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Patient Safety Learning

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  1. Patient Safety Learning
    Digital training should be “embedded” into clinical curricula rather than being “bolted on”, the Chief Executive of ORCHA has said. Liz Ashall-Payne said more needed to be done to ensure appropriate digital training for clinicians or risk a “knowledge gap” forming between current and future staff.
    Dr Sandeep Bansal, Chief Executive of Medic Creations and mentor on the Royal College of GPs innovation mentorship programme, echoed calls for digital training to be incorporated in the medical school curriculum. 
    “Your organisation is only as strong as lowest digitally mature staff member. It is all very well educating our tech-savvy junior doctors, but we must make sure those less au fait with digital advancements are not left behind. That is where patient safety could be put at risk. After all the main purpose of digital innovation is to enhance our ability to care for patients, by enabling more effective, efficient and precise clinical practice.”
    Clive Flashman, Patient Safety Learning's Chief Digital Officer, agreed with the need for clinicians to receive digital training but with a focus on how to quickly evaluate an apps. “What is essential is that all clinicians, not just GPs, have access to advice, tools and support to enable them to prescribe and monitor the effectiveness of apps and digital therapies,” he told Digital Health News.
    Read full story
    Source: Digital Health, 29 October 2019
     
  2. Patient Safety Learning
    The Health Products Regulatory Agency (HPRA) has revealed an increase in the number of adverse reaction reports to medicines as well as a rise in product recalls and quality defects in 2018. With more than 250 Irish patients dying last year while on treatment with medicines where an adverse reaction had been reported, should we be alarmed?
    The number of adverse reaction reports received by the authority last year more than doubled. It says the increase is largely accounted for by a new requirement to include non-serious reports of adverse reactions in addition to serious ones. Particular risk factors include age extremes, the prescribing of multiple drug types, co-morbidity and genetics. But in truth reporting of adverse drug reactions (ADRs) in the Republic has never been comprehensive. It is estimated that less than 5% of all ADRs are reported in practice. A 2018 Irish study found that 43% of hospital doctors and 35% of GPs had never reported a suspected ADR.
    Medication safety is an important patient safety issue. Working together, and with increased education, healthcare professionals and the public can do more to increase vigilance.
    Read full story
    Source: The Irish Times, 28 October 2019
  3. Patient Safety Learning
    Nearly 900 children in a Pakistani city have tested positive for HIV after a rogue paediatrician allegedly reused infected syringes.
    About 200 adults have also tested positive for the virus since the epidemic in Ratodero was confirmed in April. But health officials fear the true number affected could be far higher, with less a quarter of city’s 200,000 residents tested so far.
    The outbreak was initially blamed on Dr Muzaffar Ghanghro, a paediatrician who at 16p a visit was one of the cheapest in the small central city. He was arrested and charged with negligence and manslaughter after his patients accused him of frequently reusing syringes on their children.
    Despite an initial investigation by police and health officials concluding Dr Ganghro’s “negligence and carelessness” as the “prime” reason for the outbreak, officials believe he is unlikely to be the sole cause. Visiting health workers often see doctors in Ratodero reusing syringes, while dentists use unsterilised tools in roadside surgeries and barbers use the same razor on various customers, The New York Times reported.
    Read full story
    Source: The Independent, 27 October  2019
  4. Patient Safety Learning
    A coroner has criticised an NHS trust for “suboptimal care” and “missed opportunities” in the treatment of 10 patients with cancer at a urology department where relationships were “dysfunctional.”
    Coroner Penelope Schofield said that all 10 had died of natural causes but that missed opportunities, suboptimal care, and in three cases “neglect” had contributed to the deaths.
    The patients, who died from prostate or bladder cancer from 2006 to 2015, were under the care of Paul Miller, a consultant urologist at East Surrey Hospital in Redhill. 
    Read full story (paywalled)
    Source: BMJ, 25 October 2019
  6. Patient Safety Learning
    The public is being misled by scare stories about sepsis, say experts, warning that hype and misunderstandings about the so-called “hidden killer” have generated “an unhealthy climate of fear and retribution” in the UK and the US.
    Prof Mervyn Singer and colleagues from the Bloomsbury Institute of Intensive Care Medicine at University College London argue that the numbers are not that high and sepsis is not always preventable. “Many other non-contextualised or fictitious claims regularly fill media pages and airwaves,” they say in their letter to the Lancet, calling for a rethink of the approach to sepsis risk.
    The truth, they say, is that sepsis kills a very small proportion of patients – and those who die are overwhelmingly very elderly or frail. Their deaths are not always preventable because their chances of surviving their illness were not high to begin with. And the drive to ensure all patients suspected of sepsis get antibiotics within an hour is unhelpful and leading to unjust criticism of doctors and litigation against hospitals.
    A Department of Health and Social Care spokesperson said: “Sepsis can be life-threatening and it is absolutely right the NHS has focused on improving awareness, diagnosis and treatment of this syndrome. While the number of people identified as at risk of sepsis has increased, mortality rates are falling.”
    Read full story
    Source: The Guardian, 25 October 2019
  7. Patient Safety Learning
    A national survey, published by the Care Quality Commission (CQC), shows most people experience good urgent and emergency care, but waiting times are still a problem.
    More than 50,000 people, who received urgent and emergency care, took part in a CQC survey covering 132 NHS trusts across England. Findings show that the majority of their experiences were positive relating to their care and treatment but a significant number reported long waits, particularly in A&E.
    The survey, which ran between Oct and Mar 2019, reveals responses from patients who experienced either a major consultant-led A&E department (Type 1) or an urgent care or minor injury unit (Type 3) run directly by an acute hospital trust. 75% of people who attended a Type 1 department reported ‘definitely’ having enough time to discuss their condition with the doctor or nurse. This has risen from 73% who said the same in 2016, the last time the survey was carried out. A similar number (76%) said that they ‘definitely’ had confidence and trust in the staff treating them, up from 76% in 2016.
    Another improvement showed that 79% of participants were treated with respect and dignity ‘all of the time’, up from 78% in 2016.
    Professor Ted Baker, CQC’s chief inspector of hospitals, said:
    “I’m pleased to see that the majority of people surveyed continue to report positively about their experience. This is despite the pressures that urgent and emergency care services are under and is a testament to the dedication and hard work of hospital staff across the country.
    “However, it is disappointing that in some areas people’s experience continues to fall short. We cannot ignore the increasing impact of lengthy waiting times particularly for those patients attending A&E departments. Patients who are seriously ill and need urgent care should be consistently identified in a timely way, so it is concerning that such a low proportion say they waited 15 minutes or less for an assessment.
    Read full CQC report
    Source: CQC, 23 October 2019
  8. Patient Safety Learning
    Western Sussex Hospitals Foundation Trust has become the first non-specialist trust to be rated “outstanding” in all five Care Quality Commission (CQC) domains.
    The latest CQC report means the trust has not only retained its overall “outstanding” rating from its December 2015 inspection, but also improved its rating in the safe domain from “good” and in the responsiveness domain from “requires improvement”. The trust was also rated “outstanding” for critical care, improving from “requires improvement”. It was also rated outstanding for use of resources.
    Read CQC report
    Read full story (paywalled)
    Source: HSJ, 22 October 2019
  9. Patient Safety Learning
    Mike Stylianou, an operating department practioner, discusses how personal experiences led himself and a colleague to set up a debrief team for the operating theatres at Great Ormond Street hospital.
    "Healthcare professionals aren’t robots. When something goes tragically wrong, our debriefing programme supports them."
    Read full story
    Source: The Guardian, 24 October 2019
  10. Patient Safety Learning
    Poorly implemented electronic prescribing and medicines administration systems can result in potentially fatal medication errors, Healthcare and Safety Investigation Branch (HSIB) warns today.
    The report comes after HSIB looked at the case of 75-year old Ann Midson, who was left taking two powerful blood thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer.
    Ann sadly died from her cancer 18 days after being discharged and the error with her medication was only picked up three days before. This led to our investigation to question why this happened, even when the hospital had an ePMA system in place.
    Read report
    Read full story
    Source: HSIB, 24 October 2019
  11. Patient Safety Learning
    A hospital showed "poor behaviour" towards junior staff and "a culture of bullying behaviour", health inspectors have said.
    The Care Quality Commission (CQC) has downgraded Northampton General Hospital from "good" to "requires improvement".
    Inspectors also found the hospital's maternity and medical care "requires improvement".
    Dr Sonia Swart, chief executive, said staff should be treated "the way we care for patients".
    The CQC, which visited in June and July this year, also found that the hospital "requires improvement" in safety and leadership.
    Read full story
    Source: BBC News, 24 October 2019
  12. Patient Safety Learning
    The number of hospitals falling short of their planned nurse staffing by 10% or more has almost tripled in five years. An analysis of unpublished workforce data by HSJ reveals the gap between the number of nurses hospitals think they need, and what they are able to staff it with, has grown since 2014.
    The number of hospital trusts reporting a shortfall of 10% or more on their day shifts increased from 20 in June 2014 to 55 in June 2019 – nearly triple. 
    Experts said the data showed the NHS was “drifting into massive skill mix change” as hospitals overstaff with support workers, while having to run shortfalls of nurses, despite evidence this has a “detrimental impact on patient outcomes including survival”.
    Alison Leary, Professor of Healthcare and Workforce Modelling at London’s Southbank University, told HSJ: “It’s concerning but understandable that trusts are filling that gap with unregistered support staff because we know from the evidence that skill dilution has a detrimental impact on patient outcomes including survival." Professor Leary said NHS trusts needed to do more on retaining nurses and recognising their value.
    Read full story
    Source: HSJ, 24 October 2019
  13. Patient Safety Learning
    The Nursing and Midwifery Council (NMC) misled former health secretary Jeremy Hunt over its handling of fitness to practise cases linked to the Morecambe Bay maternity scandal, an independent report has said.
    In a letter to Mr Hunt, the nursing regulator’s former chief executive Jackie Smith said a document relied on by the family of one baby who died at the hospital had been considered by its lawyers ahead of a fitness to practise panel.
    Now a new report by consultancy Verita said the regulator had in fact lost the document and it was not considered ahead of the fitness to practise hearing. It said the misleading letter was “obviously concerning” and criticised the regulator for its poor practice in not checking documents.
    Verita’s report, commissioned by the NMC and published today, has also laid bare how the nursing regulator badly treated the parents of Joshua Titcombe, who died in October 2008 after poor care at Furness General Hospital. It concluded they were “unfairly attacked” in the press.
    Joshua’s father James Titcombe provided the NMC in 2010 with a chronology of what happened after his son’s death (written in 2008) in which it was mentioned that both he and his wife had been unwell before Joshua’s birth. This document was lost and not shared with a fitness to practise panel in 2016 with lawyers claiming the couple were unreliable witnesses.
    The report claims the errors were the result of “mainly accidental factors, combined with poor communication and management” at the regulator.
    It found the chronology document was never included in the original case file for the NMC, which was not noticed by NMC staff.
    Mr Titcombe, whose campaign about maternity safety at the Cumbria hospital led to the Kirkup inquiry being published in 2016, told HSJ: “Verita seem to have gone about this in a way that their objective was to provide an innocent explanation. The investigation doesn’t seem very logical and the report has changed significantly from earlier versions with significant criticisms removed.
    “If you wanted to design a process that tortured bereaved parents you couldn’t do much better than the process the NMC came up with. We were made to relive what happened again and again and when the hearing eventually took place, attempts were made to discredit our evidence with no one from the NMC challenging statements that were plainly untrue.”
    He said the actions of the NMC after he raised concerns made the situation worse: “I knew that the excuses given at the time made no sense, but the fact that it took an external investigation before we were told the truth, is something that still shocks me.”
    A report by the Professional Standards Authority last year found the NMC had put the public at risk of poor care and was guilty of “frequently incompetent” complaint handling.
    The former chief executive Jackie Smith resigned last year. Former chair Dame Janet Finch was replaced by Philip Graf in May 2018.
    Andrea Sutcliffe, new chief executive of the NMC, said: “Throughout these fitness to practise cases the way we treated Mr Titcombe and his family was unacceptable. Our actions made an awful situation much worse and I am very sorry for that. I am also very sorry that our communications with Mr Titcombe, the PSA and the secretary of state for health and social care contained incorrect and misleading information about our handling of this evidence.
    “Together with NMC Chair Philip Graf, I am writing to Mr Titcombe, the chief executive of the PSA and the current and former secretary of state to apologise for these errors which should not have occurred.”
    She said the investigation highlighted a number of failings for the regulator which “reflected a culture at the NMC at that time that prioritised process over people. When concerns were raised with us about our approach, we acted defensively and dismissed those concerns. That is frankly unacceptable.”
    The regulator has since made changes, she argued, including better record keeping, a new public support service and better training for panel members to appreciate the needs of witnesses.
    She added: “While I am clear that, if faced with the same situation again, we would do things differently, I am also very aware that for many of those going through our fitness to practise process, it remains a very difficult experience. That is why we are carrying out further work, to understand how we can better ensure that witnesses, particularly those in vulnerable circumstances, are able to give evidence in a way that causes as little distress as possible. This includes learning from other organisations and jurisdictions, such as the courts.
    “I know that this investigation does not address all of Mr Titcombe’s concerns and I am sorry for that. However, I am grateful for his continued engagement and support as we change and improve. I would like to pay tribute to him for the passion and determination he has shown to ensure women, babies and their families have the safest, best care possible – an objective shared by all of us at the NMC. I am absolutely committed to learning the lessons of the past, taking forward the recommendations of this investigation and building on recent improvements as we look to develop a just, learning culture, both within the NMC and the wider health and care system.”
    Read Verita report
    Read full story (paywalled)
    Source: HSJ, 23 October 2019
  14. Patient Safety Learning
    A dentist whose patient bled to death when she had five teeth removed has been suspended for misconduct.
    Tushar Kantibhai Patel, of Purley, south London, operated on the woman, known as Patient A, despite her telling him she was taking an anti-clotting drug for a rare blood disorder.
    The General Dental Council found he should have sought further advice prior to carrying out treatment.
    Patient A died in July 2017 from severe bleeding from her mouth.
    Read full story
    Source: BBC News, 23 October 2019
  15. Patient Safety Learning
    The daughter of a man who died in a hospital corridor after six hours on a trolley said he may still be alive if her pleas for help were acted on.
    Emma Driver said her 84-year-old father, Donald, was only seen by nurses at University Hospital Coventry when he slid off the trolley he was left on. He died moments later, shortly before 01:00 BST on 14 October.
    The hospital trust said it was "investigating this matter thoroughly" and was in contact with the family.
    Ms Driver called for paramedics at about 18:00 the day before, a Sunday, when her father was complaining of stomach pain, with symptoms similar to a stomach ulcer he had previously suffered with.
    She told the BBC it was "extremely busy" when they arrived at the hospital and it was 90 minutes before paramedics could hand him over to hospital staff. 
    Mr Driver was left to wait on a trolley in the corridor, his daughter said, and still had not been seen by midnight, despite her asking for help multiple times.
    Read full story
    Source: BBC New, 23 October 2019
  16. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) will stop carrying out external maternity incident investigations by 2021, handing them back to the NHS, HSJ has learned.
    Powers to allow HSIB to continue investigating more than 1,000 serious incidents in maternity units each year were left out of legislation which was presented to the House of Lords this week, sparking criticism from former health secretary Jeremy Hunt.
    The new bill gives HSIB statutory independence from the NHS alongside a range of powers, including the power to enter and seize documents and equipment that could be evidence. It also grants HSIB the power to keep information in a so-called safe space that cannot be shared, except in exceptional circumstances, with bodies like the General Medical Council.
    Read full story (paywalled)
    Source: HSJ, 18 October 219
  17. Patient Safety Learning
    Cancer patients are suffering side-effects of treatment in silence because they are afraid of bothering overworked NHS staff, a new survey reveals.
    More than two thirds of newly diagnosed cancer patients questioned by Macmillan Cancer Support said they are not getting all the help they need - estimated to be about 300,000 people across the UK.
    About a fifth of the 6,905 people in the survey said the healthcare professionals caring for them seemed to have "unmanageable" workloads.
    These patients were a third more likely to have physical and emotional needs that were not being addressed, such as depression, anxiety, pain and trouble sleeping, the charity said.
    Read full story
    Source: The Telegraph, 22 October 2019
  18. Patient Safety Learning
    NHS bosses knew that a low roof at a Swindon mental health unit was a safety risk before a patient slipped off it 11 hours after scaling the building.
    The woman, who suffered paranoia, needed emergency surgery after breaking her jaw, hip, pelvis and nose in the fall from the roof. 
    Avon and Wiltshire Mental Health Partnership (AWP) NHS Trust has since apologised for the incident. In August, the trust was fined £80,000 by magistrates after bosses admitted failing to provide safe care at Sandalwood Court psychiatric hospital.
    Now, an internal report on the incident has been published demonstrating AWP bosses knew the low roof was a risk. But it was agreed to manage that risk clinically, with ward staff assessing whether a patient was likely to abscond. The authors of the report, released by AWP following a freedom of information request, said there was a systematic fault.
    “The risk was on the health and safety register, it was highlighted annually and escalated trust-wide,” they wrote.
    Read full story
    Source: Swindon Advertiser, 18 October 2019
  19. Patient Safety Learning
    Diabetes teams in some NHS trusts are blocking patients’ access to new technologies that could improve their care, clinical leaders have said.
    A Westminster Health Forum session on diabetes and technology on 16 October heard that there was unwarranted variation across the country in access to insulin pumps and other clinically effective devices. Poorer access often stemmed from a lack of understanding among individual consultants and departments and a reluctance to offer new devices to patients, the experts said.
    Read full story (paywalled)
    Source: BMJ, 17 October 2019
  20. Patient Safety Learning
    The Medicines and Healthcare products Regulatory Agency (MHRA) has found around 2,000 products available to buy online since last October.
    The fake test devices for HIV and other diseases can show negative results when the person is positive, resulting in an individual believing they are infection-free and unknowingly spreading an infection to others.
    An MHRA spokesman said: “Medical devices that do not display the CE mark and four-digit number cannot be guaranteed to meet quality and safety standards and could lead to false negative results, potentially leading to STIs or blood-borne viruses to be spread further. Always purchase medical devices from a registered pharmacy or reputable retail outlet. If you have any concerns about your health, speak to a doctor or healthcare professional.”
    The MHRA is running a #FakeMeds public health campaign to reduce the harm caused by purchasing fake, unlicensed or counterfeit medical products online. It comes after research found that more than half of all medical products bought online are either substandard or counterfeit.
    Read full story
    Source: The Guardian, 20 October 2019
  21. Patient Safety Learning
    A manager has won his employment tribunal against a patient transport company he alleged had misled clients over staffing.
    Richard Mott won a claim for unfair dismissal after being made redundant one day after raising concerns about Secure Care UK, a firm that transports mental health patients, who have often been detained under the Mental Health Act.

    The tribunal heard the organisation had significant staffing difficulties, both for drivers and for manning the operations room.
    The judgment issued this month said: “The claimant says and I accept that [chief executive] Femi Sanusi had instructed him to inform a client that they had staff available to cover an assignment when they did not."

    “He told Mr Sanusi that ‘I do not work like this’. He went on to say that the [company] was in breach of CQC [Care Quality Commission] regulations, health and safety law and working time regulations. He said that the health and safety of patients and staff was in danger. He threatened to contact the CQC and the Information Commissioner.”
    Read full story (paywalled)
    Source: HSJ, 21 October 2019
  22. Patient Safety Learning
    The "most likely cause" of a bacterial outbreak that has seen 15 people die was district nursing teams, a document obtained by the BBC has revealed. 
    At least 33 people in Essex have been infected by the strain of invasive Group A Streptococcus (iGAS) bacterium. Of 32 cases initially found in the area 29 had previously been visited by Provide nurses, files obtained showed. Mid Essex Clinical Commissioning Group (CCG) said an investigation into the cause was continuing.
    Provide said it had "robust infection prevention policies" and that the cause of the infection may never be known.
    The BBC submitted a request under the Freedom of Information Act to Public Health England (PHE) and the CCG, which oversaw health spending in the area, for documents relating to the outbreak.
    A PHE briefing note received through the request said: "The most likely hypothesis as to cause of the outbreak is contact with, and spread via, district nursing services in the area."
    Read full story
    Source: BBC News, 19 October 2019
  23. Patient Safety Learning
    Patients caught up in a massive neurology recall have received letters of apology from the head of the Belfast trust – more than a year after the scandal broke.
    This is the first time trust Chief Executive Martin Dillon has corresponded with those affected, many of whom were misdiagnosed or received the wrong drug treatment while under the care of consultant neurologist Dr Michael Watt.
    The letter, seen by The Irish News, contains three separate apologies from Mr Dillon and gives "assurances" on the trust's co-operation with separate health service reviews.
    Mr Dillon announced his resignation this morning. He is retiring after almost three years in the trust's top post. During his tenure the trust has found itself at the centre of the biggest PSNI safeguarding investigation of its kind following allegations of patient abuse at Muckamore Abbey Hospital and is also dealing with the largest patient recall in Northern Ireland following the Dr Watt scandal.
    In his statement he singled out the “very serious allegations” of mistreatment at Muckamore and the neurology recall as two “major issues” he has dealt with as chief executive. He stresses that as “accountable officer” he has been “resolute” in trying to “put things right” and is confident care at Muckamore is now safe. 
    Read full story
    Source: The Irish News, 17 October 2019
  24. Patient Safety Learning
    On the first-ever World Patient Safety Day on 17 September 2019, WHO recognised the efforts of healthcare workers in the north-western Syrian Arab Republic, which has been affected by intense conflict for over 8 years.
    In support of improving the quality of healthcare delivery, WHO launched a pilot infection prevention and control project in 30 Syrian health facilities in 2019. Initial assessment highlighted that 28 out of the 30 facilities were inadequately implementing the core components of infection prevention and control programmes according to WHO guidelines for acute health facilities. This emphasised the need to improve patient safety.
    Globally, it is estimated that as many as 4 out of 10 patients are harmed in primary and ambulatory care settings; up to 80% of harm in these settings can be avoided. By investing in patient safety in health facilities, no matter how challenging the environment, WHO can save lives and improve the quality of care.
    Read full article
    Source: WHO, 16 October 2019
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