maternity failings put too much emphasis on targets instead of patient safety, according to a new review of quality governance arrangements at Cwm Taf Morgannwg University.
    It found wider failings in Cwm Taf Morgannwg health board's governance. Healthcare Inspectorate Wales (HIW) and the Wales Audit Office (WAO) also found a high level of risk to patient safety was accepted as the norm in some departments. The health board said work was under way to address the issues raised.
    The report was not an assessment of frontline care, but spoke to staff about procedures for reporting and learning from problems.
    It found Cwm Taf Morgannwg health board had not given enough attention to the safety of its services, in contrast to a strong focus on targets and financial controls.
    Read full story
    Source: BBC News, 19 November 2019
  6. Patient Safety Learning
    Babies and mothers died amid a "toxic" culture at a hospital trust stretching back 40 years, a report has said. The catalogue of maternity care failings at Shrewsbury and Telford Hospital NHS Trust are contained in a report leaked to The Independent.
    It reveals that some children were left disabled, staff got the names of some dead babies wrong and, in one case, referred to a child as "it".
    The trust apologised and said "a lot" had been done to address concerns.
    In 2017, then Health Secretary Jeremy Hunt announced an investigation into avoidable baby deaths at the trust, which runs Royal Shrewsbury Hospital and Telford's Princess Royal. It is being led by maternity expert Donna Ockenden, who authored the report for NHS Improvement.
    Its initial scope was to examine 23 cases but this has now grown to more than 270 , covering the period from 1979 to the present day. The cases include 22 stillbirths, three deaths during pregnancy, 17 deaths of babies after birth, three deaths of mothers, 47 cases of substandard care and 51 cases of cerebral palsy or brain damage.
    The interim report said the number of cases it is now being asked to review "seems to represent a longstanding culture at this trust that is toxic to improvement effort".
    Read full story
    Source: BBC News, 20 November 2019
  7. Patient Safety Learning
    The avoidable deaths of babies and mothers in Shrewsbury and Telford Hospital Trust’s maternity services are heartbreaking. What makes them a scandal, however, is that the problems have been known about for so long, and yet the instinct of managers was to deflect and minimise. 
    The Healthcare Commission, a forerunner to the Care Quality Commission, was concerned about injuries to babies in the trust’s maternity units as long ago as 2007. It was not until Rhiannon Davies and Richard Stanton insisted on answers about the death of their baby Kate in 2009 that the Parliamentary and Health Service Ombudsman concluded in 2013 that it had been the result of serious failings in care. 
    Trusts need to ensure lessons stemming from failings are being implemented while patients and their families are being treated with respect and as a valuable source of feedback.
    Read full editorial (paywalled)
    Source: The Independent, 20 November 2019
  8. Patient Safety Learning
    Hundreds of women left in debilitating pain by faulty transvaginal mesh devices have won a landmark case against multinational giant Johnson & Johnson.
    The Australian class action against companies owned by Johnson & Johnson was won on behalf of 1,350 women who had mesh and tape products implanted to treat pelvic prolapse or stress urinary incontinence, both common complications of childbirth.
    The devices all but ruined the lives of many. Women have been left in severe, debilitating and chronic pain, and often unable to have intercourse. The vast majority also suffered a significant psychological toll. The mesh eroded internally in many cases, has caused infections, multiple complications, and is near impossible to completely remove, Australia’s federal court has heard.
    The devices were not properly tested for safety before being allowed on to the Australian market, though Johnson & Johnson and the associated companies clearly knew the potential for serious complications. 
    The companies were accused of launching a “tidal wave” of aggressive promotion at doctors, marketing the devices as cheap, simple to insert, and a relatively risk-free way to boost profits. All the while, their potential dangers were minimised, downplayed or ignored, both in communications to doctors and patients, the plaintiffs alleged. When patients complained of pain, they were frequently disbelieved.
    Read full story
    Source: The Guardian, 21 November 2019
  9. Patient Safety Learning
    The Care Quality Commission (CQC) issued a warning notice to the West Suffolk Hospital in Bury St Edmunds, which must improve by 31 January.
    It has not released details but the hospital said inspectors flagged up how it recorded observations and monitored women in its care.
    A hospital spokeswoman said: "We have taken this feedback seriously and are acting accordingly."
    She added: "Concerns have been raised about how we record patient observations after we have taken them, which are currently not in line with national guidance". "The CQC also identified that we should make changes to the way we monitor women in our care, again to bring us in line with national guidance".
    "We are making the necessary changes and the CQC is satisfied with the plans we have in place to make the improvements required."
    Read full story
    Source: BBC News, 21 November 2019
  10. Patient Safety Learning
    As many as one in three women in the UK are traumatised by their birth experiences, and one in 25 of those will go on to develop full-blown PTSD. 
    Following the most recent scandal at Shrewsbury, Milli Hill, the founder of the Positive Birth Movement, talks to The Independent about why we need to bring human connection back into maternity services, as well as continuing to invest in the research and technology that can save the lives of those most at risk and, why, above all, we need to start listening to women. If we don’t do these things, history will only repeat itself.
    Milli says: "We cannot continue to see scandals like Shrewsbury and Morecambe Bay as isolated, instead we must be brave enough to view them as symptomatic of a wider problem of a maternity system that has become completely dehumanised and unable to listen to women."
    Read full story
    Source: The Independent, 20 November 2019
  11. Patient Safety Learning
    A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations.
    The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants.
    The incident took place in 2015 but only came to light when one of the sick patients attended a hospital in Wales. It had involved a surgeon from Oxford University NHS Foundation Trust.
    Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs. The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients.
    The patient, who did not want to be named, said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest. It was only when people who received the organs became unwell that the truth was told."
    Read full story
    Source: BBC News, 21 November 2019
  12. Patient Safety Learning
    In March 2015, the Morecambe Bay investigation, chaired by Dr Bill Kirkup, published its report into serious failures in care that led to the avoidable deaths of 11 babies and a mother at Furness General Hospital (FGH) between 2004 and 2012. One of the babies that died was James Titcombe's son, Joshua.
    The report described a seriously dysfunctional maternity unit where certain midwives pursued an “over-zealous” approach to promoting “normal” childbirth, relationships between doctors and midwives was poor, midwifery practice fell well below acceptable standards and, unforgivably, instances of avoidable harm and death were covered up – meaning lessons were not learned and similar failures were repeated year after year. 
    The report detailed how opportunities to intervene at Morecambe Bay were missed at all levels and how the families who raised concerns were treated as problems to be managed, rather than voices that needed to be heard. More than four years later, it is both tragic and distressing to read about the litany of failures identified in the leaked interim report into care at Shrewsbury and Telford Hospital Trust (SaTH). Far from events at Morecambe Bay being a “one-off”, it is now painfully clear that not only have similar failures in care occurred elsewhere, but that they have happened on an even larger scale.
    James, speaking to The Independent, says "Worryingly, the reason why we are reading about these issues now isn’t because the regulatory system identified a problem and called for further scrutiny, but rather because of the extraordinary efforts of bereaved families."
    Read full story
    Source: The Independent, 21 November 2019
     
     
  13. Patient Safety Learning
    The number of concerns reported to the NHS’s Freedom to Speak Up Guardians has been steadily increasing since the guardians were introduced in England in 2017. Since April that year thousands of concerns have been reported to the guardians at NHS trusts, data from the National Guardian’s Office shows.
    View full story (paywalled)
    Source: BMJ, 19 November 2019
  14. Patient Safety Learning
    Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service.
    Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining away signs of danger.
    Across the NHS there are passionate clinicians and managers dedicated to building a culture that delivers consistently high quality care. But they are undermined by a pervasive willingness to tolerate and excuse poor care and silence dissent. Until that changes, the scandals will keep coming.
    Read full story
    Source: The Guardian, 2 November 2019
  15. Patient Safety Learning
    England’s most senior nurse has called on the NHS’ million-plus frontline workers to protect themselves and their patients this year by taking up their free flu jab.
    Ruth May, the Chief Nursing Officer for England, is spearheading this year’s drive to ensure that as many NHS staff as possible get vaccinated against seasonal flu – meaning they are both less likely to need time off over the busy winter period, and less likely to pass on the virus to vulnerable patients.
    Since September, hospitals and other healthcare settings across the country have been laying on special activities designed to highlight the importance of the flu vaccine, and celebrate those staff who choose to protect themselves and their patients. A record 70% of doctors, nurses, midwives and other NHS staff who have direct contact with patients took up the vaccine through their employer last year, with most local NHS employers achieving 75% or higher.
    Ruth has been joined in writing an open letter to NHS staff by other heads of professions like the NHS National Medical Director, Professor Stephen Powis, Chief Allied Health Professions Officer, Suzanne Rastrick, Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent, and Chief Pharmaceutical Officer, Dr Keith Ridge. In it they urge every member of the NHS’ growing frontline workforce to work together to achieve even higher level of coverage this year.
    Read full story
    Source: NHS England, 25 November 2019
  16. Patient Safety Learning
    When Kea Turner’s 74-year-old grandmother checked into Virginia’s Sentara Virginia Beach General Hospital in the US, with advanced lung cancer, she landed in the oncology unit where every patient was monitored by a bed alarm.
    “Even if she would slightly roll over, it would go off,” Turner said. Small movements — such as reaching for a tissue — would set off the alarm, as well. The beeping would go on for up to 10 minutes, Turner said, until a nurse arrived to shut it off.
    Tens of thousands of alarms shriek, beep and buzz every day in every US hospital. All sound urgent, but few require immediate attention or get it. Intended to keep patients safe by alerting nurses to potential problems, they also create a riot of disturbances for patients trying to heal and get some rest.
    Alarms have ranked as one of the top 10 health technological hazards every year since 2007, according to the research firm ECRI Institute. That could mean staffs were too swamped with alarms to notice a patient in distress, or that the alarms were misconfigured. The Joint Commission, which accredits hospitals, warned the nation about the “frequent and persistent” problem of alarm safety in 2013. It now requires hospitals to create formal processes to tackle alarm system safety, but there is no national data on whether progress has been made in reducing the prevalence of false and unnecessary alarms.
    The commission has estimated that of the thousands of alarms going off throughout a hospital every day, an estimated 85-99% do not require clinical intervention. Staff, facing widespread “alarm fatigue,” can miss critical alerts, leading to patient deaths. Patients may get anxious about fluctuations in heart rate or blood pressure that are perfectly normal, the commission said.
    Read full story
    Source: The Washington Post, 24 November 2019
  17. Patient Safety Learning
    A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months.
    Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black.
    But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour.
    Read full story (paywalled)
    Source: BMJ, 25 November 2019
  18. Patient Safety Learning
    Doctors and nurses must adapt their routines and improvise their actions to ensure continued patient safety, and for their roles to be effective and to matter as new technology disrupts their working practices.
    Research from Lancaster University Management School, published in the Journal of Information Technology, found electronic patient records brought in to streamline and improve work caused changes in the division of labour and the expected roles of both physicians and nursing staff.
    These changes saw disrupted working practices, professional boundaries and professional identities, often requiring complex renegotiations to re-establish these, in order to deliver safe patient care. Managers implementing these systems are often quite unaware of the unintended consequences in their drive for efficiency.
    Read full story
    Source: EurekAlert, 25 November 2019
  19. Patient Safety Learning
    A mobile app designed by a patient is helping people with breast cancer prepare for the start of radiotherapy.
    The treatment requires them to raise their arm above their head, but patients often find that difficult or painful after breast surgery. Exercises are important but Karen Bonham said leaflets giving details did not help her enough.
    So she helped create the app to offer exercise videos and medics say it is helping more women be ready on time. Staff at Velindre Cancer Centre in Cardiff say they have noticed fewer patients needing urgent referral for physiotherapy ahead of the treatment since the "Breast Axilla Postoperative Support app", or BAPS App, was launched in February.
    Kate Baker, clinical lead physiotherapist at Velindre, who helped devise the app, said: "Previously, we've always handed out information on exercises in a leaflet, that patients would be given by a physiotherapist and taken home. But often these pieces of paper get lost and they're not followed through.
    "What we wanted to do was provide exercises, physical activity advice and further information in an app format, which would allow individuals to have it with them at all times."
    Donna Egbeare, breast surgeon at Cardiff and Vale University Health Board, who was also involved in developing the bilingual app, said the impact of being able to start radiotherapy on schedule was significant.
    Read full story
    Source: BBC News, 27 November 2019
     
  20. Patient Safety Learning
    More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire.
    Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg.
    Dr Bill Kirkup says it suggests failure might be more widespread in the NHS.
    The surge in new cases follows the leak of an interim report last week.
    Read full story
    Source: BBC News, 27 November 2019
  21. Patient Safety Learning
    More than a third of maternity doctors are “burnt out,” and at risk of lacking empathy for the women in their care, researchers have warned.
    The study of more than 3,000 obstetricians and gynaecologists found high levels of long-term stress and overwork, especially among trainee medics. 
    Researchers said the findings – from the largest UK study on the topic – were “very worrying,” with serious implications for patients. 
    Overall, 36% of those surveyed met the criteria for “burnout,” which is associated with emotional exhaustion, lack of empathy and connection with others, researchers said. 
    Medics who met the criteria for burnout were three times as likely to report anxiety, irritability and anger. They were also four times more likely than colleagues to practice “defensively”- meaning they tried to avoid difficult cases, or else carried out more interventions than necessary, for fear of error. 
    Read full story
    Source: The Telegraph, 26 November 2019
     
  22. Patient Safety Learning
    It’s been 20 years since the Institute of Medicine — known now as the National Academy of Medicine — published the groundbreaking report, To Err is Human. And in that time, the healthcare industry has seen vast changes, bringing patient safety and healthcare quality to the forefront.
    The notion that patient safety issues are not only common, but they are preventable, challenge previously held industry beliefs, Craig Clapper, a partner in strategic consulting at Press Ganey, said during a recent interview with PatientEngagementHIT.com. 
    In this article he discusses the progress that has been made and what still needs to be done.
    Looking into the future, Clapper sees an industry that integrates patient safety as a key element of everything it does. While clinicians focus on boosting patient satisfaction, delivering good clinical outcomes, and fulfilling other obligations, they should feel and see the connection with patient safety.
    “We should talk less about safety culture in isolation and more about how to make it about the entire patient experience,” Clapper concluded. “That'll be our biggest single advantage in the next decade. Instead of having a subculture for every outcome, we must have one seamless performance culture that can emphasize the safety, quality, and experience of care.”
    Read full story
    Source: PatientEngagementHIT, 26 November 2019
  23. Patient Safety Learning
    Large numbers of previously missed abnormalities have been uncovered in the biggest review of smear tests undertaken since cervical cancer screening began in Ireland.
    The review led by the Royal College of Obstetricians and Gynaecologists in the UK has found hundreds of “discordant” results after re-examining the slides of over 1,000 women who had been tested for the disease under CervicalCheck, were given the all-clear and later developed cancer, according to an informed source.
    Discordant means the re-examination of the smear test by Royal College reviewers has produced a result that is different from the original finding by CervicalCheck.
    The extent of the individual divergences from the initial results is not yet known, but the review has found some cancers could have been prevented, it is understood.
    The college is due to submit an aggregate report on its findings to Minister for Health Simon Harris shortly.
    Read full story
    Source: The Irish Times
  24. Patient Safety Learning
    Hospitals will face penalties if staff do not notify patients of serious adverse incidents under proposed new legislation.
    Due to be brought to Cabinet by the Minister for Health Simon Harris in early December, it will provide for mandatory open disclosure of patient safety issues. It is understood that the new Bill would mean that where a hospital or health service provider was satisfied that a notifiable patient safety incident had occurred, information in its possession on the issue should be disclosed. A doctor or practitioner would be obliged to inform the patient and hospital of the incident.
    Under the proposals, failure to comply with this requirement on disclosure would mean the health service provider would be penalised. The nature or extent of the proposed penalties is unknown.
    The department is preparing a list of notifiable patient safety incidents for the mandatory open disclosure proposals.
    Read full story
    Source: The Irish Times, 25 November 2019
  25. Patient Safety Learning
    Health Secretary Matt Hancock has ruled out scrapping home visits by GPs, describing the idea as “a complete non-starter”.
    Doctors argued that they were no longer able to provide home visits as part of their core work and voted at a conference on Friday to remove them from their NHS contract. Under the proposals GPs would negotiate a separate service for urgent visits to patients. However, the health secretary said he was strongly opposed to the plans and insisted that they would not come to fruition.
    “The idea that people shouldn’t be able, when they need it, to have a home visit from a GP is a complete non-starter and it won’t succeed in their negotiations,” he told BBC Radio 4’s Today programme.
    He admitted that most home visits were done by nurses but said that on some occasions a GP was needed.
    Read full story
    Source: The Independent, 24 November 2019
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