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Patient Safety Learning

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  1. Patient Safety Learning
    Grieving parents have been left waiting more than 14 months for answers about why their 12-day-old son died.
    Elijah was born at Merthyr Tydfil's Prince Charles Hospital on 25 February 2022 and died after being diagnosed with enterovirus and myocarditis.
    Joann and Christian Edwards said they were told they would have a report by the end of 2022, but are still waiting.
    Joann and Christian, from Mountain Ash, Rhondda Cynon Taf, said they were told Elijah's myocarditis was a "one off" but subsequently read about 10 babies, including one who died, getting severe enterovirus with myocarditis across south Wales.
    Public Health Wales (PHW) said Elijah's death was not being looked into as part of an investigation into this cluster of cases, as the dates were set at June 2022 to April 2023 to coincide with the enterovirus season.
    But it said it would look to include Elijah's death as part of a "wider clinical investigation" of the cases.
    Read full story
    Source: BBC News, 15 May 2023
  2. Patient Safety Learning
    The confidentiality of NHS medical records has been thrown into doubt after a “stalker” hospital doctor accessed and shared highly sensitive information about a woman who had started dating her ex-boyfriend, despite not being involved in her care.
    The victim was left in “fear, shock and horror” when she learned that the doctor had used her hospital’s medical records system to look at the woman’s GP records and read – and share – intimate details, known only to a few people, about her and her children.
    “I felt violated when I learned that this woman, who I didn’t know, had managed to access on a number of occasions details of my life that I had shared with my GP and only my family and very closest friends. It was about something sensitive involving myself and my children, about a family tragedy,” the woman said.
    The case has prompted warnings that any doctor in England could abuse their privileged access to private medical records for personal rather than clinical reasons.
    Sam Smith, of the health data privacy group MedConfidential, said: “This is an utterly appalling case. It’s an individual problem that the doctor did this. But it’s a systemic problem that they could do it, and that flaws in the way the NHS’s data management systems work meant that any doctor can do something like this to any patient.
    Read full story
    Source: The Guardian, 14 May 2023
  3. Patient Safety Learning
    Patients, doctors and nurses are enduring constant ward closures and flooding in “dilapidated and unpleasant” buildings because a new hospital promised by the government has still not been delivered, one of its most senior medics has warned.
    Patient safety could soon be at risk unless the replacement for St Helier Hospital, in south London, is finally confirmed by ministers, according to the outgoing chief medical officer of its NHS trust. Some of the buildings pre-date the NHS, while wards have been shut due to sinking foundations.
    Writing in the Observer, Dr Ruth Charlton, the chief medical officer of Epsom and St Helier University Hospitals NHS Trust, warns:
    “Right now, we are delivering safe care – but it’s not easy in such a dilapidated and unpleasant environment, and I fear we won’t be able to provide the level of care we’d like to – or should be – for much longer,” she writes. “Our patients and our staff deserve so much better than this current state – where wards are being shut down because the foundations are sinking, and floods and leaks are a certainty every winter.
    “Every day we wait costs money, and each year we have to spend more and more on updating our old, rundown buildings – diverting scarce resources from the front line … there’s no other option. We must progress our plans to build our new hospital and make improvements to our existing sites.”
    Read full story
    Source: The Guardian, 13 May 2023
  4. Patient Safety Learning
    Patients are being offered powerful drugs and told they have attention deficit hyperactivity disorder (ADHD) after unreliable online assessments, a BBC investigation has discovered.
    Three private clinics diagnosed an undercover reporter via video calls. But a more detailed, in-person NHS assessment showed he didn't have the condition.
    Panorama spoke to dozens of patients and whistleblowers after receiving tip-offs about rushed and poor-quality assessments at some private clinics, including Harley Psychiatrists, ADHD Direct and ADHD 360.
    The investigation found that:
    Clinics carried out only limited mental health assessments of patients. Powerful drugs were prescribed for long-term use, without advice on possible serious side effects or proper consideration of patients' medical history. Patients posting negative reviews were threatened with legal action. The NHS is paying for thousands of patients to go to private clinics for assessments. Commenting on Panorama's findings, Dr Mike Smith - an NHS consultant psychiatrist - said he was seriously concerned about the number of people who might "potentially have received an incorrect diagnosis and been started on medications inappropriately".
    "The scale is massive."
    Read full story
    Source: BBC News, 
  5. Patient Safety Learning
    Hospitals are failing to tackle spiralling children's surgery waiting lists as the backlog hits more than 400,000 for the first time.
    Leaked documents show children’s waiting lists for both inpatient and outpatient care are “increasing at double the rate of adults” and, despite efforts, services have failed to catch up after they were paused during the pandemic.
    NHS leaders have repeatedly raised concerns about the backlog amid warnings that services for young people have been “deprioritised” to cut adult lists.
    One NHS leader warned that the long waits would be likely to affect some children’s “ability to lead full and active lives” and worsen existing inequalities between adult and children’s care.
    Read full story
    Source: The Independent, 11 May 2023
  6. Patient Safety Learning
    A world-renowned cancer centre hit by whistleblowing concerns over alleged bullying has been downgraded by the health watchdog.
    The Care Quality Commission (CQC) told The Christie NHS Foundation Trust in Manchester it "requires improvement" in safety and leadership.
    A former trust nurse told the BBC leaders had intimidated staff to stop them voicing concerns to inspectors.
    Rebecca Wight worked at The Christie - Europe's largest cancer centre - from 2014 but quit her role as an advanced nurse practitioner in December, claiming her whistleblowing attempts had been ignored.
    She told BBC Newsnight the trust had attempted to manipulate the inspection by intimidating those who wished to paint an honest picture.
    Roger Kline, an NHS workforce and culture expert from Middlesex University Business School, told BBC Newsnight there was a culture at The Christie which was "unwelcoming of people raising concerns".
    He said: "The trust response is more likely... to see the person raising the concerns as the problem rather than the issues they have raised," adding this was "not good for patient care".
    Read full story
    Source: BBC News, 12 May 2023
  7. Patient Safety Learning
    New weight loss drugs such as Wegovy will not be a “silver bullet” in tackling obesity, the World Health Organization (WHO) has warned.
    Francesco Branca, WHO director of food and nutrition safety, said weight loss drugs must be used alongside a healthy diet and exercise.
    Ms Branca’s comments come as the health body conducts its first review of obesity management guidelines in two decades.
    Semaglutide, marketed as Wegovy by drugmaker Novo Nordisk, is an appetite suppressant drug that has been approved by the UK medicines regulator and described by some as a “game changer” in helping people to shed weight.
    People will only be given Wegovy on prescription as part of a specialist weight management service involving input from several professionals and for a maximum of two years.
    Some experts described the decision as a “pivotal moment” for the treatment of people living with obesity but others warned that the drug is not a “quick fix”.
    Read full story
    Source: The Independent, 12 May 2023
  8. Patient Safety Learning
    Monkeypox is no longer a global public health emergency, the World Health Organization (WHO) has said, almost a year after the threat was raised.
    The virus is still around and further waves and outbreaks could continue, but the highest level of alert is over, the WHO added.
    The global health body's chief Tedros Adhanom Ghebreyesus called on countries to "remain vigilant".
    More than 87,000 cases and 140 deaths have been reported from 111 countries during the global outbreak, according to a WHO count.
    But almost 90% fewer cases were recorded over the last three months compared with the previous three-month period, meaning the highest level of alert is no longer required, Tedros said.
    Read full story
    Source: BBC News, 11 May 2023
  9. Patient Safety Learning
    The death rates for black women in childbirth were revealed in a recent report from MPs and were described as “appalling”, yet action, not words, are needed for what could be considered breaches of the Human Rights Act.
    Ministers are not giving priority to reducing the gap in health inequalities, write Nicola Wainwright and Suleikha Ali in a commentary to the Times. 
    "If the response to the review is foot-dragging from the government and senior health service officials, then legal action may be the only way to draw focus to this issue and to try to reduce the number of ethnic minority women and babies dying unnecessarily."
    The report, published by the women and equalities committee last month, highlights the “glaring and persistent” disparities faced by ethnic minority women compared to their white counterparts with regards to pregnancy and birth. However, these same disparities have been known and reported on for 20 years, while progress on improving the situation has been shockingly slow.
    Read full story (paywalled)
    Source: The Times, 11 May 2023
  10. Patient Safety Learning
    Thrombosis UK has warned that deaths involving blood clots are higher than expected as it called for more transparency over the work hospitals are doing to reduce the risk for patients.
    Before the pandemic hit, hospitals were regularly publishing data on the number of patients who had been risk assessed for blood clots. In March 2020, the NHS in England took the decision to suspend the data collection on venous thromboembolism (also known as VTE) risk assessments to “release capacity in providers and commissioners to manage the Covid-19 pandemic”.
    But the data collection and publication is yet to resume. The charity said the data shows how many VTE cases are missed in hospitals.
    One bereaved man described how his mother died last year after the condition was missed. Tim Edwards, 42, said healthcare workers missed signs of the condition while Jennifer Edwards, 74, was in hospital on the south coast.
    Despite having many symptoms of a pulmonary embolism she was discharged home and died three days later. Mr Edwards said: ““My mother’s symptoms were missed from her admission to hospital right up to her time in the cardiology department.
    “She was discharged and passed away three days after phoning the NHS with shortness of breath. She should not have died. I took it upon myself to enquire about the circumstances surrounding her death and was overwhelmed by the lack of care taken.
    “Sadly, I know this is not an isolated case.”
    Read full story
    Source: Wales Online, 12 May 2023
    Further reading on the hub:
    Pulmonary embolism misdiagnosis – a systemic problem (a blog from Tim Edwards) Independent review of pulmonary embolism fatalities in England & Wales – recent trends, excess deaths, their causes and risk management concerns (Tim Edwards) Jenny, and why we must learn from her misdiagnosis of pulmonary embolism National Voices: Pulmonary embolism misdiagnosis - a blog by Helen Hughes.
  11. Patient Safety Learning
    Artificial intelligence (AI) could be “transformational” in improving heart attack diagnosis to reduce pressure on emergency departments, a new study suggests.
    Doctors could soon use an algorithm developed using AI to diagnose heart attacks with better speed and accuracy than ever before, the research from the University of Edinburgh indicates.
    It could also help tackle dangerous inequalities in diagnosing the condition, scientists suggest.
    Researchers found that, compared to current testing methods, the algorithm called CoDE-ACS was able to rule out a heart attack in more than double the number of patients, with an accuracy of 99.6%.
    Nicholas Mills, British Heart Foundation (BHF) professor of cardiology at the Centre for Cardiovascular Science, University of Edinburgh, who led the research, said: “For patients with acute chest pain due to a heart attack, early diagnosis and treatment saves lives.
    “Unfortunately, many conditions cause these common symptoms, and the diagnosis is not always straight forward.
    “Harnessing data and artificial intelligence to support clinical decisions has enormous potential to improve care for patients and efficiency in our busy emergency departments.”
    Read full story
    Source: The Independent, 11 May 2023
  12. Patient Safety Learning
    A former NHS chief executive is suing her employer, saying she was "bullied, harassed, intimidated and undermined" by the hospital trust's chairman.
    In legal papers, seen by BBC News, Dr Susan Gilby alleges she was effectively unfairly dismissed by the Countess of Chester NHS Foundation Trust, after she made a formal complaint.
    Dr Gilby claims the chairman was "highly aggressive and intimidatory" in meetings, that he banged his hand on a desk to emphasise his point, and oversaw a climate where "offensively sexist comments and ferocious and repetitive criticisms" were made by either him or his associates.
    Dr Gilby's complaint accuses the chairman of putting finance above patient safety at the hospital trust
    She made a formal whistle-blowing complaint against the chairman in July 2022, raising her concerns about his behaviour to both the trust and NHS England.
    The trust responded to her concerns, Dr Gilby claims, by proposing that she be seconded to a senior advisory role within NHS England on the condition she withdrew her allegations.
    Read full story
    Source: BBC News, 12 May 2023
  13. Patient Safety Learning
    The NHS waiting list hit a record 7.3 million incomplete pathways in March, according to new official data, as trust bosses gear up to clear the circa 95,000 patients who have waited over 65 weeks.
    NHS England also confirmed in its monthly statistical update that there remained around 10,000 patients on the waiting list who had breached 78 weeks despite a target to clear this cohort by April, as HSJ revealed would be the case in March. It instead hoped these will be cleared by June or July.
    Ten trusts are responsible for around half of the 78-week breaches, with Manchester University Foundation Trust recording the most on 969, University Hospitals Leicester Trust reporting 837 and Royal Devon University Healthcare FT on 695.
    NHSE chief executive Amanda Pritchard said the NHS “is making great strides on long waits… in the face of incredible pressure [and this] is testimony to the hard work, drive and innovation of frontline colleagues”.
    Read full story (paywalled)
    Source: HSJ, 11 May 2023
  14. Patient Safety Learning
    An autistic girl aged 16 spent nearly seven months in a busy general hospital due to a lack of suitable children's mental health services in England.
    The teenager, called Molly, spent about 200 days living in a side-room of a children's ward at the Queen Alexandra Hospital in Portsmouth. It is not a mental health unit.
    Experts say a general hospital was not the right place for her, but she had nowhere else to go because of a lack of help in the community.
    Agency mental health nurses were brought in because she needed constant, three-to-one observations to keep her safe. Her family says security guards were also often stationed outside her room.
    Like many autistic people, Molly finds dealing with noise difficult. The clamour of the hospital overloaded her senses and her behaviour sometimes became challenging. She was restrained numerous times.
    A spokesperson for Hampshire and Isle of Wight Integrated Care System (ICS) said it was sorry Molly "did not receive care in an environment better suited to her needs", adding: "Molly's safety has always been our priority."
    Campaigners describe the shortage of appropriate support for people with autism as a human rights crisis.
    Read full story
    Source: BBC News, 10 May 2023
  15. Patient Safety Learning
    ICBs should ensure there are ‘formal escalation routes’ in place for GPs after 25 daily clinical contacts, the BMA has said in new guidance.
    From next week (15 May), GP practices are contractually required to offer an ‘appropriate response’ to patients the first time they get in contact, by offering them an appointment or redirection, rather than asking them to call back at a different time.
    While GP leaders warned this would lead to increased pressure on NHS 111 and A&E, NHS England attempted to clarify in this week’s recovery plan that GPs should only redirect patients in ‘exceptional circumstances’. It also said practices should inform their ICB on each such occasion.
    However, conflicting BMA guidance has now been published, warning that practices attempting to adhere to the new requirement ‘may do so at the expense of clinician wellbeing and patient safety’.
    It reiterates the GP Committee for England’s safe working guidance recommending that clinicians have no more than 25 clinical contacts per day because anything beyond this "can lead to decision fatigue, clinical errors and patient harm, and clinician burn out".
    Read full story
    Source: Pulse, 11 May 2023
  16. Patient Safety Learning
    A simple intervention to detect and treat postpartum haemorrhage could dramatically cut maternal mortality and morbidity worldwide, a large trial led by the University of Birmingham has shown.
    Use of a special drape to measure blood loss during childbirth and rapid deployment of a “bundle” of existing treatments reduced severe bleeding, the need for laparotomy, or maternal death by 60% in a study done in 80 hospitals across Kenya, Nigeria, South Africa, and Tanzania.
    Reporting the results in the New England Journal of Medicine, the researchers said that postpartum haemorrhage was detected in 93.1% of patients in the intervention and in 51.1% of those receiving usual care.
    Read full story (paywalled)
    Source: BMJ, 10 May 2023
  17. Patient Safety Learning
    Figures showing the risk of maternal death being almost four times higher among women from black ethnic minority backgrounds compared with white women in the UK have been published.
    The figures, which relate to 2019 - 2021, have been released by MBRRACE-UK, a collaboration involving the University of Leicester.
    The MBRRACE-UK collaboration (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries), led from Oxford Population Health's National Perinatal Epidemiology Unit, looked at data on women who died during, or up to six weeks after, pregnancy between 2019 and 2021 in the UK.
    The report showed the risk of maternal death in 2019 - 2021 was almost four times higher among women from black ethnic minority backgrounds compared with white women.
    Marian Knight, professor of Maternal and Child Population Health at Oxford Population Health and maternal reporting lead, said: "Persistent disparities in maternal health remain.
    "It is critical that we are working towards more inclusive care where women are listened to, their voices are heard, and we are acting upon what they are telling us."
    Read full story
    Source: BBC News, 11 May 2023
  18. Patient Safety Learning
    The first non-prescription birth control pill in the US is on the way to approval, after a thumbs-up from an advisory committee of drug regulators.
    The Food and Drug Administration (FDA) panel's unanimous vote is not binding, but means the agency is likely to formally approve the drug this summer.
    Opill has been available, but only by prescription, for the past 50 years.
    The push for over-the-counter access in the US comes amid Republican-led efforts to restrict access to abortion and contraception at the national and state level.
    Advisors on the panel said they were mostly confident women of all ages would use the drug as appropriate without first consulting a healthcare provider.
    "In the balance between benefit and risk, we'd have a hard time justifying not taking this action," said chairwoman Maria Coyle, an Ohio State University pharmacist.
    "The drug is incredibly effective, and I think it will be effective in the over-the-counter realm just as it is in the prescription realm."
    Read full story
    Source: BBC News, 10 May 2023
  19. Patient Safety Learning
    A leading health panel in the USA has recommended the age at which women are regularly screened for breast cancer should be cut from 50 to 40.
    The US Preventive Services Task Force (USPSTF) said an extra 20 million women in their forties would benefit from a mammogram every two years.
    The change would save 20% more lives, according to the USPSTF, which has drafted the proposal in response to rising rates among middle-aged women.
    Currently, all women in the USA aged 50 to 74 are advised to get checked via a mammogram every two years.
    The number of new breast cancer cases is rising roughly two percent every year, John Wong, an internist and professor of medicine at Tufts University School of Medicine, who is on the task force, told the Washington Post.
    Dr Wong said: "It is now clear that screening every other year starting at age 40 has the potential to save about 20 percent more lives among all women, and there is even greater potential benefit for black women, who are much more likely to die from breast cancer."
    Read full story
    Source: Mail Online, 9 May 2023
  20. Patient Safety Learning
    Online pharmacies operating in the UK are approving and dispatching prescriptions of controversial slimming jabs for people of a healthy weight, a Guardian investigation has found.
    Some pharmacies appear to be issuing prescriptions of such medications to people who lie about their body mass index (BMI) on an online form. In one case a reporter was issued a prescription after accurately saying their BMI was about 20. A healthy BMI lies between 18.5 and 24.9.
    The findings have raised alarm among eating disorder charities, which have warned that weight-loss medications should only be sold under the strictest conditions. Their concern has prompted calls for online pharmacies to employ stronger health checks and screening for eating disorders.
    Read full story
    Source: The Guardian, 10 May 2023
  21. Patient Safety Learning
    Hundreds of children who manage their type 2 diabetes by regularly pricking their finger can now monitor their glucose levels using automated sensors, the government’s expert health advisers have announced.
    Doctors and nurses in England, Wales and Northern Ireland have been advised they can now give glucose monitoring devices to children with type 2 diabetes who currently use the more intrusive finger-prick testing methods, the National Institute for Health and Care Excellence (NICE) said on Thursday.
    The health minister Helen Whately said that offering children the devices would relieve a burden and “empower them to manage their condition more easily”.
    She said: “Type 2 diabetes is increasingly being diagnosed in children, many of whom face the constant stress of needing to monitor their blood glucose levels by finger-prick testing – often multiple times a day – just to stay healthy and avoid complications.”
    The NICE committee that reached the decision heard that children found finger pricking to check their glucose levels several times a day “burdensome”, “tiring” and “stressful”.
    The devices, which give a continuous stream of real-time information on a smartphone, have already been recommended for children with type 1 diabetes, a less aggressive form of the disease.
    Read full story
    Source: The Guardian, 11 May 2023
  22. Patient Safety Learning
    Staff shortages forced pharmacies to shut for 100,000 hours in a year, new figures show, just as the government has unveiled plans to shift more GP work their way.
    The data, shared exclusively with The Independent by the organisation which represents pharmacies in England, also showed that almost 1,000 establishments closed for good between October 2016 and November 2022.
    The Pharmaceutical Services Negotiating Committee (PSNC) figures revealed that pharmacies in the most deprived areas were more likely to shut permanently due to lack of staff, with areas such as Birmingham and Manchester among the worst affected.
    The figures come as the government announced plans on Tuesday to allow pharmacists to prescribe medicines for conditions including earache, sore throats and urinary tract infections without GP involvement.
    However, experts have said the plans are unlikely to significantly reduce pressure on GP practices as prescriptions for these conditions make up just 3 per cent of all appointments.
    And the King’s Fund health think tank warned of the potential for a postcode lottery – saying some pharmacies will not be able to offer the services because they may not have access to diagnostic tools, or sufficient staff and consultation rooms.
    Read full story
    Source: The Independent, 10 May 2023
  23. Patient Safety Learning
    Every time a mistake is made in a healthcare setting, there can be serious repercussions. Patients may suffer lifetime injuries or even pay the ultimate price for someone else's mistake. Hospitals may wind up paying the price literally — financially and legally — and suffer costly public reputation troubles in the aftermath. 
    Increased patient loads combined with the workforce shortage and often decreasing financial resources have created "chaos" in hospitals, said Doug Salvador MD, chief quality officer at Baystate Health in Springfield, Mass. 
    Safety watchdog organizations, including The Joint Commission and The Leapfrog Group, have reported the result of that chaos: soaring cases of preventable medical errors. 
    The solution, he and several other sources who spoke with Becker's said, is to create standard operating procedures in every department, at every step of the patient journey. These SOPs are more than lists of guidelines; they require strict adherence and limited room for error thanks to built-in cross-check points. And, when instituted properly, they highlight system flaws in real time by creating what Dr. Salvador called "situational awareness." 
    Situational awareness, he added, keeps front-line healthcare professionals on top of their safety game. 
    Read full story
    Source: Becker's Healthcare, 9 May 2023
  24. Patient Safety Learning
    AI could harm the health of millions and pose an existential threat to humanity, doctors and public health experts have said as they called for a halt to the development of artificial general intelligence until it is regulated.
    Artificial intelligence has the potential to revolutionise healthcare by improving diagnosis of diseases, finding better ways to treat patients and extending care to more people.
    But the development of artificial intelligence also has the potential to produce negative health impacts, according to health professionals from the UK, US, Australia, Costa Rica and Malaysia writing in the journal BMJ Global Health.
    The risks associated with medicine and healthcare “include the potential for AI errors to cause patient harm, issues with data privacy and security and the use of AI in ways that will worsen social and health inequalities”, they said.
    One example of harm, they said, was the use of an AI-driven pulse oximeter that overestimated blood oxygen levels in patients with darker skin, resulting in the undertreatment of their hypoxia.
    Read full story
    Source: The Guardian, 10 May 2023
  25. Patient Safety Learning
    Patients, or carers of patients, who carry Emerade 300 or 500 microgram adrenaline auto-injector pens should immediately contact their GP to obtain a prescription for, and be supplied with two auto-injectors of a different brand. Pharmacists and pharmacy teams can also help with obtaining new prescriptions and dispensing of new pens. Patients or carers should then return all Emerade 300 and 500 micrograms auto-injectors to their local pharmacy.
    Patients should only return their Emerade pens when they have received a replacement from their pharmacy which will be an alternative brand - either EpiPen or Jext. They should ensure they know how to use the replacement pen, as each brand of pen works differently. Patients should ask their doctor, pharmacist, or nurse for help with this. Instructions are included inside the pack, along with details of the manufacturer’s website that also provides information, including videos, on how to use a new EpiPen or Jext adrenaline pen.
    This precautionary recall is because some 300 microgram and 500 microgram Emerade auto-injector pens may rarely fail to activate if they are dropped, meaning a dose of adrenaline would not be delivered. Premature activation has also been detected in some of the 300 microgram and 500 microgram pens after they have been dropped, meaning that a dose of adrenaline is delivered too early.
    The activation failure and premature activation was detected during a design assessment conducted by the manufacturer and therefore means there is a potential for some 300 microgram and 500 microgram Emerade pens to fail during use after having been dropped.
    Read MHRA Press Release. 9 May 2023
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