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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    This report explores why capital investment is key to boosting productivity and transforming long-term care.
  2. Content Article
    The 3 December is International Day of Persons with Disabilities. More than 1.3 billion people experience significant disability today, which represents 16% of the global population. Many persons with disabilities die earlier, are at increased risk of developing a range of health conditions, and experience more limitations in everyday functioning than the rest of the population. To mark International Day of Persons with Disabilities, we are sharing eight resources, blogs and reports from the hub on improving care, treatment and outcomes for people with disabilities.
  3. Content Article
    The MHRA is asking organisations to put a plan in place to implement new regulatory measures for sodium valproate, valproic acid and valproate semisodium (valproate). This follows a comprehensive review of safety data, advice from the Commission on Human Medicines and an expert group, and liaison with clinicians and organisations. This alert is for action by: Integrated Care Boards (in England), Health Boards (in Scotland), Health Boards (in Wales), and Health and Social Care Trusts (in Northern Ireland).
  4. News Article
    Moving less complex procedures out of operating theatres and into other care settings to free up capacity to support elective recovery has ‘inadvertently’ increased the risk of ‘never events’ at an acute trust, a report has warned. The warning was made in a report into four never events at North Bristol Trust’s Southmead Hospital between November 2022 and January 2023 – two of which involved the same patient. The review was commissioned by Bristol, North Somerset and South Gloucestershire integrated care board to examine common issues in never events involving invasive procedures. It found an increase in never events when procedures were moved away from operating theatres to other care settings. The review found moving procedures from theatres to outpatient or day case facilities to “support the reduction in the [elective] backlog and improve the waiting times for patients… may also inadvertently increase the risk of never events”. It added: “It is likely that a theatre environment has more established and embedded safety control mechanisms. Governance processes in moving such procedures should consider the impact on quality, for example, the gaps between safety processes and consideration of the minimum requirements for the new procedure location.” Read full story (paywalled) Source: HSJ, 29 November 2023
  5. News Article
    The NHS has been accused of “breaking the law” by creating a massive data platform that will share information about patients. Four organisations are bringing a lawsuit against NHS England claiming that there is no legal basis for its setting up of the Federated Data Platform (FDP). They plan to seek a judicial review of its decision. NHS England sparked controversy last week when it handed the £330m contract to establish and operate the FDP for seven years from next spring to Palantir, the US spytech company. The platform involves software that will allow health service trusts and also integrated care systems, or regional groupings of trusts, to share information much more easily in order to improve care. Rosa Curling, director of Foxglove, a campaign group that monitors big tech and which is co-ordinating the lawsuit, said: “The government has gambled £330m on overhauling how NHS data is handled but bizarrely seems to have left off the bit where they make sure their system is lawful. NHS England says the platform will help hospitals tackle the 7.8m-strong backlog of care they are facing and enable them to discharge sooner patients who are medically fit to leave. But this may be the first in a series of legal actions prompted by fears that the FDP could lead to breaches of sensitive patient health information, and to data ultimately being sold. “You can’t just massively expand access to confidential patient data without making sure you also follow the law.” Read full story Source: The Guardian, 30 November 2023
  6. News Article
    Opt-out blood tests for HIV, Hepatitis B and Hepatitis C will be rolled out to a further 46 hospitals across England, the government has announced. Health Secretary Victoria Atkins said the new £20m programme would lead to earlier diagnoses and treatment. Under the scheme, anyone having a blood test in selected hospital A&E units has also been tested for HIV, Hepatitis B and Hepatitis C, unless they opted out. The trials have been taking place for the last 18 months in 33 hospitals in London, Greater Manchester, Sussex and Blackpool, where prevalence is classed by the NHS as "very high". Figures released by the NHS earlier show those pilots have identified more than 3,500 cases of the three bloodborne infections since April 2022, including more than 580 HIV cases. Ms Atkins said: "The more people we can diagnose, the more chance we have of ending new transmissions of the virus and the stigma wrongly attached to it." She added that rolling out the tests to more hospitals would help ensure early diagnoses so people "can be given the support and the medical treatment they need to live not just longer lives but also higher quality lives". Read full story Source: BBC News, 29 November 2023
  7. News Article
    People with Covid-19 were discharged to care homes over fears about the NHS getting “clogged up”, the pandemic inquiry has heard. Professor Dame Jenny Harries, England’s deputy chief medical officer during the pandemic and now head of the UK Health Security Agency, told the inquiry of how an email she sent in mid-March 2020 described the “bleak picture” and “top line awful prospect” of what needed to happen if hospitals overflowed. Discharging people to care homes – where thousands of people died of Covid – has been one of the central controversies when it comes to how the Government handled the pandemic. On Wednesday, the Covid inquiry was read an email exchange between Rosamond Roughton, an official at the Department of Health, and Dame Jenny on March 16 2020. Ms Roughton asked what the approach should be around discharging symptomatic people to care homes, adding: “My working assumption was that we would have to allow discharge to happen, and have very strict infection control? Otherwise the NHS presumably gets clogged up with people who aren’t acutely ill.” Ms Roughton added that this was a “big ethical issue” for care home providers who were “understandably very concerned” and who were “already getting questions from family members”. In response, Dame Jenny emailed: “Whilst the prospect is perhaps what none of us would wish to plan for, I believe the reality will be that we will need to discharge Covid-19 positive patients into residential care settings for the reason you have noted. “This will be entirely clinically appropriate because the NHS will triage those to retain in acute settings who can benefit from that sector’s care. “The numbers of people with disease will rise sharply within a fairly short timeframe and I suspect make this fairly normal practice and more acceptable, but I do recognise that families and care homes will not welcome this in the initial phase.” Read full story Source: The Independent, 29 November 2023
  8. Content Article
    The helicopter, G-MCGY, was engaged on a Search and Rescue mission to extract a casualty near Tintagel, Cornwall and fly them to hospital for emergency treatment. The helicopter flew to Derriford Hospital (DH), Plymouth which has a Helicopter Landing Site (HLS) located in a secured area within one of its public car parks. During the approach and landing, several members of the public in the car park were subjected to high levels of downwash from the landing helicopter. One person suffered fatal injuries, and another was seriously injured. The investigation carried out by the Air Accidents Investigation Branch identified the following causal factors: The persons that suffered fatal and serious injuries were blown over by high levels of downwash from a landing helicopter when in publicly accessible locations near the DH HLS. Whilst helicopters were landing or taking off, uninvolved persons were not prevented from being present in the area around the DH HLS that was subject to high levels of downwash. Helicopters used for Search and Rescue and Helicopter Emergency Medical Services (HEMS) perform a vital role in the UK and, although the operators of these are regulated by the UK Civil Aviation Authority, the many helicopter landing sites provided by hospitals are not. It is essential that the risks associated with helicopter operations into areas accessible by members of the public are fully understood by the HLS Site Keepers, and that effective communication between all the stakeholders involved is established and maintained. Therefore, nine Safety Recommendations have been made to address these issues.  
  9. Content Article
    Patients who visit their GP practice with an ongoing health problem may see several different GPs about the same symptoms. To make sure they receive safe and efficient care, there needs to be a system in place to ensure continuity of care. In the context of this report, continuity of care is where a patient has an ongoing relationship with a specific doctor, or when information is managed in a way that allows any doctor to care for a patient. While some GP practices in England operate a formalised system of continuity of care, many do not. This investigation explored the safety risk associated with the lack of a system of continuity of care within GP practices. The investigation focused on: How GP practices manage continuity of care. This includes how electronic record systems alert GPs to repeat attendances for symptoms that are not resolving and how information is shared across the healthcare system. Workload pressures that affect the ability of GP practices to deliver continuity of care. This investigation’s findings, safety recommendations and safety observations aim to prevent the delayed diagnosis of serious health conditions caused by a lack of continuity of care and to improve care for patients across the NHS.
  10. News Article
    The management of fragile maternity services is being hamstrung by a lack of clear standards and direction from government and regulators, trust chairs and chief executives have told HSJ. Kathy Thomson, the retiring chief executive of Liverpool Women’s Foundation Trust, told HSJ that a major overhaul of regulation and oversight of maternity care was needed. She warned that trust leaders were confused about what was expected of their stewardship of maternity services. Much of the increased scrutiny of the sector was coming from people with little knowledge and experience of maternity care, and maternity was beset by too many initiatives which “somebody thinks are a nice thing to do”. Ms Thomson’s comments were echoed by a wide range of other NHS leaders (see ’damaging confidence’ below). Ms Thomson told HSJ: “How clear are we nationally about the real ask of maternity services? Are we going to say it’s the ten NHS Resolution (NHSR) safety standards, which are really tough to achieve and which we agonise over? Or is it the CQC standards, because they will often take a different view around very similar issues? “We’ve had that this year after we’ve been assessed as compliant by NHSR, but then had to re-provide evidence after we’ve been criticised by the CQC for something… and then NHSR have written back to say we’re still fully compliant. “So, should you put your time and energy into the NHSR standards, or do you spend the time on the more subjective drivers? Because we can’t keep doing all of it and having different parts of the NHS saying this is what you need to do or expecting something different.” Read full story (paywalled) Source: HSJ, 30 November 2023
  11. Content Article
    The first 14 minutes of this programme are focused on a Newsnight investigation into allegations of cover-up, avoidable harm and patient deaths relating to University Hospitals Sussex NHS Foundation Trust. At the time of broadcast, Sussex Police were investigating 105 claims of alleged medical negligence at the Trust.
  12. News Article
    According to analysis from the NHS Confederation, capital budgets within the NHS must double to ensure that the delivery of faster and more productive patient care can be supported. Published yesterday, the Investing to Save: The Capital Requirement for a More Sustainable NHS in England report has outlined that a further £6.4 billion of capital funding must be committed through all three years of the next Spending Review so that the NHS’ maintenance backlog can be addressed. This will also help with the refurbishment of dilapidated buildings, the upgrading of equipment, and the increasing of staff productivity. Chief Executive of the NHS Confederation, Matthew Taylor, said: “Some of our members have parts of their estate that are barely fit for the 19th century, let alone the 21st, so any future Secretary of State for Health and Social Care must make the physical and digital condition of the NHS a priority if the health service is to reduce backlogs and get productivity levels to where the government want them to be. “Lack of capital across different care settings, covering digital and physical infrastructure and mental and physical health, is clearly not just leading to missed opportunities to improve productivity, but actively undermining it and causing patient safety issues. Health leaders across England have endless ideas about how capital funding could drive large productivity increases. “Equipping staff with the right tools, and allowing them to operate in safe, modern, optimised environments will improve efficiency, meaning that an increase to the capital budget will help limit the need for growth in revenue spend, relieve pressure on wider NHS finances and services, and put the NHS on the path to longer-term financial sustainability. “This will require a significant increase to the NHS capital budget to make up for years of under-resourcing and repeated raids on capital that has left much of the estate broken. Based on the assessment of health leaders, this will need to be an increase of £6.4 billion to take the capital budget to £14.1 billion for each year of the next spending review in order to fully address the repairs backlog and realise some of the innovative transformation projects which have previously fallen by the wayside. The next government must grasp the nettle.” Read full story Source: National Health Executive, 29 November 2023
  13. News Article
    The failure of trusts to offer stroke patients the level of rehab required by standards introduced 10 years ago has not prevented the publication of new guidance which demands even higher performance. New guidance has been issued by the National Institute for Health and Care Excellence (NICE) which says recovering stroke patients should receive therapy for at least three hours a day, five days each week. Performance against this standard is not yet measured, but figures analysed by HSJ show nearly all units treating stroke patients are falling well short of the previous NICE standard issued in 2013. This required a much less ambitious 45 minutes per day. The figures suggest it is inconceivable the NHS will meet the new NICE rehab requirements in the near future. When they were launched, NICE said: “It shouldn’t be underestimated how important it is for people who have been left with disabilities following a stroke to be given the opportunity to benefit from the intensity and duration of rehabilitation therapies outlined in this updated guideline.” But Chartered Society of Physiotherapy chief executive Karen Middleton said there was no funding for physios to work on rehab, despite increases in staff supply. “Funding that we know is already limited is being prioritised to other things rather than into rehab,” she said. Read full story (paywalled) Source: HSJ, 29 November 2023
  14. Content Article
    New developments in artificial intelligence (AI) are extensively discussed in public media and scholarly publications. While in many academic disciplines debates on the challenges and opportunities of AI and how to best address them have been launched, the human factors and ergonomics (HFE) community has been strangely quiet. In this paper, Gudela Grote discusses three main areas in which HFE could and should significantly contribute to the socially and economically viable development and use of AI: decisions on automation versus augmentation of human work; alignment of control and accountability for AI outcomes; counteracting power imbalances among AI stakeholders. She then outlines actions that the HFE community could undertake to improve their involvement in AI development and use, foremost translating ethical into design principles, strengthening the macro-turn in HFE, broadening the HFE design mindset, and taking advantage of new interdisciplinary research opportunities.
  15. News Article
    Health Education England (HEE) and NHS England have warned BMA that its stance on medical associate professionals (MAPs) is impacting NHS relationships and patient confidence. HEE published an open letter to the BMA in response to the union’s call to halt recruitment of MAPs – which includes physician associates (PAs) working in general practice – until regulation is in place. The BMA Council passed a motion calling for a halt to recruitment of MAPs two weeks ago, on the grounds of patient safety. This followed a previous motion to that effect from its GP committee for England earlier this month. Proposing to bring forward a planned meeting with the BMA to discuss the matter, HEE’s letter said: "This continuing public discourse around MAPs is impacting relations between your members and their MAP colleagues, the health and wellbeing of MAPs already working in the NHS, and potentially the confidence of patients." HEE chief workforce, training and education officer Dr Navina Evans and NHS England medical director Sir Stephen Powis argued in the letter that evidence shows "MAPs are safe", and that they "increase the breadth of skill, capacity and flexibility of teams" and reduce workload pressure on other clinicians. ‘Any issues of patient safety identified resulting from MAPs ‘must be addressed in the same way we would any other profession’, the letter added. Read full story Source: Pulse, 27 November 2023
  16. Content Article
    Learn from Patient Safety Events (LFPSE) is a centralised system that healthcare staff can use to record patient safety events and access data and analytics about patient safety events nationwide using the NHS database. It replaces the National Reporting and Learning System (NRLS) that was used to upload incidents to the NHS. Homerton University Hospital have shared a presentation on how they are going to implement LFPSE into Datix, a quick reference guide and a screen saver they are using to introduce it to staff. Others may find the resources useful and can adopt/adapt them in their own organisations. They can be downloaded from the attachments below. Additional resources on the hub: CSH Surrey share their presentation slides on LFPSE and Datix.
  17. Community Post
  18. News Article
    Mortuary abuser David Fuller was able to offend without being caught because of "serious failings" at the hospitals where he worked, an inquiry has found. Between 2007 and 2020, Fuller abused the bodies of at least 101 women and girls in Kent hospitals. Inquiry chair Sir Jonathan Michael said "there were missed opportunities to question Fuller's working practices". He added the abuse "had caused shock and horror across our country and beyond". The inquiry has made 17 recommendations to prevent "similar atrocities". Read full story Source: BBC News, 28 November 2023
  19. Content Article
    This is the phase 1 report by the independent inquiry into the issues raised by the David Fuller case. The inquiry has been established to investigate how David Fuller was able to carry out inappropriate and unlawful actions in the mortuary of Maidstone and Tunbridge Wells NHS Trust and why they went apparently unnoticed, for so long. A phase 2 report, looking at the broader national picture and the practices and procedures in place to protect the deceased in the NHS and other settings, is planned for publication at a later date.
  20. News Article
    GP appointments over the phone or online risk harming patients, a new study published in the BMJ has found. An analysis of remote NHS doctor consultations between 2020 and 2023 found that “deaths and serious harms” had occurred because of wrong or missed diagnoses and delayed referrals. Distracted receptionists were also found to be responsible for deaths after they failed to call patients back. The report, led by the University of Oxford, suggested doctors should stop giving phone appointments to the elderly, people who are deaf, or technophobes. As many as a third of GP appointments are now virtual after face-to-face appointments slumped to less than half during the pandemic. Restoring access to face-to-face appointments has been a priority of multiple health secretaries, with Steve Barclay last year promising to name and shame GPs who did not see patients in person. Patient groups said the study was likely to be “just the tip of the iceberg” given the “potential for tragic misdiagnoses because of the limitations of online or telephone consultations”. Read full story (paywalled) Source: The Telegraph, 29 November 2023
  21. Content Article
    Hospital leaders need to embed a safety culture across their organisations - read the latest guest blog on the Patient Safety Commissioner website from Maria Caulfield, the minister for mental health and women's health strategy. Maria gives three examples of how we are advancing patient safety across our NHS.
  22. News Article
    Parents of a two-day-old girl who died in hospital after an emergency C-section are calling for a national inquiry into maternity services. Abigail Fowler Miller died at Brighton's Royal Sussex County Hospital (RSCH), in January last year. On 21 January 2022, Mr Miller and Katie Fowler contacted the hospital's maternity assessment unit four times during the day. Their first phone call was to inform the maternity assessment unit Ms Fowler was in labour, then to report bleeding, and finally to tell them she had become faint and short of breath. According to the Health Safety Investigation Branch's (HSIB) report, staff recorded that Ms Fowler sounded "distressed" in the fourth phone call to the unit, and she thought she was having a panic attack. Staff said she could not answer questions in the fourth phone call because of her "distressed state" and she was asked to come into the hospital. Ms Fowler went into cardiac arrest on the journey in a taxi due to a uterine rupture. An inquest last week found her life would have been prolonged if her mother had been admitted to hospital sooner. In October, families whose babies have died or been harmed in the care of the NHS called for a statutory public inquiry into England's maternity services. Robert Miller, Abigail's father, told BBC Newsnight: "A national inquiry is the only way forward - we cannot continue to treat every incident as a separate tragedy." Read full story Source: BBC News, 28 November 2023
  23. News Article
    A new risk calculator will help to identify people with type 2 diabetes who are at high risk of developing heart and circulatory diseases with greater accuracy than ever before. By spotting high-risk individuals years in advance, doctors will be able to offer vital preventative treatment that can help save lives by warding off future heart attacks and strokes. The risk calculator is included in the new European Society of Cardiology (ESC) Guidelines advising doctors on the management of cardiovascular disease in people with type 2 diabetes, which were announced at the ESC’s annual Congress in August. There are around 4.5 million people in the UK with type 2 diabetes, and one third of adults with diabetes die from a heart or circulatory disease. The SCORE2-Diabetes risk calculator, published in the European Heart Journal, will allow doctors to estimate the risk of developing a heart or circulatory disease in the next 10 years, with much improved accuracy. Professor Sir Nilesh Samani, our Medical Director, said: “People with diabetes are overall nearly twice as likely to die of heart disease or stroke as those who do not have the condition. "This increased risk can be substantially reduced by interventions such as blood pressure control and statins, but this requires more accurate identification of those at increased risk. “SCORE2-Diabetes is a valuable advance that will allow doctors to tailor pre-emptive treatments for individuals with type 2 diabetes based on their personal risk of heart and circulatory diseases. "Such an approach is vital as clinicians in the UK and across Europe find new ways to reduce the high levels of ill health associated with diabetes.” Read full story Source: British Heart Foundation, 26 November 2023
  24. News Article
    “Gut-wrenching,” says Lisa McManus. She is looking for words to describe how she and other thalidomide survivors feel ahead of a historic apology by Anthony Albanese for government failings in the tragedy. She is grateful for recognition of the medical disaster and relieved that a decade of advocacy has come to fruition. Around 80 of the 146 recognised survivors will witness the apology in Canberra on Wednesday in what McManus hopes will be “a step in the healing process”. But she is also frustrated that too many others have not lived to see the day. Thalidomide caused birth defects including “shortened or absent limbs, blindness, deafness or malformed internal organs”, according to the Department of Health. The drug was not tested on pregnant women before approval, and the birth defect crisis led to greater medical oversight worldwide, including the creation of Australia’s Therapeutic Goods Administration. Survivors and independent reports have criticised the government of the day for not acting sooner to remove thalidomide from shelves when problems became apparent. McManus leads Thalidomide Group Australia, having lobbied governments for a decade for an apology and better support. She’s “extremely grateful” for the apology, and says many survivors are anxious, excited and nervous – but that the apology itself can’t be the end. “I’m relieved it’s happening, I just can’t say ‘thank you’,” McManus says. “I’m very happy to think it’s here, but it won’t fix things, and I don’t want the government thinking they will deliver this and it’ll all be fine.” Read full story Source: The Guardian, 28 November 2023
  25. Content Article
    In a multicultural society, individuals from diverse linguistic backgrounds may face language barriers when seeking healthcare. Effective communication is essential to ensure that patients can accurately express their symptoms, concerns and medical history, and understand the information given to them by healthcare providers. In this blog, Kathryn Alevizos discusses some of the common language barriers non-native English speaking patients can experience, and offers practical advice on how we can all improve our intercultural communication skills.
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