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Patient Safety Learning

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  1. Patient Safety Learning
    Thousands of lives a year could be saved by providing cancer screening in supermarkets and other convenient locations so people can go in their lunch breaks, a report has suggested.
    Sir Mike Richards, the NHS’s first cancer director, was asked to review national screening programmes and suggest how to improve early detection rates. The Report of The Independent Review of Adult Screening Programme in England, released yesterday, recommends that people “should be able to choose appointments at doctors’ surgeries, health centres or locations close to their work during lunchtime or other breaks rather than having to attend their GP practice”.
    It adds: “Local screening services should put on extra evening and weekend appointments for breast, cervical and other cancer checks. And as people lead increasingly busy lives, local NHS areas should look at ways that they can provide appointments at locations that are easier to access.”
    Sir Mike said that screening programmes save 10,000 lives per year but added: “Yet we know that they are far from realising their full potential. We need to make it as easy and convenient as possible for people to attend these important appointments.”
    Read full story (paywalled)
    Source: The Times, 16 October 2019
  2. Patient Safety Learning
    A GP has been struck off the UK medical register after a tribunal found that she dishonestly recorded patients’ temperature, pulse, and other key variables without ever actually measuring them or carrying out a proper examination.
    Kathleen Bilton was an out-of-hours GP at Royal Glamorgan Hospital in south Wales in early 2018 when two complaints arose from patients she had sent home with antibiotic prescriptions. Both were admitted to hospital soon after and diagnosed with sepsis.
    Their medical records showed that Bilton had entered specific figures for their pulse, temperature, respiration, and other variables, but both complainants denied that she had taken such measurements.
    Read full story (paywalled)
    Source: BMJ, 15 October 2019
  4. Patient Safety Learning
    Encouraging diversity in the NHS isn’t simply a matter of inclusion, it’s a matter of patient safety, delegates at the Healthcare Excellence Through Technology (HETT) conference have heard.
    Speaking on 2 October, Heather Caudle and Ijeoma Azodo, both members of the Shuri Network, stressed the importance of diversity when developing new technologies like artificial intelligence (AI). Without a diverse and inclusive team, “unconscious bias” can be built into technology, ultimately putting patients at risk.
    The next step in ensuring inclusive digital health solutions is including technology teams throughout the whole process, Heather Caudle, Chief Nursing Officer at Surrey and Borders Partnership NHS Foundation Trust said. “In health what we have done really well is developed multidisciplinary teams when looking at the patient,” she told the audience at ExCel London.
    “I think our technology colleagues are the next member of our multidisciplinary teams. If you think about AI and these new ways of doing things, how are we including the creators and the developers when thinking about patient care?
    “We will have unintended consequences of artificial intelligence that hard-wires things like unconscious biases, that we are only going to treat people that are this age, this weight, this colour, because that’s how we think.
    “Having that diversity on the team will help.”
    Read full story
    Source: Digital Health, 2 October 2019
     
  5. Patient Safety Learning
    Royal Papworth Hospital in Cambridge, a leading heart hospital, has become the first NHS hospital trust to earn "outstanding" ratings across the board by inspectors.
    The hospital earned the top rating across all five tested areas – safety, effectiveness, care, responsiveness and leadership.
    The Care Quality Commission (CQC) inspectors said: "A caring culture ran through the trust."
    The CQC's Chief Inspector of Hospitals, Prof Ted Baker, said he was "very impressed by the high-quality care and treatment offered".
    "Patients received exemplary care from committed and qualified staff," the report concluded.
    Read full story
    Source: BBC News, 16 October 2019
  6. Patient Safety Learning
    The husband of a woman who died after repeated failures to diagnose her cervical cancer says he is "convinced there are other victims out there".
    Julie O'Connor was given the all-clear by doctors at Southmead Hospital in Bristol more than three years before a private doctor diagnosed her cancer. Mrs O'Connor and her husband Kevin later sued the hospital for its failings.
    An independent report concluded there were "serious errors" and a failing by the trust to act urgently when it was discovered Mrs O'Connor did have advanced cervical cancer.
    But Mr O'Connor criticised the report and said it did not cover the full length of his wife's cancer care. "It doesn't go back to 2014, it doesn't cover the smears, the biopsies and the missed clinical observations," he said. "We need to consider other victims, look further back, look back to 2014, and make sure we've got a safe and effective screening."
    Prof Tim Whittlestone, North Bristol NHS Trust's acting deputy medical director, said: "We are determined to learn from this and have made significant changes to the way we examine and test for cervical cancer, which I am confident will detect and prevent more cases in future."
    Read full story
    Source: BBC News, 16 October 2019
  7. Patient Safety Learning
    Women are half as likely as men to receive treatment for a heart attack – even after it has been diagnosed, research shows.
    Experts warned that "unconscious bias" means doctors are far less likely to think that female patients are suitable for interventions which can save lives. It follows evidence that 8,000 women have died needlessly from heart attacks in the last decade because they have not received the same standards of care as men.
    Some of the death toll was blamed on a failure to diagnose cases in women, with medics too often assuming symptoms signified a less serious ailment. But the new study by Edinburgh University found that even when women received a diagnosis, they were half as likely as men to be put on any of the main treatments available. 
    Read full story
    Source: The Telegraph, 14 October 2019
  8. Patient Safety Learning
    Today is Global Handwashing Day, a global advocacy day dedicated to increasing awareness and understanding about the importance of handwashing with soap as an effective and affordable way to prevent diseases and save lives.
    hub content on handwashing:
    WHO: Guidance on engaging patients and patient organisations in hand hygiene initiatives
    Safety and Health Practitioner: Tips for hand hygiene 
    Hand washing dance - this is how we do it
    What initiatives are in your hospital to ensure "clean hands for all"? Share your tips on the hub.
  9. Patient Safety Learning
    A new report reveals alarming shortage of country doctors. Just 15% of consultants take jobs in hospitals serving rural or coastal areas.
    Hospitals in rural and coastal Britain are struggling to recruit senior medical staff, leaving many worryingly “under-doctored”, a major new report seen exclusively by the Observer reveals. Some hospitals in those areas appointed no consultants last year, raising fears that the NHS may become a two-tier service across the UK with care dependent on where people live.
    Disclosure of the stark urban-rural split emerged in a census of consultant posts across the UK undertaken by the Royal College of Physicians (RCP), whose president, Andrew Goddard, has warned that patients’ lives may be at risk because some hospitals do not have enough senior doctors.
    Read full story
    Source: The Guardian, 13 October 2019
     
  10. Patient Safety Learning
    Doctor shortages are jeopardising patient safety and rota gaps are pushing the NHS to “breaking point”, Scottish physicians have warned.
    A lack of doctors in NHS Scotland due to unfilled vacancies, sick leave and a shortage of staff is often putting patients’ welfare at risk, a survey of consultants has found. More than a third of Scottish doctors (34%) reported, in the Royal Colleges’ annual census, that trainee rota gaps occurred at least daily, while 16% warned they are causing “significant patient safety problems”.
    A further 78% of those who responded said rota gaps potentially cause patient safety problems, but that there are solutions in place.
    Read full story
    Source: The Scotsman, 14 October 2019
  11. Patient Safety Learning
    A shortage of skilled staff, coupled with rising demand, has created a “perfect storm” for patients using mental health and learning disability services, England’s healthcare regulator has warned.
    In its annual State of Care report for 2018-19, the Care Quality Commission said that although quality ratings across health and social care, including community mental health services, had been maintained overall, this masked “a real deterioration” in some specialist inpatient services over the past 12 months.
    Read full story (paywalled)
    Source: BMJ, 14 October 2019
  12. Patient Safety Learning
    More than half of A&E units are providing substandard care because they are understaffed and cannot cope with an ongoing surge in patients, the NHS watchdog has said.
    The Care Quality Commission (CQC) said 44% of emergency departments in England required improvement and another 8% were inadequate, its lowest rating. Last year 48% of A&Es fell into the two ratings brackets combined.
    Prof Ted Baker, the CQC’s chief inspector of hospitals, said A&Es were getting overloaded because too few NHS services existed outside hospitals, meaning patients’ health could worsen. He said: “There needs to be a system-wide change: people need to get the care they need in the community… so they do not need to attend A&E unnecessarily,.."
    Dr Katherine Henderson, the president of the Royal College of Emergency Medicine, said: “As well as more patients coming to emergency departments due to a lack of accessible alternatives, there are fewer and fewer staffed beds in hospitals to admit sick patients to, which results in long waits for patients and overcrowded emergency departments. It is little wonder just over half of urgent and emergency services are rated as needing to improve.”
    Read full story
    Source: The Guardian, 15 October 2019
  13. Patient Safety Learning
    Only 15% of healthcare apps meet minimum safety standards, highlighting a “desperate need” for a proper review process, new research has concluded.
    Health app evaluation organisation ORCHA evaluated more than 5,000 apps against 260 performance and compliance factors and found that majority do not meet the minimum safety requirements.
    Liz Ashall-Payne, ORCHA’s Chief Executive, said: “We believe that digital health apps are one of the most important tools available to help tackle health issues in an ageing population that’s facing more complex, long-term problems. The fact that only 15% of apps that we review meet the minimum standards show there is a desperate need to regularly and properly assess the apps available to ensure that people are protected against the serious risks associated with downloading ineffective or even harmful apps.”
    Helen Hughes, Chief Executive of Patient Safety Learning, which is working with ORCHA to improve the safety of apps, said the research reiterated the need for consistent regulatory standards and accreditation frameworks to be applied to healthcare apps.
    “One of the areas we are beginning to explore with ORCHA is whether or not we can consider what patient safety would be in part of the review process,” she said. “Essentially what we want is patient safety embedded in all of the review processes so that we can inform and guide clinicians and inform and guide patients."
    “And that there is appropriate research on their use and their impact so that information can feed the improvement of standards.”
    Read full story
    Source: Digital Health. 9 October 2019
     
  14. Patient Safety Learning
    A Bill to fully establish the Healthcare Safety Investigation Branch (HSIB) as an arm’s-length body has been one of 26 proposed bills announced in the Queen’s speech at the State Opening of Parliament.
    The Queen announced: “New laws will be taken forward to help implement the National Health Service’s long-term plan in England and to establish an independent body to investigate serious healthcare incidents.”
    Keith Conradi, HSIB Chief Investigator, said: “This announcement marks the start of a significant change to our organisation that will result in us becoming an independent statutory body with significant legal powers.
    The legislation will prohibit the disclosure of information held by the investigations body, except in limited circumstances. This will allow participants to be candid in the information they provide and ensure thorough investigations.
    The Bill will also improve the quality and effectiveness of local investigations by developing standards and providing advice, guidance and training to organisations.
    There will also be a pledge to update the Mental Health Act to reduce the number of detentions made under the act.
    Read Queen's speech in full
    Read HSIB's response
  15. Patient Safety Learning
    Prisoners are at risk of being transferred without crucial medication, according to the latest Healthcare Safety Investigation Branch (HSIB) report.
    The report reveals errors and delays in the prison healthcare system. The investigation looks into the case study of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison.
    Each day around 120 prisoners with ongoing medication needs are moved between jails. Martin’s case is just one example of a serious outcome when medication was missed. Prisoners may also need to be treated in the community at local hospitals, with prison security staff being taken away from planned duties to accompany them.
    Dr Lesley Kay, Deputy Medical Director at HSIB and a Consultant Rheumatologist, has experience of working with prisoners that have long-term conditions: “I have seen first-hand the impact that the lack of medication management can have on patients, particularly when they have long-term conditions. This also places additional pressure on an already stretched NHS and prison service.
    “With over 2,400 transfers a month where medication is needed, we recognise how busy prison healthcare staff are and how challenging it is to get medication to the right place at the right time. We know that the system needs to be better and the recommendations we have made are aimed at making the whole process smoother and safer for everyone.”
    Read story and full report
    Source: HSIB, 10 October 2019
  17. Patient Safety Learning
    The Healthcare Safety Investigation Branch (HSIB) latest report highlights that mislabelling of blood samples could pose a deadly risk to patients.
    National data indicates there were 792 ‘wrong blood in tube’ near misses (where the error was spotted in time and no patient suffered harm) relating to blood transfusion samples, in 2018 across England.
    The reference event in the report is a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating. There’s the potential for serious injuries and even death. 
    Dr Stephen Drage, HSIB Director of Investigations and ICU consultant, said: “Millions of blood tests are carried out across the NHS each year, from GP surgeries to large teaching hospitals. Most happen without incident but when it does go wrong it could represent a catastrophic outcome for patients, families and staff."
    Read the full report
    Source: HSIB, 26 September 2019
  19. Patient Safety Learning
    Initiatives to increase staff engagement and make leadership teams more approachable have helped to improve NHS trusts’ ratings from the health and social care watchdog, a report by NHS Providers has found.
    Trusts’ performance has gradually improved, showed the results of inspections by the Care Quality Commission (CQC). In 2014, the year that the CQC began rating trusts, 24 of 35 trusts inspected (68%) were designated “requires improvement” or “inadequate.” Five years later, most of the 224 trusts inspected (59%) were rated “good” or “outstanding.”
    Read full story (paywalled)
    Source: BMJ, 10 October 2019
  20. Patient Safety Learning
    This summer was the worst for A&E waiting times in England since the four-hour target was introduced.
    Analysis by BBC Newsnight and the Nuffield Trust found an average of 86% of patients were admitted, transferred or discharged from A&E within four hours in the six months to September.
    This is the worst performance in that period since the 95% target was brought in in 2004.
    Doctors warned that the system was "running out of resilience" and that winter in A&Es was going to be "really difficult".
    In September, there were 41,000 more people treated in A&Es within four hours, but there were 64,921 patients waiting more than four hours from decision to their actual admission to further care. Of these patients, 455 waited more than 12 hours. This is a 195.5% increase from the previous year. These are known as trolley waits, because patients are left on trolleys in temporary waiting areas while a bed is found.
    "Lying on a trolley is not good for you in any way," said Dr Katherine Henderson, President of the Royal College of Emergency Medicine. "We know these patients can suffer harm because they're in the department for so long."
    Read full story
    Source: BBC News, 10 October 2019
  21. Patient Safety Learning
    One in four patients with secondary breast cancer had to visit their GP three or more times before they got a diagnosis, a survey suggests.
    The breast cancer charity, Breast Cancer Now, said there should be more awareness that the disease can spread to other parts of the body. In the UK, 35,000 people are living with the incurable form of the disease.
    GPs said they were doing their best for patients but symptoms could be difficult to spot.
    Breast Cancer Now said it was "unacceptable" that some people whose cancer had spread were not getting early access to treatments which could alleviate symptoms and improve their quality of life.
    Prof Helen Stokes-Lampard, from the Royal College of GPs, called for GPs to have better access to the right diagnostic tools and training to use them.
    Read full story
    Source: BBC News, 11 October 2019
  22. Patient Safety Learning
    NHS Chief Executive Simon Stevens has announced that a new taskforce will be set up to improve current specialist children and young people’s inpatient mental health, autism and learning disability services in England.
    The NHS Long Term Plan sets out an ambitious programme to transform mental health services, autism and learning disability; with a particular focus on boosting community services and reducing the over reliance on inpatient care, with these more intensive services significantly improved and more effectively joined up with schools and councils.
    The NHS Chief Executive said: “This taskforce will place a spotlight on services and care for some of the most vulnerable young people in our society, bringing together families, leading clinicians, charities, and other public bodies to help make these services as effective, safe and supportive as possible for thousands of families."
    “The NHS Long Term Plan lays out a package of measures which will mean more than two million extra children and adults get the mental health care they need and while early intervention to stop ill health escalating is a priority, we are also determined to provide the strongest possible safety net for families living with the most acute conditions.”
    Read full story
    Source: NHS England, 10 October 2019
  24. Patient Safety Learning
    The British Medical Association (BMA) is calling on employers to sign up to a wellbeing charter to improve doctors’ working lives. 
    The association commissioned qualitative research to establish which factors contributed to poor mental health among doctors. Researchers conducted 30 interviews with doctors from a range of specialties and levels of seniority, as well as two online focus groups with medical students and junior doctors.
    Read full story (paywalled)
    Source: BMJ, 10 October 2019
  25. Patient Safety Learning
    As a doctor himself, Jonathan Phillips knows how isolating the job can be, which is why he is raising awareness of mental wellbeing at his trust.
    Jonathan first heard of his daughter Lauren’s disappearance in the early hours of the morning on 1 March 2017. Her car was found abandoned near a beach in Devon after she had been reported missing from her job in the A&E department of a NHS trust.
    Lauren was 26 and in her third year as a junior doctor in the south-west of England when she took her own life.
    "From the moment they start, all newly qualified doctors encounter sexism, racism and verbal, physical and sexual abuse, as well as extremes of distress, rage and despair. They are in a highly stressful working environment where mistakes may prove fatal to their patients and career," says Jonathan. "Young trainees are individuals with differing life experiences, resulting in varying strengths and vulnerabilities; some will need shielding from certain situations at the start of their careers. If we are lucky enough to identify someone in a crisis we should not merely signpost the route to help, but guide and accompany them along the path to recovery."
    Prompted by his own experience and other junior doctor suicides, Jonathan and colleagues constructed a wellbeing and resilience training day for foundation year doctors at his trust. It was delivered by senior doctors with a responsibility and interest in junior doctor training and supervision, and was quite separate from the already congested induction programme.
    Read full story
    Source: Guardian, 10 October 2019
     
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