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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
     Results of Age UK’s research into the experience of people aged 50 and over accessing health and social care services. This research into older people’s experiences of health and care services has revealed the extent of the challenges they face in accessing and receiving them. These challenges are confronted at a time in their lives when people are likely to be most reliant on such services to keep them well, independent, connected and safe. People from across the age spectrum, from 50 to over 100 years old, told Age UK about difficulties in accessing primary care services, including GPs and dentists. Health problems that could have been quickly and easily resolved have worsened through long waits for appointments and treatment. In some cases, older people have given up seeking treatment and care as they had lost hope of being able to see a clinician at all. For those of working age the problems in accessing appointments, referrals and treatment have had an impact on their ability to maintain good health, to remain in work and to care for others. Lack of access to support for carers has led to deteriorations in their physical and mental health.
  2. News Article
    Patient safety issues have increased since One Medical shifted care to a call centre staffed by contractors, employees say Since Amazon acquired the primary care service One Medical, elderly patients have been routed to a call centre — staffed partly by contractors with limited training — that failed on more than a dozen occasions to seek immediate attention for callers with urgent symptoms, according to internal documents seen by The Washington Post. When one patient reported a “blood clot, pain and swelling,” call centre staff scheduled an appointment rather than escalating the matter for medical evaluation, according to a note in an internal incident tracking spreadsheet dated 19 February. Over the following two days, clinical staffers flagged four more call-centre errors involving elderly patients with urgent complaints, including stomach pain and blood in stool, a spike in blood pressure, an insect bite and sudden rib pain, according to the internal spreadsheet. The call-centre incidents were among dozens flagged by doctors, nurses and assistants at One Medical Seniors between 19 February and 18 March in the documents, a year after Amazon acquired the primary-care service. Read full story (paywalled) Source: The Washington Post, 15 June 2024
  3. News Article
    Millions of people over the age of 50 in the UK have concerns about struggling to access healthcare, according to new analysis by Age UK. It comes as one elderly and disabled patient admitted he cannot afford to wait on hold to his GP practice for an appointment for long due to rising phone bill costs. A new report by Age UK – It’s a Struggle to be Seen – analysed the results of a representative poll, conducted for the charity by Kantar, of 2,621 UK adults over 50, as well as its own online survey which attracted more than 17,000 responses. The report claims less than half (48%) of people over 50 are confident their medical issue would be solved by NHS services. Some 49% – which Age UK equates to 12.6 million people – were concerned about their ability to access their GP, while 42% were worried about access to hospital appointments. The same proportion expressed concerns about access to emergency departments, the charity said. Caroline Abrahams, charity director at Age UK, said: “Sadly, for some older people, healthcare delayed means healthcare denied, because they do not have time on their side. “Our new analysis highlights just how many are being subjected to distress and, in some cases, enduring pain, because of their difficulties in accessing the GP services that they need.” Read full story Source: Medscape. 17 June 2024
  4. News Article
    Government has been warned by its own advisory group that maternity services are being “overwhelmed with reporting requirements” which are hindering safety improvement work, according to documents seen by HSJ. The Department of Health and Social Care (DHSC) set up the “independent working group” on neonatal and maternal care to oversee its response to Donna Ockenden’s spring 2022 inquiry report into Shropshire maternity services; and was then asked to do the same for key recommendations from Bill Kirkup’s report later that year on failings in East Kent. The group is led by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists and made up of representatives of maternity staff. It was asked particularly to look into advising on two Kirkup recommendations: first, on improving standards of professional behaviour and “embedding compassionate care”, including asking royal colleges and others how this can be done. Second, charging the royal colleges and others “with reporting on how teamworking in maternity and neonatal care can be improved, with particular reference to establishing common purpose, objectives, and training from the outset”. However, a recent report from the working group, to the DHSC, released under the Freedom of Information Act, suggests the staff groups are arguing there is little scope to introduce more change. Read full story (paywalled) Source: HSJ, 18 June 2024
  5. News Article
    A woman is battling a terminal cervical cancer diagnosis after an NHS trust misdiagnosed her test results as constipation several times. Sarah Roch, a 43-year-old mother of two from Plymouth, faced nine years of missed opportunities from 2010 by Derriford Hospital and only discovered she had cervical cancer after a voluntary hysterectomy in 2019. By the time she was diagnosed - which occurred by accident following her hysterectomy - Ms Roch was told she had late-stage cervical cancer. Ms Roch, who worked at the same hospital which misdiagnosed her, has had to give up her job to have chemotherapy three times a week. She is now calling for greater awareness of cervical cancer symptoms and has urged women to seek a second opinion if they feel something isn’t right. Read full story Source: The Independent, 17 June 2024
  6. News Article
    The number of children receiving treatment in private hospitals across the UK rose by almost a quarter last year to more than 46,000, according to new data seen by the BBC. In each case, families either paid for treatment or used medical insurance - rather than being referred by the NHS. The record figures from private healthcare providers come as England's NHS trusts tell File on 4 that children have become the “forgotten generation” in the race to reduce health service backlogs. The Department of Health says NHS staff are “working tirelessly” to cut waiting lists. But the Royal College of Surgeons of England told us children were lagging behind adults and spending years waiting for NHS surgery - with potentially life-long consequences for their health and development. The BBC has spoken to a number of families whose children’s conditions have deteriorated during long waits. They include 16-year-old Georgina Smith from Hertfordshire, who is waiting for open-heart surgery to repair a valve on her right side which doesn’t close properly. It can cause her blood to flow the wrong way, making it harder for her heart to work. Georgina is one of 601 children waiting for heart surgery in England - 139 have been waiting more than six months. She suffers chest pains, extreme fatigue and fainting episodes and has been forced to miss a lot of school. Georgina says she feels like her operation will never happen. “It’s like a cloud over my head, it’s always just this waiting and waiting and waiting,” she says. Read full story Source: BBC News, 18 June 2024
  7. Content Article
    Learning Disability Week is the third week of June every year. The event, organised by the charity Mencap, is an opportunity to raise awareness about different learning disabilities and challenge some of the barriers people who have learning disabilities face. According to Mencap, a learning disability is a person's reduced intellectual ability, meaning they can face difficulty with everyday activities. People with a learning disability can sometimes need extra support to learn new skills, understand complicated information or interact with other people. It can be particularly challenging for people with learning disabilities and their families when accessing healthcare services. To mark Learning Disability Week, we are sharing 11 resources, blogs and reports from the hub for patients, their families and healthcare professionals on breaking down these barriers.
  8. News Article
    Families affected by hormone pregnancy tests have been “recognised as having suffered an injustice” a leading campaigner has said as she was given an award in the King’s Birthday Honours. Marie Lyon, chairwoman of the Association For Children Damaged by Hormone Pregnancy Tests, has been campaigning for decades for justice for people affected by hormone pregnancy tests, including Primodos. The 77-year-old has been awarded the British Empire Medal (BEM) for “advocating for scientific research and improving patient safety for women”. She said she was accepting the award on behalf of members of the association and that the medal is “recognition of what has happened”. The tests were given to more than a million women from 1958 to 1978, but Ms Lyon said many were never told of the risks and were instructed to take the drug – which is 40 times the strength of an oral contraceptive pill – by their GPs as a way of finding out whether or not they were pregnant. Read full story Source: The Independent, 15 June 2024 Read our Patient Safety Spotlight interview with Marie Lyon
  9. News Article
    Nurses in the United States continue to voice concerns about artificial intelligence and its integration into electronic health records (EHR), saying the technology is ineffective and interferes with patient care. Nurses from health systems around the country spoke to National Nurses United, their largest labor union, about issues with such programmes as automated nurse handoffs, patient classification systems and sepsis alerts. Multiple nurses cited problems with EHR-based programs from Epic and Oracle Health that use algorithms to determine patient acuity and nurse staffing levels. "I don't ever trust Epic to be correct," Craig Cedotal, RN, a paediatric oncology nurse at Kaiser Permanente Oakland (Calif.) Medical Center, told the nurses' union. "It's never a reflection of what we need, but more a snapshot of what we've done." He said the technology does not account for the hours of preparing and double-checking the accuracy of chemotherapy treatments before a pediatric patient even arrives at the hospital. Read full story Source: Becker's Health IT, 14 June 2024
  10. News Article
    Almost half of adults in the UK have struggled to get medicine they have been prescribed – and more people blame Brexit than anything else for the situation, research shows. Forty-nine per cent of people said they had had trouble getting a prescription dispensed over the past two years, the period during which supply problems have increased sharply. Drug shortages are so serious that 1 in 12 Britons were unable to find the medication they needed, despite asking a number of pharmacies. The survey of 2,028 people representative of the population, undertaken by Opinium for the British Generic Manufacturers Association (BGMA), found that: One in 12 people (8%) have gone without a medication altogether because it was impossible to obtain. Thirty-one per cent found the drug they needed was out of stock at their pharmacy. Twenty-three per cent of pharmacies did not have enough of the medication available. “Shortages are deeply worrying for patients’ physical health, alongside the stress of not knowing if an essential medicine will be available,” said Mark Samuels, the chief executive of the BGMA. Read full story Source: The Guardian, 16 June 2024
  11. News Article
    A troubled NHS trust has apologised to the family of a man who died after a series of delays led to him waiting four times longer for an operation than a national cancer target. Before he died in November 2022, Ken Valder, 66, complained of “delays after delay” to his treatment for oesophageal cancer. University Hospitals Sussex – the focus of a separate police investigation into allegations of surgical negligence and cover-ups over dozens of deaths between 2015 and 2021 – admitted that errors, failures and disagreements between surgeons contributed to delays to Valder’s treatment. They also accepted that the case highlighted patient safety concerns that prompted the hospital regulator in 2022 to suspend upper gastrointestinal cancer services at the trust, which includes the Royal Sussex County hospital in Brighton. An independent review of the case also found that Valder’s care was “suboptimal” and that if he had received surgery earlier it “might have led to a better oncological outcome”. Read full story Source: The Guardian, 17 June 2024
  12. News Article
    London pathology providers are “running too hot” to give enough support the large system hit by a cyber attack last week, HSJ has been told. HSJ has learnt that all the capital’s pathology services have now been approached to help Guy’s and St Thomas’ and King’s College Hospital after the IT systems for their provider Synnovis went down, the pressure on the capital’s labs and technical issues limited what help could be given. But one senior manager told HSJ: “Many trusts are keen to help but their hands are tied. The difficulties are that so many medium-sized NHS labs are already running hot and have not got the capacity." HSJ was told there was significant clinical risk in primary care as well. Routine tests that might have picked up something important are not happening and one manager said: “Patients in primary care include those in nursing homes – blood tests and test for infections can be the only way to work out why a frail patient is deteriorating.” Read full story (paywalled) Source: HSJ, 17 June 2024
  13. News Article
    An ambulance chief has said his trust “exited” more than 170 staff due to culture and behavioural problems in the last three years. East of England Ambulance Trust chief executive officer Tom Abell gave the figure while speaking publicly about his team’s efforts to get a grip on the organisation’s long-standing cultural problems. Mr Abell, who is leaving the trust next month to lead Mid and South Essex Integrated Care Board, told a session at the NHS Confed Expo conference that the trust’s leadership knew suspending a large number of staff would create challenges in providing services. But he said it was the only way to ensure the right cultural standards were met and he did not want to “bottle” the decision to tackle this issue. Mr Abell, who became CEO in 2021, said: “The decision we had to make was do we suspend [the staff] and recognise the fact that’s potentially going to have a significant impact in terms of our ability to deliver services, or do we bottle it? “And [so] we suspended and dismissed [the staff in question]. Staff told me after that, ‘we never thought the organisation would ever do that’. “We’ve tried to be consistent. We’ve exited, probably over 170 people from the trust, since I started, for issues around culture and behaviour. It’s not just about being fluffy and engaging, it’s around actually taking practical symbolic action.” Read full story (paywalled) Source: HSJ, 17 June 2024
  14. Content Article
    These top tips and key actions have been co-developed to support effective collaborative partnership working in the planning and delivery of community mental health services. They recognise that every heath and care system will experience challenges in relation to partnership working given the statutory and cultural differences of organisations working across the mental health pathways and that there will be different arrangements to frame local partnership working, including for example a Section 75 agreement.
  15. News Article
    A scandal-hit hospital trust has come under fire yet again after advertising for a maternity doctor with "a desire to promote normal birth". Hampshire Hospitals NHS Foundation Trust said it was seeking an obstetrics and gynaecology consultant in its high risk baby unit who would support "active" labour. Yet safe birth campaigners have reacted with fury online, claiming 'normal' has become a codeword for 'natural' birth — a fixation which has led to many midwives frowning on medical intervention and caesareans, even when needed. This 'obsession', they add, has been linked to failures at a number of maternity units in recent years where hundreds of babies died, major inquiries have found. The trust was embroiled in a similar controversy last year after Winchester's Royal Hampshire County Hospital faced a claim of unfair dismissal by a former consultant obstetrician and gynaecologist. Martyn Pitman, who had worked at the hospital for 20 years, was sacked last March after raising concerns about midwifery care and patient safety at the hospital. In a post on X, Catherine Roy linked to the advert, adding: "Where Martyn Pitman used to work. The takeover by normal birth is now complete I think. What a scandal." In response, consultant paediatrician Dr Ravi Jayaram, whose evidence helped catch convicted serial baby-killer Lucy Letby at Countess of Chester Hospital, said: "Anyone who applies for this should be immediately excluded from consideration for the post." He added: "[It] should read 'desire to support and promote safe birth' — if it needed to be said at all." Read full story Source: The MailOnline, 13 June 2024
  16. Content Article
    Drug shortages are a chronic and worsening issue that compromises patient safety. Despite the destabilising impact of the Covid-19 pandemic on pharmaceutical production, it remains unclear whether issues affecting the drug supply chain were more likely to result in meaningful shortages during the pandemic. This study estimated the proportion of supply chain issue reports associated with drug shortages in the USA overall and with the Covid-19 pandemic. It found that supply chain issues associated with drug shortages increased at the beginning of the Covid-19 pandemic. Ongoing policy work is needed to protect US drug supplies from future shocks and to prioritize clinically valuable drugs at greatest shortage risk.
  17. Content Article
    Falls are reported by more than 14 million US adults aged 65 years or older annually and can result in substantial morbidity, mortality, and health care expenditures. This study reviewed interventions to reduce falls.
  18. Content Article
    Infections due to multidrug-resistant organisms (MDROs) are associated with increased morbidity, mortality, length of hospitalisation, and health care costs. Regional interventions may be advantageous in mitigating MDROs and associated infections. This study evaluated whether implementation of a decolonisation collaborative is associated with reduced regional MDRO prevalence, incident clinical cultures, infection-related hospitalisations, costs, and deaths. It found a regional collaborative involving universal decolonisation in long-term care facilities and targeted decolonisation among hospital patients in contact precautions was associated with lower MDRO carriage, infections, hospitalisations, costs, and deaths.
  19. Content Article
    The Global Strategy for Infection Prevention and Control (GSIPC) vision is that by 2030 everyone accessing and providing healthcare is safe from associated infections. The GPIPC outlines eight strategic directions, providing the guiding framework for country action plans. A Guide to Implementation is being developed to support countries in the development of their national action plans towards the 'vision of 2030'.
  20. News Article
    The NHS supply chain contains “absolutely massive” cybersecurity risks which have not “really been talked about”, an integrated care board and trust chair has warned. Lena Samuels, who is chair of two London trusts and of Hampshire and Isle of Wight Integrated Care Board, said: “We’ve been talking internally about our own organisations but we haven’t really talked about the supply chain and the risks within that – and that is absolutely massive.” Ms Samuels, speaking at the NHS Confed Expo conference yesterday, said many NHS organisations still needed to question: “How do our risk registers capture what our supply chain resilience looks like in terms of cyber protection?” She said NHS organisations also needed to be considering “who on my board is going to ask that question” and “whether they’re going to even think of asking that question”, adding: “There’s so much that we’ve got to think about.” Read full story (paywalled) Source: HSJ, 14 June 2024
  21. Content Article
    Managing medicines for someone can be a challenge, particularly if they're taking several different types. Although the person you care for may appreciate your support with their medicines, bear in mind that they have a right to confidentiality. It's up to them to decide how much of their health and medicines information is available to you as their carer, and how much you should be involved in their care. This NHS page gives tips on how to give pills correctly, dosette boxes and medicine reminders, asking for a structured medication review and medicine safety.
  22. News Article
    The owner of a group of privately-run children’s mental health hospitals is facing legal action by dozens of former patients, who claim they suffered inhuman and degrading treatement at the facilities. Hospitals formerly run by The Huntercombe Group face at least 54 individual clinical negligence claims, The Independent can reveal. Patients treated within several of the hospitals, now owned by Active Care Group, came forward to solicitors Hutchoen Law following several exposés by this publication, revealing allegations of “systemic abuse.” Documents submitted to Manchester Civil Court on Thursday before Judge Nigel Bird, who will decide if permission is be granted for claims to be brought, revealed allegations including: Assault and battery, relating to the inappropriate and unnecessary forced feedings and physical restraint. False imprisonment. Breaches of the Human Rights Act including prohibition of inhuman and degrading treatment. Read full story Source: The Independent, 13 June 2024
  23. News Article
    The mother of a 13-year-old girl who died of sepsis has said she hopes Martha’s rule, which gives patients and their families the right to a second medical opinion, will “upend” the “hierarchy” on hospital wards. Merope Mills, who campaigned with her husband, Paul Laity, to give families more say regarding care following the death of their daughter Martha, also called for a “mutual respect” between patients and doctors. More than 140 NHS sites in England have agreed to implement Martha’s rule, a patient safety initiative that will give patients and their families round-the-clock access to a rapid review by an independent critical care team from elsewhere in the hospital if they feel their health, or that of a family member, is deteriorating and they are not being listened to. Speaking at NHS ConfedExpo on Wednesday, Mills, an executive editor at the Guardian, said: “My big thing is, I think we need to be more equal. “It’s a very unequal place, a hospital ward, and there’s hierarchy and it’s very steep and it’s very strict. And, you know, when I first started talking about that, I sort of thought the nurses were at the bottom of the hierarchy. “And I refer to that because they didn’t feel that ability to speak up in Martha’s case. But I’ve actually come to realise that the people at the bottom of the hierarchy are the patients. “They are the ones with the least power and I just would like to upend that and just have a sense of mutual respect between doctor and patient.” Read full story Source: The Guardian, 14 June 2024
  24. News Article
    NHS England’s head of patient safety has suggested too much time and resource is being spent on “burdensome” inquiries to investigate failings in the system. Aidan Fowler said national chiefs want to see a shift away from “looking back 10 years and asking ‘what did we miss’”, and instead wants teams to be resolving problems in real time. At trusts where safety concerns have been highlighted, he said “people descend, and there are a lot of asks, and the pressure mounts, and they end up with an action list of hundreds of things, and it becomes very burdensome – we have to avoid that”. Speaking at a session at the NHS Confederation Expo event in Manchester this week, he encouraged organisations to report concerns early so NHSE can respond more quickly, supporting them and working through problems to prevent public inquiries from needing to happen in the first place. Mr Fowler added: “We have to get more proactive. We will spend less of our time in the future, is the plan, than we are now – doing what I call driving in the rear view mirror. “We don’t want to be looking back 10 years and asking, ‘what did we miss’, we want to be seeing things in real time… we don’t want to be spending our time in big inquiries into failings in the system.” Read full story (paywalled) Source: HSJ, 14 June 2024
  25. News Article
    Three staff have been put on “improvement plans” after a patient’s death which a coroner said nurses had been dishonest about, HSJ has learnt. North East London Foundation Trust was heavily criticised over the death of Winbourne Charles at an inquest last year. Coroner Graeme Irvine said staff “had not told the truth” about how Mr Charles came to take his own life in an inpatient unit at Goodmayes Hospital, in east London. Two witnesses refused to give evidence, citing a rule that they could not be compelled to incriminate themselves. Mr Irvine recorded a verdict of “suicide, contributed to by neglect, to which failures in medical intervention contributed and to which failures to respond to an obvious risk of self-harm contributed”. His prevention of future deaths report also noted “observation records appeared to have been created utilising a ‘cut and paste’ function” while there were “factually inaccurate entries” stating Mr Charles “was alive and well” up to two days after his death. In comments reported by the Barking and Dagenham Post last year, Mr Irvine said: “I think witnesses who have given evidence to me in this inquest have not told the truth. “It seems to me that this remarked upon a culture of impunity and that, unless someone sees there are consequences to their actions, nothing is going to change.” Read full story (paywalled) Source: HSJ, 14 June 2024
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