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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Northern Care Alliance NHS Foundation Trust (NCA) has published an independent report by Barrister Mr Carlo Breen into the Trust’s historic management of concerns in relation to a Consultant Spinal Surgeon. The investigation found that certain patients, relatives and colleagues had been significantly let down. The Trust fully accepts the findings and apologises for any distress or harm caused by the issues identified within the report. In response to a significant Freedom to Speak Up concern, NCA Chief Executive Dr Owen Williams commissioned Mr Breen in March 2022 to investigate how historic concerns and complaints dating back to 2007 relating to this consultant’s conduct, probity and capability had been previously handled and what lessons could be learned. Mr Breen’s review is the second review commissioned by the Trust relating to these important matters. The first report detailed the findings of the “Spinal Patient Safety Look Back Review” and was published last year. Dr Williams said: “I am deeply sorry and apologise to the patients and their families for the care which is described in both Mr Breen’s report released today and the patient look back review from last year. “I also apologise to my NCA colleagues who have had to work too hard to get their concerns heard and thoroughly investigated. I am thankful that they persisted. We will do right by them and our patients by continuing to put into practice what we have learned”.
  2. News Article
    More than 7,300 people waited longer than 24 hours for emergency treatment in Scottish hospitals last year, with the longest wait more than 122 hours. Public Health Scotland statistics obtained by Scottish Labour through freedom of information (FoI) revealed that 7,367 patients were in an emergency department for more than 24 hours before being discharged, admitted or transferred in 2023. The longest wait in A&E last year occurred at NHS Ayrshire and Arran’s University Hospital Crosshouse, where a patient waited more than 122 hours, or the equivalent of five days. Waits of more than 88 hours were recorded in NHS Borders, and 72 hours in NHS Lanarkshire. Dame Jackie Baillie, Scottish Labour’s health spokeswoman, has demanded action from Neil Gray, the health secretary. “Scotland’s A&E departments are in the grip of a deadly crisis, with lives being put on the line day in and day out,” she said. “That some people have waited days — even a working week — to be seen is dangerous and disgraceful. “Hard-pressed A&E staff are working tirelessly to look after patients, but SNP mismanagement has created a perfect storm in our hospitals. Neil Gray has inherited an NHS in deadly disarray from his colleagues. “It’s time for action to be taken now to bolster A&E departments by tackling delayed discharges and investing in primary care to avoid putting further pressure on hospital services.” Read full story (paywalled) Source: The Times, 11 March 2024
  3. News Article
    Distressed elderly patients are being “treated like animals” and left begging for care as NHS staff struggle to cope with overwhelmed wards and an ever-increasing ageing population, an investigation by The Independent has revealed. Scores of families have come forward to share harrowing allegations of neglect as one top doctor warns that elderly people are receiving care “well below the standards they should expect” – including long waits in waiting rooms and “degrading” corridor care. In one shocking case, a 96-year-old patient admitted to the hospital with a urinary tract infection (UTI) was allegedly left semi-naked and delirious in his hospital bed – before choking on vomit after being sedated without his family’s permission, his daughter told The Independent. Another patient, 99, was traumatised after being left in a bed next to the body of a dead woman. The investigation was sparked by the horrific story of 73 year old Martin Wild who was left so desperate for pain medication he was forced to call 999 from his hospital bed. It comes as analysis by the Independent shows the government was warned three times last year by coroners over the increasing risk to elderly patients’ lives amid fears they are not being “effectively safeguarded”. Read full story Source: The Independent, 11 March 2024
  4. News Article
    England’s NHS Ombudsman has warned that cancer patients could be put at risk because of over-stretched and exhausted health staff working in a system at breaking point and delays in diagnosis and treatment. The Parliamentary and Health Service Ombudsman (PHSO) revealed that between April 2020 and December 2023, his Office carried out 1,019 investigations related to cancer. Of those 185 were upheld or partly upheld. Issues with diagnosis and treatment were the most common cancer-related issues investigated by PHSO. These issues included treatment delays, misdiagnosis, failure to identify cancer, the mismanagement of conditions, and pain management. Complaints about cancer care also included concerns about poor communication, complaint handling, referrals, and end-of-life care. Most investigations were about lung cancer, followed by breast cancer and colorectal cancer. The Ombudsman recently closed an investigation around the death of Sandra Eastwood whose cancer was not diagnosed for almost a year after scans were not read correctly. The delay meant she missed out on the chance of treatment which has a 95% survival rate. In 2021, PHSO published a report about recurrent failings in the way X-rays and scans are reported on and followed up across the NHS service. Mr Behrens said, “What happened to Mrs Eastwood was unacceptable and her family’s grief will no doubt have been compounded by knowing that mistakes were made in her care. “Her case also shows, in the most tragic of ways, that while some progress has been made on my recommendations to improve imaging services, it is not enough and more must be done. “Government must act now to prioritise this issue and protect more patients from harm.” Read full story Source: Parliamentary Health and Health Service Ombudsman, 9 March 2024
  5. News Article
    The lives of thousands of blind and partially sighted people are being put at risk by delays in vital care that they have a legal right to after being assessed as visually impaired, according to a report. More than a quarter of English councils are leaving people who have just been diagnosed as blind waiting more than a year for vision rehabilitation assessments and potentially life-saving support, the report by the RNIB revealed. It cited the example of one person who died while waiting for council help. The Guardian can reveal that the case involved a woman from Church Stretton in Shropshire who had been waiting 18 months for an assessment when she tripped on a pothole and died later from head injuries. She had been trying to teach herself how to use a white cane, without any support or training, despite getting a certificate of visual impairment. Councils are obliged to provide such help for those coping with a recent visual impairment under the 2014 Care Act. The support involves helping people cope practically and mentally with visual impairment at a critical time after a diagnosis. The social care ombudsman recommends that councils should provide these services within 28 days of someone receiving a certificate of visual impairment. But the RNIB report, which is based on freedom of information requests to councils in England, found that 86% were missing this 28-day deadline. The report, Out of sight – The hidden scandal of vision rehabilitation warned that the delays uncovered in the figures were dangerous. Read full story Source: The Guardian, 10 March 2024
  6. Content Article
    Thousands of people with sight loss remain 'Out of Sight' in the hidden scandal of vision rehabilitation. Life changes after sight loss, sometimes overnight, often in dramatic ways. Done well, vision rehabilitation equips people with new ways to stay independent: to get out and about, adapt their work, shop and enjoy hobbies. However, the reality is stark. 86% of local authorities in England miss the 28-day recommended deadline to explore a person’s needs. Threadbare services mean people wait without the support they’re entitled to, at risk of physical accidents and injuries as well as mental health crises. The RNIB are calling on all UK political parties to commit to ensuring blind and partially sighted people get the support they need, when they need it.
  7. News Article
    A fertility clinic in London has had its licence to operate suspended because of “significant concerns” about the unit, the regulator has said. The Homerton Fertility Centre has been ordered by the Human Fertilisation and Embryology Authority (HFEA) to halt any new procedures while investigations continue. The clinic in east London said there had been three separate incidents highlighting errors in some freezing processes. This resulted in the “tragic loss of a small number of embryos” that either did not survive or became “undetectable”, which means an embryo stored in frozen liquid solution in a container cannot be found during subsequent thawing. The clinic has informed the patients affected and apologised for any distress caused. Homerton Healthcare NHS foundation trust said it began an investigation in late 2023 and immediately made regulators fully aware of it. The HFEA is now conducting its own investigation alongside the trust. In a statement, the clinic said that while the investigators had not been able to find any direct cause of the errors, it had made changes in the unit to prevent the recurrence of such incidents. All staff now work in pairs to ensure all clinical activities are checked by two healthcare professionals, competencies of staff within the unit have been rechecked, and security at the unit has been increased. Read full story Source: The Guardian, 8 March 2024
  8. News Article
    Patients are being exposed to radiation doses at the “upper limit of safe” because a hospital is relying on a radiology machine three years after its “end of life” with a substandard second-hand part. The risk was revealed in board papers from Medway Foundation Trust, in Kent, among several other serious problems linked to outdated equipment. Recent board papers said the machine was necessary for maintaining the trust’s interventional radiology service which includes being on-call 24/7. It said: “Owing to the age of the machine we are experiencing a growing number of faults and breakdowns and due to its age no new parts are available. “At present a second hand tube has been installed to replace the existing faulty equipment.” But the papers went on to say the second-hand part has a defect “causing serious issues with the imaging [which] has the potential to increase imaging acquisitions required which will increase patient radiation dose and lengthen the procedure time”. A business case for a new machine described current radiation doses as “within the upper limit of safe”. The trust indicated “mitigations” are in place, including additional reviews of patients who use it. Read full story (paywalled) Source: HSJ, 11 March 2024
  9. Content Article
    This case study shares learning from the approach to retention at University Hospitals Birmingham. In particular it highlights how the trust adopted a new approach to organisational culture and staff engagement which has had a positive impact on staff retention. Effective use of data is a key element and has played a key role in making progress. The trust still faces challenges but has improved retention and is moving in right direction.
  10. Content Article
    This report examined whether the NHS has been successful in improving the patient safety culture, encouraging reporting and learning from patient safety incidents. 
  11. Content Article
    Enthusiasm has grown about using patients’ narratives—stories about care experiences in patients’ own words—to advance organisations’ learning about the care that they deliver and how to improve it, but studies confirming association have not been published. This study assessed whether primary care clinics that frequently share patients’ narratives with their staff have higher patient experience survey scores. It found that sharing narratives with staff frequently is associated with better patient experience survey scores, conditional on confidence in knowledge. Frequently sharing useful patient narratives should be encouraged as an organizational improvement strategy. However, organisations need to address how narrative feedback interacts with their staff’s confidence to realize higher experience scores across domains.
  12. Content Article
    Adverse safety events (ASE) are common in paediatric out-of-hospital cardiac arrests (OHCA). This retrospective chart review study sought to estimate the prevalence of adverse safety events in children under age 18 experiencing OHCA. The researchers found that 60% of those children experienced at least one severe ASE, with the highest odds of ASE occurring when the OHCA was birth-related.
  13. Event
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    Join Hill Dickinson for the third meeting of their national patient safety network in their series on the Patient Safety Incident Response Framework (PSIRF). They will be joined by guest speakers from Mid Cheshire Hospitals NHS Foundation Trust, Lancashire and South Cumbria NHS Foundation Trust, and HCA Healthcare to share their experiences and provide valuable insight following the implementation of PSIRF in their organisations. This will include practical feedback on what has worked well, and what in practice has needed tweaking. This will be followed by an opportunity to ask questions to our esteemed panel including NHS England, Hill Dickinson and our guest speakers, giving you valuable insight from acute, mental health and independent provider perspectives. Guest speakers: Dr Caroline Worthington, Lancashire and South Cumbria NHS FT Karen Luscombe, Associate Medical Director for Patient Safety at Mid Cheshire Hospitals NHS Foundation Trust Judi Ingham, Divisional Vice President of Quality at HCA Healthcare Tracey Herlihey, Head of Patient Safety Incident Response Policy at NHS England Register
  14. Event
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    Antipsychotic medication management and monitoring can be challenging. Join us to learn how handheld ECG devices support vulnerable patients and improve the physician and patient experience through: Comfortable, accurate, and fast ECG readings with the first personal ECG device to be recommended by the National Institute for Health and Care Excellence (NICE) More accessible and available measurements for detecting cardiac abnormalities in psychiatric services, such as a prolonged QT interval Reducing stress and anxiety among psychiatric patients with tests in familiar surroundings Key learnings: Local NHS experience: How the pandemic ushered innovation into clinical practice. How NICE recommended technology can implement new pathways and break down barriers. Register
  15. News Article
    Patients in parts of England are facing an uphill struggle to see a GP, experts say, after an analysis showed wide regional variation in doctor numbers. The Nuffield Trust think tank found Kent and Medway had the fewest GPs per person, followed by Bedfordshire, Luton and Milton Keynes. It comes as ministers have struggled to hit the pledge to boost the GP workforce by 6,000 this Parliament. But the government said it had plans in place to tackle shortages. However, Dr Billy Palmer, of the Nuffield Trust, said: "Solely boosting the number of staff nationally in the NHS is not enough alone - the next government should set a clear aim of reducing the uneven distribution of key staffing groups and shortfalls to tackle unfairness in access for patients." The think-tank report found while the government had met its target to increase the number of nurses by 50,000 this Parliament, the rises had not been felt evenly, with some specialist nurse posts, such as health visitors and learning-disability nurses, seeing numbers shrink. Dr Palmer said minimum numbers of GPs may have to be set for local areas - and better incentives to attract them to those with the fewest. Read full story Source: BBC News, 8 March 2024
  16. News Article
    More than 58,000 NHS staff reported sexual assaults and harassment from patients, their relatives and other members of the public in 2023 in the health service’s annual survey. For the first time ever, the NHS staff survey for England asked workers if they had been the target of unwanted sexual behaviour, which includes inappropriate or offensive sexualised comments, touching and assault. Of the 675,140 NHS staff who responded, more than 84,000 reported sexual assaults and harassment by the public and other staff last year. About 1 in 12 (58,534) said they had experienced at least one incident of unwanted sexual behaviour from patients, patients’ relatives and other members of the public in 2023. Almost 26,000 staff (3.8%) also reported unwanted sexual behaviour from colleagues. Rates were highest among ambulance workers, with more than 27% reporting sexual harassment from the public and just over 9% from colleagues. The survey also found record numbers of health workers experienced discrimination, including racism, sexism, homophobia and ableism, from patients and colleagues last year. Read full story Source: The Guardian, 7 March 2024
  17. News Article
    Coroners in England and Wales sent 109 warnings to health bodies and the government in 2023 highlighting long NHS waits, staff shortages or a lack of NHS resources, the BBC has found. The number of cases identified that were linked to NHS pressures was the highest in the past six years. Prevention of future death reports (PFDs) are sent when a coroner thinks action is needed to protect lives. About 35,000 inquests take place in England and Wales each year. In a fraction of those - about 450 - the coroner writes a PFD, or Regulation 28, report. The BBC analysed 2,600 PFDs - and supporting documentation - sent between 2018 and 2023. The proportion of the total number of PFD reports that referenced an NHS resource issue rose to one in five in 2023, from one in nine in the two years before Covid. Of the 540 reports written last year, 109 were found that highlighted a long wait for NHS treatment, a shortage of medical staff or a lack of NHS resources such as beds or scanners. Of these, 26 involved mental illness or suicide, and 31 involved ambulances and emergency services. The government says it "responds to, and learns from, every report". Read full story Source: BBC News, 8 March 2024
  18. Content Article
    About 1 in 5 people who have had chickenpox develop shingles, predominantly those who are over 70. However, uptake rates of the shingles vaccine are falling in London and across England. The purpose of this toolkit is to help GPs better protect their patients by suggesting ways to improve uptake of the shingles vaccine. These suggestions are based on best practice and evidence and have been shown to work with little or no cost to practices.
  19. Community Post
    From the Campaign Against Painful Hysteroscopy Facebook Group: "According to NHS England's 'Getting It Right First Time' plan hysteroscopies will be done in Women's Health Hubs independent from hospitals. So what will that mean for women who'd prefer not to be awake during hysteroscopy? We need to ask NHS England."
  20. Event
  21. News Article
    Physician associates should never see ‘undifferentiated’ patients in a GP setting, the BMA has declared in new ‘first of its kind’ guidance. Today, the union has published a national scope of practice laying out how physician associates (PAs) and anaesthesia associates (AA) should work safely in GP practices and secondary care. According to the BMA, the guidance is different from what it describes as the current ‘piecemeal or fragmented approach’ whereby individual organisations set their own guidelines for how PAs should be supervised. In general practice, the guidance said a GP ‘should first triage’ all patients and ‘decide which ones a PA can see’, suggesting annual health checks as an appropriate contact. The union is also clear that PAs ‘must not make independent management decisions for patients’ and must be clear in all their communications that ‘they are not doctors’. Read full story Source: Pulse, 7 March 2024
  22. Content Article
    Landmark national guidance outlining how MAPs (medical associate professionals) can work safely and effectively in the NHS, has been published by the British Medical Association (BMA). The association has unveiled its report Safe Scope of Practice, which sets out in highly detailed terms the responsibilities of MAPs including PAs (physician associates) and AA (anaesthesia associates). Described as a ‘first of its kind’ the report uses a traffic light-style system to illustrate what clinical duties MAPs should be able to carry out, as well as those responsibilities from which they should be prohibited.  The guidance also sets out six general principles for how MAPs should be deployed in primary and secondary-care settings. The guidance comes as the Government continues to press ahead with its plans to have PAs regulated by the GMC despite intense opposition to such a move from the BMA.
  23. News Article
    It is a high-stakes scenario for any surgeon: a 65-year-old male patient with a high BMI and a heart condition is undergoing emergency surgery for a perforated appendix. An internal bleed has been detected, an anaesthetics monitor is malfunctioning and various bleepers are sounding – before an urgent call comes in about an ectopic pregnancy on another ward. This kind of drama routinely plays out in operating theatres, but in this case trainee surgeon Mary Goble is being put through her paces by a team of researchers at Imperial College London who are studying what goes on inside the brains of surgeons as they perform life-or-death procedures. Goble looks cool and collected as she laparoscopically excises the silicon appendix, while fending off a barrage of distractions. But her brain activity, monitored through a cap covered in optical probes, may tell a different story. The researchers, led by Daniel Leff, a senior researcher and consultant breast surgeon at Imperial College healthcare NHS Trust, are working to detect telltale signs of cognitive overload based on brain activity. In future, they say, this could help flag warning signs during surgery. “The operating theatre can be a very chaotic environment and, as a surgeon, you have to keep your head and stay calm when everyone is losing theirs,” said Leff. “As the cognitive load increases, it has major implications for patient safety. There’s no tool we can use to know that surgeon is coping with the cognitive demands of that environment. What happens when the surgeon is maxed out?” In the future, Leff envisages a system that could read out brain activity in real-time in the operating theatre and trigger an intervention if a surgeon is at risk of overload. Read full story Source: 2 March 2024
  24. News Article
    It has been well-documented that Covid-19 took a devastating toll on emergency departments nationwide, revealing and exploiting the fragility of our acute-care system. Less has been written, however, about the side effects of hospitals’ attempts to recover from that era — one of the most serious of which is the proliferation of boarding. As hospitals scramble to regain their footing (and their profit margins), the financial incentive structure that undergirds US medicine has gone into overdrive. Inpatient beds that might previously have been reserved for patients who require essential care but generate very little money for the hospital, are increasingly allocated for patients undergoing more lucrative procedures. The consequences of this systemic failure cannot be overstated. Four hours is supposed to be the maximum time spent boarding in an emergency department, but recent data shows that hospitals in the US are failing to meet that goal when occupancy is high (which it routinely is). "On any given shift, hallways in the emergency department are lined with patients on stretchers. Boarding leads to a cascade of harms — including ambulances diverted to hospitals far from patients’ homes, patients charged for beds they haven’t yet occupied and overwhelmed emergency medicine personnel leaving the field because of burnout," says Hashem Zikry, an emergency medicine physician and a scholar in the National Clinician Scholars Program at UCLA. Many narratives around boarding focus on the patients themselves, shaming some for inappropriately using the emergency department. Proposed solutions include pushing patients to urgent-care centers or modifying “patient flow.” But the issues with boarding cannot be addressed with such minor tweaks. Read full story (paywalled) Source: The Washington Post, 28 February 2024
  25. Content Article
    The NHS Staff survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. Of the 1.4 million NHS employees in England, 707,604 staff responded to the survey in 2023.
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