Jump to content
 View Profile  See their activity

  • Posts

    11,906

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

News posted by Patient Safety Learning

  1. Patient Safety Learning
    Back in 2009, healthcare experts, including mainly members of the American Medical Informatics Association, envisioned creating a national databank to track reports of deaths, injuries and near misses linked to issues with the move to have computerised medical records.
    The experts at that September 2009 meeting agreed that safety should be a top priority as federal officials poured more than $30 billion into subsidies to wire up medical offices and hospitals nationwide. However, it never happened. Instead, plans for putting patient safety first — and for building a comprehensive injury reporting and reviewing system — have stalled for nearly a decade, because manufacturers of electronic health records (EHRs), health care providers, federal health care policy wonks, academics and Congress have either blocked the effort or fought over how to do it properly, an ongoing investigation by Fortune and Kaiser Health News (KHN) shows.
    Meanwhile, patients remain at risk of harm. In March, Fortune and KHN revealed that thousands of injuries, deaths or near misses tied to software glitches, user errors, interoperability problems and other flaws have piled up in various government-sponsored and private repositories. One study uncovered more than 9,000 patient safety reports tied to EHR problems at three pediatric hospitals over a five-year period.
    Despite such incidents, experts believe EHRs have made medicine safer by eliminating errors due to illegible handwriting and in some cases speeding up access to vital patient files. But they also acknowledge they have no idea how much safer, or how much the systems could still be improved because no one — a decade after the federal government all but mandated their adoption — is assessing the technology’s overall safety record.
    Read full story
    Source: Kaiser Health News, 21 November 2019
  2. Patient Safety Learning
    At least 74,000 older people in England have died, or will die, waiting for care between the 2017 and 2019 general elections. A total of 81 older people are dying every day, equating to about three an hour, research by Age UK has found.
    In the 18 months between the last election and the forthcoming one, 1,725,000 unanswered calls for help for care and support will have been made by older people. This, said the charity, was the equivalent of 2,000 futile appeals a day, or 78 an hour.
    Age UK’s director, Caroline Abrahams, said: “This huge number of requests for help did not lead to any support actually being given for three main reasons: because the older people died or will die before services were provided, because of a decision that they did not meet the eligibility criteria as interpreted by their local authority, or because their local authority signposted them to some other kind of help than a care service.”
    Read full story
    Source: The Guardian, 22 November 2019
  3. Patient Safety Learning
    The General Medical Council (GMC) has asked the NHS to share concerns about any doctors involved in poor care at the Shrewsbury and Telford Hospital Trust.
    It comes as West Mercia Police said it was considering a range of criminal charges against the hospital including corporate manslaughter.
    Anthony Omo, Director of Fitness to Practice for the GMC, said the reports of poor maternity care at the trust were “shocking” and his thoughts were with the families. He added: “We are in contact with the trust and have asked NHS England and NHS Improvement for details of any concerns about individual doctors." 
    “All doctors have a responsibility to take action if they are aware that patient safety may be put at risk.”
    Meanwhile, the Royal College of Obstetricians and Gynaecologists has said it will make changes to the way it inspects hospitals after criticism of the way it allowed a report into the Shrewsbury trust in 2017 to be used.
    Read full story
    Source: The Independent, 22 November 2019
  4. Patient Safety Learning
    Progress on treating cancer has stalled in Scotland because of staff shortages and a lack of funding, according to a parliamentary report.
    The Scottish Parliament's Cross-Party Group on Cancer found that 18% of cancer patients in June were not seen within the six-week target. Their report, which will be published later, has been described as "deeply concerning" by Cancer Research UK.
    The Scottish government said its £100m strategy would improve survival rates.
    Cancer Research UK Chief Executive Michelle Mitchell said the Scottish government must "publish a long-term cancer workforce plan" to enable the NHS to prepare for rising demand in the future. She said: "The findings of this inquiry are deeply concerning".
    "Diagnosing cancer early can make all the difference, but there are major shortages in the staff trained to carry out the tests that diagnose cancer. Cancer services in Scotland are already struggling. Without urgent action, this will only worsen as demand increases."
    Read full story
    Source: BBC News, 18 November 2019
  5. Patient Safety Learning
    Patients are being left in pain and having operations delayed or denied because insurers are overruling consultants’ decisions on treatment.
    Policy holders with breast cancer, heart conditions, arthritis and knee problems are among those who have been unfairly denied procedures, The Times has found.
    Analysis of Financial Ombudsman Service reports shows that complaints about private medical insurers have risen sharply.
    Richard Packard, chairman of the Federation of Independent Practitioner Organisations, estimates that hundreds of patients a year are denied recommended treatments. “Consultants have reported that their expert decisions for the benefit of the patient are being overturned,” he said. “This is being done by insurance administrators at the end of a telephone. Some would seem to lack medical knowledge and [make] decisions based on computer algorithms, which can result in delayed treatment and patients suffering pain for longer than necessary.”
    Read full story (paywalled)
    Source: The Times, 18 November 2019
  6. Patient Safety Learning
    The World Health Organization's (WHO) World Antibiotic Awareness Week (WAAW) aims to increase awareness of antibiotic resistance as a global problem, and to promote best practices among the general public, health workers and policy-makers to avoid the further emergence and spread of antibiotic resistance.
    Since their discovery, antibiotics have served as the cornerstone of modern medicine. However, the persistent overuse and misuse of antibiotics in human and animal health have encouraged the emergence and spread of antibiotic resistance, which occurs when microbes, such as bacteria, become resistant to the drugs used to treat them.
    As part of preparations for the 2019 Awareness Week this November, a group of senior leaders from across the health system, including NHS England and Improvement, have co-signed a letter, coordinated by Public Health England, that reminds commissioners and providers alike of their responsibility to contribute to this important agenda. The letter also reminds colleagues that this year’s WAAW campaign is the first of a new five-year UK National Action Plan for antimicrobial resistance, which contains stretching ambitions for reducing inappropriate prescriptions; as well as controlling and preventing infections.
  7. Patient Safety Learning
    At a launch event last week, Bradford Teaching Hospitals NHS Foundation Trust has officially opened its new Command Centre.
    The Command Centre, using technology from GE Healthcare Partners, went live earlier this year and was recently awarded Tech Project of the Year in the innovative Health Tech Awards 2019.
    The Trust said it helps staff to optimise patient flow and allow real-time co-ordination of care for each and every patient. Using advanced analytics and machine learning, the new system provides staff with real-time information to help them make speedy and informed decisions on managing patient flow across the Trust’s hospitals.
    Sandra Shannon, Chief Operating Officer and Deputy Chief Executive at the Trust “Demand for services is growing at Bradford Teaching Hospitals every year, with up to 400 patients coming through our A&E every day, and we have to get smarter at how we manage the needs of patients with the resources we have.”
    “The Command Centre is a major investment in how we, as a very busy acute Trust, can improve our performance, maintain and improve patients’ experience of coming into hospital and support our staff to do their jobs more efficiently, so they can concentrate on delivering excellent patient care.”
    Read full story
    Source: Health Tech Newspaper, 12 November 2019
  8. Patient Safety Learning
    A&E waiting times are at their worst on record as the NHS comes under intense pressure before what doctors and hospital bosses fear will be a very tough winter for the service.
    Less than three-quarters (74.5%) of people who sought care at A&E unit in England in October were treated and then discharged, admitted or transferred within four hours – the smallest proportion since the target was introduced in 2004.
    That is far below the 95% of patients that ministers and NHS chiefs say should be dealt with by A&E staff within four hours.
    “As political parties vie to prove their NHS credentials, today’s figures highlight that the NHS is desperately struggling to stay afloat,” said Dr Rebecca Fisher, a GP and senior policy fellow at the Health Foundation.
    Read full story
    Source: The Guardian, 14 November 2019
  10. Patient Safety Learning
    Having spent 5 months in a hospital bed, Jame Hale, a disabled poet and essayist, urges us as we go into this election not to forget the damage that’s been done to the NHS – and the individual, human casualties that have resulted. 
    "High-quality staff are not enough if we put them in environments where they cannot do their best", Jame says to the Guardian newspaper. 
    "An NHS in this state is a stain on the country, and an ongoing risk to patient safety. It’s come about because of nine years of persistent underfunding and austerity, which has come on top of PFI hospital-building initiatives that have loaded hospital trusts with unsustainable repayments."
    Read full story
    Source: The Guardian, 7 November 2019
     
  11. Patient Safety Learning
    A whistleblower claimed a cancer patient died as a result of contaminated water at Scotland's largest hospital. The whistleblower raised concerns about the findings of a review into infections in child cancer patients.
    Jeane Freeman, the health secretary, says she knew in September a child had died after contracting an infection possibly linked to water at the Queen Elizabeth University Hospital, but did not make it public. She told BBC Scotland she acted on the information but chose to maintain patient confidentiality.
    Ms Freeman said she felt for the child's parents. She said: "I deeply regret not only the death of their child. In any circumstance that has to cause a pain that I can't possibly imagine, but I also deeply regret that they feel they haven't been given the information that they have a perfect right to receive and are entitled to. They have my commitment to act to ensure that situation does not happen to parents in the future".
    "I don't regret honouring patient confidentiality. But upholding patient confidentiality does not mean I don't act on the information I am given."
    Labour MSP Anas Sarwar had raised the issue - which was brought to light by an NHS whistleblower - during First Minister's Questions on Thursday. He  described the situation as a "cover-up".
    The MSP said he had seen information which showed that senior managers were repeatedly alerted to the fact a previous review failed to include cases of infection related to the water supply in 2017. He said the parents of the child had never been told the true cause of their child's death.
    Greater Glasgow Health Board say a link between the infection and the hospital cannot be proven because regulations at the time did not require water testing.
    Read full story
    Source: BBC News, 14 November 2019
  12. Patient Safety Learning
    Reports that medical errors are the third leading cause of death in the US have led the Institute of Medicine and several state legislatures to suggest that data from patient safety event reporting systems could help health care providers better understand safety hazards and, ultimately, improve patient care.
    "Tens of thousands of these safety report databases provide a free text field that does not constrain the reporter to fixed, predefined categories," said Srijan Sengupta, Assistant Professor of Statistics in the College of Science and a faculty member at the Discovery Analytics Center.
    Sengupta has received an $815,218 Research Project Grant (R01) from the National Institutes of Health (NIH) to develop novel statistical methods to analyze such unstructured data in safety reports.
    "Detailed information that spans multiple categories can be more valuable than identifying an event by just checking off a category," he said.
    Read full story
    Source: EurekAlert, 13 November 2019
  13. Patient Safety Learning
    Existing claims that locum GPs present a greater risk of harming patients are unfounded, according to new research published in the Journal of the Royal Society of Medicine. It found that there is little evidence that locum doctors, including GPs, have a 'detrimental' impact on patient care delivery.
    Researchers from the University of Manchester looked at 42 international papers, including 24 from the UK, on the impact of locum doctors working in various healthcare settings to determine whether this group is more likely to harm patients than permanent doctors. 
    Previous reports highlight longstanding and growing concerns about the quality, safety and cost of locum doctors among a range of stakeholders such as policymakers, employers, regulators and professional bodies. These include locum GPs being less aware of local policies and less familiar with the patient's healthcare history and lacking commitment. 
    However, the researchers found there is 'very limited evidence' to support claims that these healthcare professionals deliver lower quality of care than their permanent counterparts. 
    Read full story (registration required)
    Source: Pulse, 12 November 2019
  14. Patient Safety Learning
    A new £700,000 computer system has been deployed in an intensive care unit at Aberdeen Royal Infirmary. The new Philips system will replace bedside charts, freeing up clinical time and improving patient safety at the NHS Grampian hospital.
    ICU clinical director Dr Iain MacLeod said: “At the heart of this change is patient safety. The system records physical measurements like blood pressure and heart rate as well as blood results and parameters from the various machines used in ICU, such as dialysis machines and ventilators."
    “It will also save on staff time. Currently medical staff members waste lots of time transcribing blood results from a computer onto sheets of paper. The new system allows this to happen automatically. That’s great from a timesaving point of view but more importantly there will be a reduction of errors that can happen when writing something down.”
    Read full story
    Source: FutureScot, 11 November 2019
  15. Patient Safety Learning
    Thousands of bowel cancer cases are being missed due to “unacceptable” testing failures, research in the BMJ shows. 
    The UK research found that some providers carrying out colonoscopies were three times as likely as others not to spot signs of disease. At the worst units, almost one in ten cases which turned out to be bowel cancer were not picked up during the tests, the study led by the University of Leeds found. 
    Researchers said that almost 4,000 more cases could have been prevented or treated sooner had there been better screening over a nine year period tracked. 
    Researcher Roland Valori, Consultant Gastroenterologist from Gloucestershire Hospitals NHS Foundation Trust, said: “We are seeing unacceptable variation in post colonoscopy bowel cancers between providers in the English NHS and this variation in quality needs to be addressed urgently.” 
    Read full story
    Source: The Telegraph, 2019
  16. Patient Safety Learning
    A privately run mental health unit has been banned from admitting new patients after inspectors found numerous safety failings, one of which led to a resident dying by hanging.
    The Care Quality Commission (CQC) has stopped the Cygnet Acer Clinic, in Chesterfield, Derbyshire, from accepting new inpatients. It declared that the facility was “not safe” for people to use.
    Inspectors found that clinic patients had opportunities to hang themselves, and the unit had soaring levels of patient self harm, and a huge shortage of trained staff.
    The CQC’s report is one of the most damning it has issued about poor and unsafe care affecting vulnerable and potentially suicidal patients in a mental health facility.
    Read full story
    Source: The Guardian, 13 November 2019
  17. Patient Safety Learning
    Fragmented patient data can lead to redundant and unnecessary care, potentially harming individuals. Thought leaders are calling for standardised methods to identify patients and minimise potential harm.
    At a recent US Food and Drug Administration conference for improved data standards, Shaun Grannis, Regenstrief Institute Vice President of Data and Analytics, advocated for standards that promote better patient matching.
    “Any time you lack complete information to make the best decision possible, there's an opportunity for error,” Grannis said. “Patient matching is a safety issue. Patient identification is paramount to making sure that patients receive appropriate, safe care.”
    Grannis noted that patient data is currently fragmented across healthcare systems. Patients often do not receive care at just one facility or in one health system.
    “They’re going to be identified differently across organizations. You might go to your primary care doctor or they refer you to a specialist who’s outside of your system, so your data is fragmented,” he continued.
    Disjointed data can make it difficult for providers to make decisions about patient care. Without a complete picture of the patient’s medical history, it is more challenging for clinicians to make care decisions.
    Read full story
    Source: EHR Intelligence, 12 November 2019
  18. Patient Safety Learning
    Dozens of doctors from across Greater Manchester have warned health bosses plans to reform cancer services in the city will put patients at risk and destabilise smaller hospitals.
    In a letter, seen by The Independent, to the head of the devolved NHS and social care system for the city, almost 40 urological consultants called on the NHS to abandon its plans.
    NHS leaders are aiming to centralise hundreds of bladder and kidney cancer operations a year at the University Hospital of South Manchester but the doctors warn this will make their roles in smaller district general hospitals harder to recruit to and leave patients who need input from urologists at a disadvantage. Ultimately they fear the reorganisation could put services at smaller hospitals such as emergency care, gynaecology, trauma and obstetrics at risk because of the role urologist play in their delivery.
    The letter added: “The inevitable consequences of centralisation of complex urological cancer services on a single site will result in an inability to provide a safe sustainable comprehensive service to large areas of the city, particularly those areas which are already under resourced with regard to access to care and which have the highest levels of social deprivation."
    Read full story
    Source: The Independent, 12 November 2019
     
  19. Patient Safety Learning
    Radiology failings at a teaching hospital led to eight patients coming to severe harm, with three dying, a hospital trust has admitted. 
    A report into issues at St George’s University Hospitals Foundation Trust identified multiple problems, including staff missing cancers, improperly reported results and diagnoses being sent to unmonitored inboxes.
    Read full story (paywalled)
    Source: HSJ, 11 November 2019
  21. Patient Safety Learning
    Family doctors are calling for an end to home visits - saying they are too busy to visit the frail and elderly.
    The radical proposal, to be put forward at a conference of the British Medical Association, would see the duties removed from the standard contract for GPs. Medics said house calls were too “time consuming” for family doctors, who were overloaded. 
    But patients’ groups said the threat to withdraw such services from GPs was “appalling” and would put the vulnerable at risk. 
    Doctors will vote later this month on a proposal to remove home visits from the core GP contract, requiring a separate service to be created for those in need of urgent visits. 
    Read full story
    Source: The Telegraph, 11 November 2019
  22. Patient Safety Learning
    A coroner questioned the regulation of online pharmacies after a woman died as a result of her addiction to the painkiller codeine.
    Debbie Headspeath, 41, collapsed at home in Ipswich in 2017. The inquest heard she had been prescribed the opiate for back pain by her GP in 2008 and had later bought more online without his knowledge. The inquest found Mrs Headspeath died from pneumonitis caused by acute pancreatitis which in turn was caused by chronic codeine use. An investigation by the coroner's office found she had been prescribed codeine from 16 online companies spending more than £10,000 - on top of her prescriptions from her local NHS surgery.
    The Suffolk Coroner, Nigel Parsley, said he would ask the government to look at closing "regulatory gaps" in the system. He said Mrs Headspeath had been able to "manipulate" the system and he delivered a narrative conclusion that she died as a result of the "uncoordinated availability of codeine from multiple suppliers". The coroner said he would prepare a full prevention of future deaths report for the family and Department of Health.
    Read full story
    Source: BBC News, 12 November 2019
  23. Patient Safety Learning
    Five-day-old Abel Cepeda died in Geisinger Medical Center’s neonatal intensive care unit in the US. Cepeda’s parents didn’t know it at the time, but their son was the eighth baby since the summer to get sick after exposure to the same bacteria in Geisinger Medical Center’s NICU. Two had died by the time Cepeda’s mother was admitted on 18 September, according to the family’s lawsuit. Geisinger staff have admitted noticing “unusual” illness weeks before the hospital went public with its problem.
    On Friday, Geisinger announced that its own equipment contaminated the donor breast milk that exposed premature infants to a bacteria called pseudomonas. The medical center in Danville, Pa., says it changed its equipment on 30 September, switching to single-use materials — the same day Cepeda died while his parents remained in the dark about the ongoing bacteria problem, the family’s lawsuit alleges.
    Matt Casey, a Philadelphia-based lawyer representing Cepeda’s parents, says findings that Geisinger’s breast milk measurement materials led to the infections have reinforced his belief that Geisinger — which runs sites around Pennsylvania — was negligent both in cleaning its equipment and in taking steps to save lives once red flags surfaced.
    Read full story
    Source: The Washington Post, 9 November 2019
  24. Patient Safety Learning
    Alder Hey is leading on a new study called DETECT (Dynamic Electronic Tracking and Escalation) to reduce critical care transfers and to record vital signs.
    The study has received £1.25m in funding from the National Institute for Health Research Invention for Innovation Programme (NIHR i4i) and involves The University of Liverpool, Edge Hill University, Lancaster University and System C.
    Healthcare professionals at Alder Hey are currently using electronic devices to record breathing rate, effort of breathing, oxygen saturation, oxygen requirement, heart rate, blood pressure, capillary refill time, temperature and nurse or parental concerns.
    The DETECT Study is the first research study of its kind in the UK as an early warning system for children.
    The recorded data will automatically calculate an age-specific paediatric early warning score (PEWS), which categorises the risk of developing serious illness into low, medium, high or critical. These scores and signs suggestive of sepsis are automatically flagged to staff to help them recognise the early signs of deterioration, with a view to reducing emergency admissions to critical care.
    Read full story
    Source: Health Tech Newspaper, 11 November 2019
×
×
  • Create New...