Jump to content
 View Profile  See their activity

  • Posts

    11,906

  • Joined

  • Last visited

Patient Safety Learning

Administrators

 Content Type 

News posted by Patient Safety Learning

  1. Patient Safety Learning
    Thousands of people in England who get migraines could benefit from a drug that has been approved on the NHS.
    The National Institute for Health and Care Excellence (Nice), the drugs regulator, said it was recommending rimegepant for preventing migraines in the approximately 145,000 adults where at least three previous preventive treatments had failed.
    The drug, also called Vydura and made by Pfizer, is taken as a wafer which dissolves under the tongue. It is the first time Nice has recommended an oral treatment for preventing migraines.
    “Each year the lives of millions of people in England are blighted by migraine attacks,” said Helen Knight, the director of medicines evaluation at Nice. “They can be extremely debilitating and can significantly affect a person’s quality of life.
    “Rimegepant is the first oral treatment for migraine to be recommended by Nice and for many thousands of people it is likely to be a welcome and more convenient addition to existing options for a condition that is often overlooked and undertreated.”
    Read full story
    Source: The Guardian, 31 March 2023
  2. Patient Safety Learning
    The US Food and Drug Administration has proposed to add to what you get with your prescription drugs.
    The proposed rule would require the prescriptions you get to come with a new kind of single-page medication guide with an easy-to-use set of directions and easy-to-understand safety information, a goal the FDA has been working toward for years.
    One study found that nearly 75% of Americans have had trouble taking their medicine as directed. A lot of that is due to cost – people might not be able to afford their medicine, so they don’t take it – but some is due to confusion. They might get more than one kind of written information with their prescription, or the information they receive can be conflicting, incomplete or repetitive, the FDA said.
    When people are confused or misinformed about their prescription, there is a good chance they will not take it or will stop taking it, and that can directly hurt their health.
    “Research suggests that medication nonadherence can contribute to nearly 25% of hospital admissions, 50% of treatment failures, and approximately 125,000 deaths in our country each year,” the FDA says.
    The agency said the new proposal is also meant to help fight the “nation’s crisis with health care misinformation and disinformation.”
    Read full story
    Source: CNN, 30 May 2023
  3. Patient Safety Learning
    Multiple trusts have expressed disappointment at being overlooked in the government’s latest announcement on the ‘40 new hospitals’ programme.
    In 2021, ministers expanded the new hospitals programme by inviting bids for another eight projects to be funded nationally. However, last week they confirmed that just five new bids – all acute hospitals with unsafe roof plank structures – had been accepted.
    Multiple mental health trusts have also expressed frustration, after just one new mental health scheme has been included in the list of 40 “new” hospitals, although the government is counting three which were already in progress outside the programme.
    Joe Rafferty, chief executive of Mersey Care, has compared a lack of investment into mental health estate to “institutionalised discrimination”. Bradford District Care said it was “very disappointing” to find out its bid to replace “wholly unsuitable” wards designed in the 1950s had not been accepted, adding: “Still no parity for mental health in the total NHP funding allocation so far.”
    Read full story (paywalled)
    Source: HSJ, 31 May 2023
  4. Patient Safety Learning
    The decision last week by the Metropolitan police commissioner, Sir Mark Rowley, that in future his officers will attend emergency calls related to mental health only where a threat to life is feared, was both a wake-up call and a threat. His letter, and deadline of 31 August, have raised the stakes in negotiations with health bosses. The danger is that his combative approach will undermine attempts to find a solution to a problem that no one denies.
    In Humberside, a scheme called Right Care, Right Person resulted in 1,100 police officer hours a month being clawed back as health practitioners took over tasks that were previously done by them. The scheme attracted plaudits from the police inspectorate. This is the example that Sir Mark aims to follow as part of his plan to put his discredited force back on its feet.
    This is a sound idea. Humberside police has been judged the best force in the country, and successful innovations in public service should be copied. But the Met is a special case. At almost 20 times the size of Humberside’s service, with 43,000 officers, it is a huge organisation with responsibility for policing a growing city of almost 9 million people. Its relationships with local health and care services are far more complicated than in a smaller area. In London, there are five integrated care systems (partnership organisations that plan and deliver care). Given how overstretched these services already are, it is alarming to learn of the capital’s police chief announcing a unilateral withdrawal.
    Read full story
    Source: The Guardian, 29 May 2023
  5. Patient Safety Learning
    People concerned about the safety of patients often compare health care to aviation. Why, they ask, can’t hospitals learn from medical errors the way airlines learn from plane crashes?
    That’s the rationale behind calls to create a 'National Patient Safety Board,' an independent federal agency that would be loosely modelled after the US National Transportation Safety Board (NTSB), which is credited with increasing the safety of skies, railways, and highways by investigating why accidents occur and recommending steps to avoid future mishaps.
    But as worker shortages strain the US healthcare system, heightening concerns about unsafe care, one proposal to create such a board has some patient safety advocates fearing that it wouldn’t provide the transparency and accountability they believe is necessary to drive improvement. One major reason: the power of the hospital industry.
    The board would need permission from health care organisations to probe safety events and could not identify any healthcare provider or setting in its reports. That differs from the NTSB, which can subpoena both witnesses and evidence, and publish detailed accident reports that list locations and companies.
    A related measure under review by a presidential advisory council would create such a board by executive order. Its details have not been made public.
    Learning about safety concerns at specific facilities remains difficult. While transportation crashes are public spectacles that make news, creating demand for public accountability, medical errors often remain confidential, sometimes even ordered into silence by court settlements. Meaningful and timely information for consumers can be challenging to find. However, patient advocates said, unsafe providers should not be shielded from reputational consequences.
    Read full story
    Source: CNN, 30 May 2023
    Related reading on the hub:
    Blog - It is time for a National Patient Safety Board: Pittsburgh Regional Health Initiative  
  6. Patient Safety Learning
    Pioneering new technology could help patients with non-healing wounds avoid infections and the need for antibiotics, scientists say.
    Wirelessly powered, environmentally friendly “smart bandages” have been developed by a team of scientists from the UK and France, with the University of Glasgow and the University of Southampton leading the research.
    The bandage could help improve the quality of life for people with chronic non-healing wounds as a result of conditions such as cancer, diabetes or damaged blood vessels, they said.
    Currently, wounds require painful cleaning and treatment.
    Researchers believe the technology could help to slow the rise of dangerous new strains of antibiotic resistant bacteria known as superbugs.
    Read full story
    Source: The Independent, 30 May 2023
  7. Patient Safety Learning
    An NHS maternity department has been handed a warning notice by the health regulator because of safety failings.
    The Care Quality Commission (CQC) said it was taking the action over the James Paget Hospital in Norfolk to prevent patients coming to harm.
    Inspectors found the unit did not have enough staff to care for women and babies and keep them safe.
    The maternity department has been deemed "inadequate" by the CQC, which meant the overall rating for the hospital has now dropped from "good" to "requires improvement".
    Between June and November 2022 there were 30 maternity "red flags" that the inspectors found, of which more than half related to delays or cancellations to time-critical activity.
    In one instance, there was a delay in recognising a serious health problem and taking the appropriate action.
    The report also highlighted the service did not have enough maternity staff with the right qualifications, skills, training and experience "to keep women safe from avoidable harm and to provide the right care and treatment".
    Read full story
    Source: BBC News, 31 May 2023
  8. Patient Safety Learning
    Complaints to the national medical practitioner regulator arising from telehealth appointments have increased by 413% in three years, a significant number of these relating to prescriptions.
    The data provided to Guardian Australia by the Medical Board of Australia comes as the body prepares to release new guidelines for health practitioners and companies that provide telehealth consultations with patients.
    Guardian Australia understands the guidelines, to be made public by Friday, will state that real-time video or phone consults are “preferred” over real-time text-based consults such as online chat because identification is harder to establish without video.
    The guidelines will not ban real-time text-based consults but they will mean online quizzes, for example, can not be used to diagnose and prescribe medications to patients.
    “Prescribing or providing healthcare for a patient with whom you have never consulted, whether face-to-face, via video or telephone is not good practice and is not supported by the board,” the draft guidelines state.
    “This includes requests for medication communicated by text, email or online that do not take place in real-time and are based on the patient completing a health questionnaire but where the practitioner has never spoken with the patient.”
    Read full story
    Source: The Guardian, 20 May 2023
     
  9. Patient Safety Learning
    Waiting times for gynaecology services in Northern Ireland are so bad that an independent and rapid review is taking place, BBC News NI has learned.
    It is being conducted by the Getting it Right First Time (GIRFT) programme which helps improve the quality of care within the NHS.
    A GIRFT team spent a week this month visiting all five health and social care trusts.
    In October 2022, 36,900 women in NI were on a gynaecology waiting list. A report from the Royal College of Obstetricians and Gynaecologists said that figure was a 42% increase since the start of the Covid-19 pandemic and that Northern Ireland had the longest gynaecological waiting lists in the UK.
    While waiting lists show that some women are waiting about 110 weeks to see a consultant gynaecologist for the first time, consultants have told BBC News NI that the reality is women depending on their medical issue are waiting much longer.
    Read full story
    Source: 31 May 2023
  10. Patient Safety Learning
    Northern Ireland GPs are being hit with bills of thousands of pounds as they are sued by patients coming to harm on hospital waiting lists.
    Family doctors are being taken to court by their patients as a result of spiralling hospital waiting lists — even though GPs are not responsible for the crisis.
    It comes as official figures show 14% of the population — around one in seven — had been waiting longer than a year for an outpatient or inpatient appointment at the end of March.
    The growing risk to patient safety, as the health service struggles to cope with demand, and the potential for primary care doctors to be held accountable have been blamed as reasons for the rising number of GPs who are handing back their contracts.
    Sixteen GP surgeries in Northern Ireland have handed back contracts in recent months, bringing the key NHS service closer to collapse.
    Read full story
    Source: Belfast Telegraph, 30 May 2023
  11. Patient Safety Learning
    NHS England has expanded its drive to increase overseas recruitment, introducing funding for trusts to hire more types of health professionals from abroad.
    Employers are now able to use national NHS England funding to recruit physiotherapists, therapeutic radiographers and operating department practitioners from overseas.
    Until now, within allied health professionals, the scheme has only covered diagnostic radiographers, occupational therapists and podiatrists. None of the professions are on the government’s shortage occupation list.
    NHSE said it decided to expand the AHP scheme to more staff groups where it had decided there were NHS shortages, and others where it had identified there was global availability of staff. For example, it said other groups such as prosthetics professionals still could not be recruited from abroad as there is limited international supply. 
    Read full story (paywalled)
    Source: HSJ, 30 May 2023
     
  12. Patient Safety Learning
    The depth of suffering in care homes in England as Covid hit has been laid bare in a court case exposing “degrading” treatment with residents being “catastrophically let down”.
    Care levels at the Temple Court care home in Kettering collapsed so badly in April 2020, when ministers rushed to free up NHS capacity by discharging thousands of people, that residents were left lying in their own faeces, dehydrated, malnourished and suffering necrotic, infected wounds, the Care Quality Commission found. Fifteen of its residents died with Covid in the first weeks of the pandemic.
    The case foreshadows the UK Covid-19 public inquiry module on the care sector, which next year will test Matt Hancock’s claim to have thrown “a protective ring around social care”.
    The prosecution resulted in a £120,000 fine handed down at Northampton magistrates court last week. The operator, Amicura, apologised but said it had been “acting in the national interest and supporting the NHS by accepting patients discharged from hospitals into care homes under government policy”.
    Read full story
    Source: The Guardian, 29 May 2023
  13. Patient Safety Learning
    NHS leaders have raised concerns about the delay to the long-awaited workforce plan, after the health secretary, Steve Barclay, refused to give a deadline for its publication and with rumours suggesting it is considered too costly.

    The plan, which was expected to be published on Tuesday, appears to have been delayed, according to the deputy chief executive of NHS Providers, Saffron Cordery.
    Barclay blamed the pandemic and “various things that have been happening in recent years” for the delay during broadcast interviews over the weekend. He had previously promised that the plan to increase the number of doctors and nurses would be published before the next general election.

    Cordery said the plan, which aims to fix the UK’s crumbling healthcare system by plugging chronic staff shortages but which has already been postponed from last year, was needed “as quickly as possible”.
    Until this weekend NHS Providers – which represents all England’s hospital, ambulance, community and mental health trusts – had believed publication of the plan was “imminent”. Cordery suggested that the failure to release it could be linked to the need for funding.
    Read full story
    Source: The Guardian, 29 May 2023
  14. Patient Safety Learning
    After health inspectors considered closing a maternity unit over safety fears, the BBC's Michael Buchanan looks at a near-decade of poor care at East Kent Hospitals NHS Trust.
    "I've been telling you for months. The place is getting worse."
    The message in February, which Michael received from a member of the maternity team, was stark but unsurprising. In a series of texts over the previous few months, the person had been getting increasingly concerned about what was happening at the East Kent trust.
    The leadership is "totally ineffective" read one message. "How long do we have to keep hearing this narrative - we accept bad things happened, we have learned and are putting it right. Nothing changes."
    Friday's report from the Care Quality Commission (CQC) is unfortunately just the latest marker in a near-decade of failure to improve maternity care at the trust. The revelation that inspectors considered closing the unit at the William Harvey Hospital in Ashford comes nine years after the trust's head of midwifery made a similar recommendation for the same reasons - that it was a danger to women and babies. The failure to act decisively then allowed many poor practices to continue.
    Read full story
    Source: BBC News, 28 May 2023
  15. Patient Safety Learning
    The Met Police's plan to stop attending emergency mental health incidents is "potentially alarming", a former inspector of constabulary has said.
    From September, officers will only attend mental health 999 calls where there is an "immediate threat to life".
    The Met argues the move will free up officers after a significant rise in the number of mental health incidents being dealt with by the force in the past five years.
    Metropolitan Police Commissioner Sir Mark Rowley wrote to health and social care services in Greater London to inform them of the plan last week.
    In the letter, which has been seen by the BBC, Sir Mark said it takes almost 23 hours on average from the point at which someone is detained under the Mental Health Act until they are handed into medical care.
    He writes that his officers are spending more than 10,000 hours a month on "what is principally a health matter", adding that police and other social services are "collectively failing patients" by not ensuring they receive appropriate help, as well as failing Londoners more generally because of the effect on police resources.
    However Zoe Billingham, who is now chair of the Norfolk and Suffolk NHS mental health trust after 12 years as Her Majesty's Inspector of Constabulary and Fire and Rescue, warned mental health services are "creaking" and "in some places are so subdued with demand they are not able to meet the requirements of people who need it most".
    Speaking to BBC Radio 4's Today programme, she warned there is "simply no other agency to call" other than the police for people in crisis, adding: "There isn't another agency to step in and fill the vacuum."
    Read full story
    Source: BBC News, 29 May 2023
  16. Patient Safety Learning
    Lord O’Shaughnessy has carried out a widespread review of clinical trials in Britain and found it is falling behind in medical research.
    He has suggested a raft of reforms, which include financial incentives for GPs who carry out community drugs and treatments trials on their patients at local surgeries or in their own homes.
    Patients who receive genomic testing on the NHS should also be automatically asked to consent to their genetic data being used for research, the report recommends.
    The Medicines and Healthcare products Regulatory Agency (MHRA) has been told to cut red tape and speed up approvals for medicines. It has also been asked to approve clinical trials within 60 days of submission.
    Writing in The Telegraph, Will Quince, Minister of State for Health and Secondary Care, said: “Cutting the time it takes for new medicines to reach patients is vital and has a direct impact on how patients recover faster or better manage conditions.
    “We want to make it easier for more people to be a part of life-changing research and giving the option to take part in trials virtually will improve the scope of who wants to, or can take part.
    “From cancer to obesity, these research studies can lead to billions of pounds in savings for the NHS and cut waiting lists through faster diagnosis and enhanced treatment.”
    Read full story (paywalled_
    Source: The Telegraph, 26 May 2023
  17. Patient Safety Learning
    A 14-year-old girl who should have been under constant supervision at a mental health hospital died after a member of staff on his first shift left her unattended, an inquest has heard.
    Ruth Szymankiewicz died at Taplow Manor Hospital in Maidenhead on 12 February 2022 after a care worker responsible for her one-to-one supervision “sporadically” left his post, the hearing was told.
    It also emerged at the hearing that the care worker, who is now abroad, was allegedly using a fake name. Detectives are investigating him as part of a fraud investigation although he has not yet been interviewed by police.
    After Ruth’s death, the Care Quality Commission launched a criminal investigation. In an update to the coroner, it said that the investigation was looking at whether the provider had “brought about avoidable harm or exposure to risk” in relation to the young girl’s death.
    Read full story
    Source: The Independent, 26 May 2023
  18. Patient Safety Learning
    A review into how a reporting error came about has uncovered tension among an ambulance trust’s previous senior leaders, including that its new CEO felt it was ‘the least cohesive team I have ever joined’.
    Management consultancy Verita was commissioned by London Ambulance Service Trust to carry out a review of how it came to be misreporting category 1 (the most serious) response times.
    The report, published in board papers on Thursday, said it was caused by a contractor’s programming error going unnoticed and concluded it was “impossible to typify the events of August 2020 as other than an avoidable failure of governance and process”. 
    Daniel Elkeles, who joined the trust as CEO in August 2021, told the review that when he joined the senior team it was “the least cohesive team I have ever joined” and said the organisation was not “psychologically safe” for those who wanted to speak up.
    Read full story (paywalled)
    Source: HSJ, 26 May 2023
  19. Patient Safety Learning
    Health inspectors considered shutting down a maternity unit earlier this year over safety concerns.
    The Care Quality Commission (CQC) instead called for "immediate improvements" following a visit to the William Harvey hospital in Ashford, Kent.
    Helen Gittos, whose newborn daughter died in the care of the East Kent Hospitals Trust, said there were "fundamental" problems at the trust.
    The inspection of East Kent's William Harvey hospital laid bare multiple instances of inadequate practices at the unit, including staff failing to wash their hands after each patient, and life-saving equipment not being in the right place.
    Days after the visit, the watchdog raised safety concerns and threatened the trust with enforcement action to ensure patients are protected.
    Ms Gittos, whose baby Harriet was born at the East Kent trust's Queen Elizabeth the Queen Mother Hospital (QEQM) in 2014 and died eight days later, said: "When my daughter Harriet was born, the then head of midwifery was so concerned about safety that she thought that the William Harvey in particular should be closed down."
    She told BBC Radio 4's Today programme: "Here we are, almost nine years later, in a similar kind of situation. What has been happening has not worked.
    "I keep being surprised at how possible it is to keep being shocked about all of this, but I am shocked, that under so much scrutiny, and with so much external help, it's still the case that so much is not right.
    "The problems that are revealed are so fundamental that we have to do things differently."
    Read full story
    Source: BBC News, 26 May 2023
  20. Patient Safety Learning
    A brand-new genetic research resource, known as a ‘biobank’, will be piloted by the Medicines and Healthcare products Regulatory Agency (MHRA) in a joint venture with Genomics England to better understand how a patient’s genetic makeup can impact the safety of their medicines.
    The Yellow Card biobank, which will contain genetic data and patient samples, will operate alongside the MHRA’s Yellow Card reporting site for suspected side effects and adverse incidents involving medicines and medical devices. It forms part of a long-term vision for more personalised medicine approaches, as scientists will use the repository of genetic information in the biobank to determine whether a side effect from a medicine was caused by a specific genetic trait. This will in turn enable doctors to target prescriptions using rapid screening tests, so patients across the UK will receive the safest medication for them, based on their genetic makeup.
    Adverse Drug Reactions (ADRs), or side effects, continue to be a significant burden on the NHS and account for one in 16 hospital admissions. Understanding the underlying mechanism of an adverse reaction would support the development of pharmacogenetic testing strategies, such as the screening tests enabled through the information provided by the Yellow Card biobank. These strategies would in turn provide the opportunity to prevent rather than react to adverse drug reactions.
    The biobank pilot will officially begin on 1 June 2023 with participant recruitment commencing later this year, on 1 September.
    Read full story
    Source: MHRA, 25 May 2023
     
  21. Patient Safety Learning
    The number of people paying privately for operations and treatments in the UK has risen by more than a third since the pandemic started, the latest figures from the Private Healthcare Information Network (PHIN) show.
    Last year 272,000 used their own money to pay for treatments, such as knee or eye surgery - up from 199,000 in 2019.
    The NHS backlog has been blamed for the trend, with some of the treatments costing more than £15,000.
    But there does appear to have been a shift away from private insurance driven by the cost of living crisis.
    The numbers treated through that route were just below 550,000 - more than 30,000 fewer than three years ago.
    Health providers are reporting patients desperate for treatment because of NHS waits are increasingly turning to the private market.
    Read full story
    Source: BBC News, 24 May 2023
  22. Patient Safety Learning
    A safety investigation has warned that young people with complex mental health needs are being put at significant risk, by being placed on general children's wards in England.
    The findings come from the Healthcare Safety Investigation Branch (HSIB).
    BBC News recently highlighted the plight of a 16-year-old autistic girl, who spent several months in a children's ward.
    Other families have since contacted the BBC describing similar situations.
    The majority had faced similar difficulties getting appropriate support.
    HSIB says that paediatric wards are designed to care for patients who only have physical health needs and not for those with mental health needs.
    It describes the situation in 18 hospitals it visited as "challenging", and 13 were described as "not safe" for children who were suicidal or at risk of harming themselves to be on their paediatric wards.
    Read full story
    Source: BBC News, 25 May 2023
  23. Patient Safety Learning
    A doctor with a key role in reforming a controversial gender identity clinic for children has been recorded questioning the need for change.
    Prof Gary Butler, clinical lead for the children's gender clinic in England and Wales, also appeared to accuse the author of a report, which will underpin the new service, of "nepotism".
    He was recorded making the comments in a keynote speech at a major conference.
    The Gender Identity Development Service (Gids), based at London's Tavistock and Portman NHS Foundation Trust, was rated as "inadequate" by inspectors, who visited in late 2020. It was earmarked for closure in July 2022.
    An independent review, led by Dr Hilary Cass, also called for a "fundamentally different" model of care for children with gender dysphoria.
    Prof Butler has been awarded a key role in shaping the new service, as one of several people tasked with implementing a new training programme, underpinned by Dr Cass's recommendations.
    However, BBC Newsnight has learned Prof Butler has publicly questioned the need for change and described Dr Cass's recommendations as "slightly unusual".
    In the 14-minute speech at the conference, he talked about current services across the UK, the legal challenges to the situation in England, and how he felt Gids has been the subject of "lies" in the media.
    Read full story
    Source: BBC News, 24 May 2023
  24. Patient Safety Learning
    Patients who fail to turn up for surgical day case procedures are costing the health service thousands of pounds.
    It is a problem across Northern Ireland's five health trusts.
    Over a 10-month period in the South Eastern area 14,000 patients did not attend or cancelled review appointments on the day they were due to turn up.
    Assistant Director of Elective Surgery at the South Eastern Trust Christine Allam said it was "frustrating".
    The South Eastern trust review showed between April 2022 and January 2023, 7,755 people did not attend or cancelled new outpatient appointments on the day.
    During the same period, 14,003 or 10% of patients didn't show for review appointments.
    Ms Allam said the situation was "frustrating for those patients who are waiting to be seen".
    "Those slots where people don't turn up are lost capacity because we haven't been given notice - and this only lengthens the waiting lists," she added.
    It is a problem that all health trusts are experiencing.
    Read full story
    Source: BBC News, 24 May 2023
  25. Patient Safety Learning
    A proposed exercise trial for Long Covid is being criticised by some of the patients the government-funded researchers want to study.
    The trial is part of the Researching COVID to Enhance Recovery (RECOVER) initiative, funded by the US government for $1.15 billion over four years. It aims to study Long Covid and help find treatments for the millions of people experiencing a range of long-lasting symptoms, including extreme fatigue, brain fog and shortness of breath.
    The exercise study protocol has not been finalised, but it will test physical therapy at different intensity levels, tailored to the patient’s capabilities, and aim to improve endurance, said Adrian Hernandez, executive director of Duke Clinical Research Institute.
    Some Long Covid advocates, however, say that any exercise trial could be potentially dangerous for long-covid patients with myalgic encephalomyelitis (ME/CFS), also known as chronic fatigue syndrome.
    Studies show that people with ME/CFS don’t have the same response to physical exertion as healthy individuals, and many ME/CFS patients report a worsening of symptoms after even small amounts of activity. This crash is called post-exertional malaise.
    Advocates now worry that Long Covid patients with ME/CFS could be similarly harmed if they take part in any exercise study.
    Read full story (paywalled)
    Source: Washington Post, 22 May 2023
    Further reading on the hub:
    Understanding Covid-19 as a vascular disease and its implications for exercise
     
×
×
  • Create New...