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Patient Safety Learning

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  1. Content Article
    Triage and clinical consultations increasingly occur remotely. In this study, published in BMJ Quality & Safety, Payne et al. aimed to learn why safety incidents occur in remote encounters and how to prevent them. They found that rare safety incidents (involving death or serious harm) in remote encounters can be traced back to various clinical, communicative, technical and logistical causes. Telephone and video encounters in general practice are occurring in a high-risk (extremely busy and sometimes understaffed) context in which remote workflows may not be optimised. Front-line staff use creativity and judgement to help make care safer. As remote modalities become mainstreamed in primary care, staff should be trained in the upstream causes of safety incidents and how they can be mitigated. The subtle and creative ways in which front-line staff already contribute to safety culture should be recognised and supported.
  2. Content Article
    Delayed discharges from hospital are a widespread and longstanding problem that can have a significant impact on both patients’ recovery and the efficiency and effectiveness of health and care services. In England, it has become normal practice for government to provide additional one-off funding to reduce delays every winter, as the problem is particularly acute during the colder months.
  3. News Article
    Police are investigating 105 cases of alleged medical negligence at the Royal Sussex County Hospital in Brighton amid claims of a cover-up. Specialist officers from the National Crime Agency and Sussex police are looking into cases of harm, which include at least 40 deaths, in the general surgery and neurosurgery departments between 2015 and 2021. An email from Sussex police, released to The Times after a court application, revealed the huge investigation is looking into 84 cases connected to neurology and 21 related to gastroenterology. Most of the families are yet to be told that their case is among them. Officers were called in by the senior coroner after she heard of allegations made by two consultant surgeons at University Hospitals Sussex NHS Foundation Trust, one of the largest NHS organisations with 20,000 staff. The trust has been accused of bullying the whistleblowers and attempting to cover up the circumstances of the deaths. Mansoor Foroughi, a consultant neurosurgeon, was sacked for “acting in bad faith” in December 2021 after raising concerns about 19 deaths and 23 cases of serious patient harm. Another whistleblower, Krishna Singh, a consultant general surgeon, claimed that he lost his post as clinical director because he said the trust promoted insufficiently competent surgeons, introduced an unsafe rota and had cut costs too quickly. Read full story (paywalled) Source: The Times, 27 November 2023
  4. News Article
    The police have begun an investigation into the clinical practices of former consultant neurologist Michael Watt. He was at the centre of Northern Ireland's largest patient recall in 2018. Over 5,000 patients were recalled amid concerns over his clinical practice. In a highly significant move, an email was sent to patients and families of deceased patients and explained that the investigation is called Operation Begrain. It will be conducted by a major investigation team led by Det Ch Insp Neil McGuinness and Det Insp Gina Quinn. Danielle O'Neill, a former patient of Dr Watt, said she and others are in "complete shock and hope that at last justice will be done". "It's been a long and difficult five years and it is not over yet," she added. Earlier this month a medical tribunal found that the former doctor's fitness to practice was "currently impaired" and that his professional performance was "unacceptable". An appeal will be made to former patients who have concerns regarding their medical treatment by Michael Watt, to come forward to the police. A short questionnaire will also be shared in order to "capture patients' concerns", that information will go straight to the investigation team and will be the first step in the police investigative process. Read full story Source: BBC News, 28 November 2023
  5. News Article
    At least 20,000 cancer deaths a year could be avoided in the UK with a national commitment to invest in research and innovation, and fix the NHS, says Cancer Research UK. Progress is being made in finding new treatments for the condition that affects 50% of people at some point. But the charity says the UK lags behind comparable countries for survival. It has launched a manifesto of priorities for this government and the next, ahead of a general election. The document sets out what the charity says needs to change - and fast. Whoever is running the country must commit to developing a 10-year cancer plan, spearheaded by a National Cancer Council accountable to the prime minister to bring government, charities, industry and scientific experts together, it says. Key areas to focus on include: More investment in research to close an estimated £1bn funding gap. Greater disease prevention - banishing smoking to the history books, for example. Earlier diagnosis, through screening. Better tests and treatments, as well as cutting NHS waiting lists and investing in more staff. Read full story Source: BBC News, 28 November 2023
  6. Content Article
    Cancer Research UK has set out how the next UK Government could dramatically improve cancer outcomes and prevent 20,000 cancer deaths a year by 2040.  'Longer better lives: A manifesto for cancer research and care' has been developed with the insights of cancer patients and experts from across health, life sciences, government and academic sectors.   The charity said that huge strides have been made in beating cancer – with survival in the UK doubling over the last 50 years.  But it warned that with NHS cancer services in crisis and around half a million new cancer cases each year expected by 2040 – this hard-won progress is at risk of stalling.    With the UK lagging behind comparable countries when it comes to cancer survival, the charity is calling on all political parties to make cancer a top priority in their party manifestos. 
  7. Content Article
    How would you feel if your doctor offered you a treatment your health condition with good results and very little risk? You might snap it up. But what if you subsequently found out your doctor took thousands of pounds from the treatment makers to write a scientific paper promoting it, attend an all-expenses paid conference to talk about it, or spent time working as their expert consultant? In America, industry must log payments which are published on the open database system. Reporting to this is backed up by law following the American Sunshine Payment Act (2013). Sling the Mesh is calling for similar legislation in the UK to provide up-to-date evidence on industry money exchanging hands we Kath Sansom discusses in a blog on the Patient Safety Commissioner website.
  8. News Article
    A patients group representing several British victims has launched legal action against the Spanish government over claims it failed to safeguard people against the potentially fatal side effects of one of the country’s most popular painkillers, involved in a series of serious illnesses and deaths. The drug metamizole, commonly sold in Spain under the brand name Nolotil, is banned in several countries, including Britain, the US, India and Australia. It can cause a condition known as agranulocytosis, which reduces white blood cells, increasing the risk of potentially fatal infection. The Association of Drug Affected Patients (ADAF) says adverse reactions to the drugs have led to sepsis, organ failure and amputations. It has identified about 350 suspected cases of agranulocytosis between 1996 and 2023, including those of 170 Britons who live in Spain or were on holiday there. The ADAF is examining more than 40 fatalities in which it considers the drug may have led, or contributed, to death. The patients group says that case reports, including a 2009 study, suggest the British population may be more susceptible to the drug’s side effects, but this has not been confirmed by independent scientific study. The group is demanding an investigation into the drug and new controls. It filed its action on 14 November in the national court in Madrid. Cristina García del Campo, founder of the organisation, said: “This drug has destroyed people’s lives and it should now be withdrawn. One lady took three tablets and she had part of her feet amputated and several fingers. Even if it doesn’t kill you, once you’ve had sepsis your body is never the same.” Read full story Source: The Guardian, 26 November 2023
  9. News Article
    Almost half of all English maternity units are offering substandard care, making it one of the worst performing acute medical services in the NHS, Byline Times analysis has found. The analysis, based on inspections of English hospitals by the Care Quality Commission (CQC), found that 85 of 172 inspected maternity services in England received ratings of ‘inadequate’ (18) or ‘requires improvement (67) at their latest inspection. Some 65% of maternity wards were given subpar ratings for patient ‘safety’ one of several metrics looked at by the CQC. The findings come after the health regulator began a focused inspection programme of maternity wards last year after the a government review into the Shropshire maternity scandal, which saw 300 babies left dead or brain damaged by shoddy care. In one unit at Gloucestershire Royal Hospital, there was a shortage of midwives, not all medicines practices were safe which “potentially placed women at risk of harm” and serious incidents were not being investigated. The report found a backlog of 215 patient safety incidents that had not yet been looked into, as of March this year. Maria Caulfield, Minister for Women’s Health Strategy, told Byline Times that “maternity care is of the utmost importance to this Government” and stressed they have “invested £165 million a year since 2021 to grow the maternity workforce and improve neonatal services”. “Every parent must be able to have confidence in the care they receive when giving birth, and we are working incredibly hard to improve maternity services, focusing on recruitment, training, and the retention of midwives,” she added. Read full story Source: Byline Time, 28 November 2023
  10. Content Article
    Sepsis, characterised by significant morbidity and mortality, is intricately linked to socioeconomic disparities and pre-admission clinical histories. This study in eClinical Medicine looked at the association between non-COVID-19 related sepsis and health inequality risk factors amidst the pandemic in England, with a secondary focus on their association with 30-day sepsis mortality. It found that socioeconomic deprivation, comorbidity and learning disabilities were associated with an increased odds of developing non-COVID-19 related sepsis and 30-day mortality in England. This study highlights the need to improve the prevention of sepsis, including more precise targeting of antimicrobials to higher-risk patients. It also revealed that people with learning disabilities were almost four times as likely to develop the life-threatening illness. People with chronic liver disease were just over three times as likely, and chronic kidney disease stage 5 over 6 times more likely to develop non-COVID-19 sepsis. Cancer, neurological disease, immunosuppressive conditions, and having multiple prior courses of antibiotics were also associated with developing non-COVID-19 sepsis.
  11. Content Article
    Retrospective chart review is the standard for estimating prevalence of adverse events. Manual review of the electronic health record (EHR) is resource intensive. This study from Garzón González et al. describes the construction and validation of electronic trigger set, TriggerPrim, to rapidly identify charts with potential adverse events in primary care. The resulting set has five triggers: ≥3 appointments in a week at the PC center, hospital admission, hospital emergency department visit, prescription of major opioids, and chronic benzodiazepine treatment in patients 75 years or older. Use of TriggerPrim reduced time in the EHR by half.
  12. News Article
    Mental health patients have been left languishing in hospitals for years due to a chronic shortage in community care, as the number of people trapped on wards hits a record high, The Independent can reveal. Analysis shows 3,213 patients were stuck on units for more than three months last year, including 325 children kept in adult units. Of those a “deeply concerning” number have been deemed well enough to leave but have nowhere to go. One of these cases was Ben Craig, 31, who says he was left “scarred” after being stranded on a ward for two years – despite being fit enough to leave – because two councils fought over who should pay for his supported housing. He missed his daughter's birth and didn’t meet her until she was 18 months old while waiting to be discharged, which only exacerbated his depression. He told The Independent: “I was promised I was going to be moving on, but it just seemed like it went on forever.” Saffron Cordery, deputy chief executive for NHS Providers, which represents hospitals, told The Independent mental health patients stuck in hospitals were experiencing “personal distress” and getting ill again while they wait. She called on the government to put mental health on an “equal foot” to physical care and said not doing so suggested the government was content not to treat all patients equally. Read full story Source: The Independent, 27 November 2023
  13. News Article
    Almost 8,000 people were harmed and 112 died last year as a direct result of enduring long waits for an ambulance or surgery, prompting warnings that NHS care delays are “a disaster”. The fatalities included a man who died of a cardiac arrest after waiting 18 minutes for his 999 call to be answered by the ambulance service and was dead by the time the crew arrived. The figures are the first time NHS England has disclosed how often doctors and nurses file a patient safety report after someone suffers harm while waiting for help. They show that patient deaths arising directly from care delays have risen more than fivefold over the last three years, from 21 in 2019 to 112 last year, as the NHS has come under huge strain. The number of people who came to “severe harm” has also jumped from 96 to 152 during that period. “These data are alarming and show quite clearly the human impact the crisis in the NHS is having on individual patients,” said Rachel Power, the chief executive of the Patients Association. “We have been watching a disaster unfolding across the NHS and have repeatedly warned about the threat to patient safety because of it.” Read full story Source: The Guardian, 27 November 2023
  14. News Article
    A North Wales coroner has concluded there was a ‘gross failure’ in the case of a coeliac patient, who tragically died in Wrexham Maelor hospital. Mrs Hazel Pearson, 79, had coeliac disease and a number of other medical conditions and died from aspiration pneumonia four days after being given Weetabix for breakfast while at the hospital. Whilst her coeliac disease was noted on her admission records, there was no sign above her bed and staff were unaware of her dietary needs and as a result Mrs Pearson had been fed gluten containing food on multiple occasions. Tristan Humphreys, Head of Advocacy for Coeliac UK said: “We are deeply saddened and concerned by this verdict and our thoughts go out to Mrs Pearson’s loved ones at this very difficult time. Her death reflects a clear failure of care and it is patently unacceptable that this was allowed to happen. Coeliac disease is a serious autoimmune condition for which the only treatment is a medically prescribed gluten free diet. It is critical that people with coeliac disease can access the gluten free food they need to be healthy. This is all the more important when someone is unwell and, as in Mrs Pearson’s tragic case, unable to advocate for themselves. Wales has mandatory food standards which make very clear the level of care that should be provided yet these have not been met. As a charity, we are empowering patients, family members, carers and working with hospital caterers by providing advice and guidance to support safe provision of gluten free food. However, it’s high time the health service consistently delivered the care people with coeliac disease deserve.” Read full story Source: Coeliac UK, 24 November 2023
  15. Community Post
    "Hysteroscopy without anaesthetic like being flayed alive" Hysteroscopy is in the news today. A woman from Wales describes her horrific experience of undergoing a hysteroscopy with an anaesthetic.
  16. Content Article
    Productivity is misunderstood at every level in the NHS, not least because the leadership so often use the word to mean something entirely different. So what is it and what are the big misunderstandings about it? In his LinkedIn post, Stephen Black discusses what productivity is and what misunderstandings are feeding the problem.
  17. News Article
    Chaotic communication by the NHS in England is causing harmful delays to treatment and endangering patient health, according to research. Widespread communication problems that leave patients and staff scrambling to find their referrals, missing appointments, or receiving late diagnoses have been uncovered in a study by the Demos thinktank, the Patients Association, and the PMA, a professional membership body for healthcare workers. In a poll of 2,000 members of the public and NHS staff across England in October, more than half said they had experienced poor communication from the health service in the past five years, with one in 10 saying their care had been affected as a result. The research also found that over the last year, 18% had their care, or the care of an immediate family member, delayed or affected because they were referred to the wrong service, while 26% said they or a close family member had been inconvenienced because they were given the date and time of an appointment without enough notice. Miriam Levin, the director of participatory programmes at Demos, said that despite the great esteem and pride in the NHS, patients found navigating the system frustrating and stressful. “We heard countless stories of critical appointments missed, diagnoses not shared or shared too late, and referrals for treatment that went missing. This leads to real harm,” she said. Read full story Source: The Guardian, 27 November 2023
  18. News Article
    Undergoing a medical procedure without an anaesthetic felt like being "flayed alive", according to Dee Dickens. The 53-year-old is one of many in the UK who have reported having a hysteroscopy, which is used to examine the uterus, without enough pain relief. Clinical guidelines say patients must be given anaesthetic options before the gynaecological exam. Cwm Taf Morgannwg health board said it was concerned by the experiences of Ms Dickens and urged her to get in touch. Ms Dickens, from Pontypridd, Rhondda Cynon Taf, had a hysteroscopy as an outpatient at the Royal Glamorgan Hospital in Llantrisant after experiencing bleeding despite being menopausal. Ms Dickens said her medical notes and past childhood sexual abuse were not considered and she was not offered a local anaesthetic prior to the procedure in October 2022. Due to underlying health conditions, including fibromyalgia and Ehlers-Danlos Syndromes (EDS), she was reluctant to have a general anaesthetic as it would have left her "poorly for weeks" so she had the hysteroscopy on painkillers only. "Everybody's bustling, so it's really difficult to advocate for yourself," said Ms Dickens. When the procedure began, she said she felt extreme pain, adding: "I was very aware that I was a black woman who felt like she was being experimented on with no anaesthetic. "They took out my coil and then they started on the biopsies and good God, that felt like being flayed alive. It was awful. "It was like having my insides scraped out and blown up all at the same time." Read full story Source: BBC News, 27 November 2023 What is your experience of having a hysteroscopy? Add your story to our painful hysteroscopy hub community thread.
  19. Content Article
    Doctors should be taught physical examination skills that are inclusive of all patients, says Joy Hodkinson in this BMJ opinion piece.
  20. News Article
    A surgeon has said it would have been "cruel and unacceptable" to have woken up a patient to get consent for a mesh operation. Anthony Dixon is accused of failing to provide adequate clinical care to five patients at Southmead Hospital and the private Spire Hospital in Bristol. He had pioneered the use of artificial mesh to lift prolapsed bowels. Mr Dixon appeared at a Medical Practitioners Tribunal Service (MPTS) hearing in Manchester on Thursday. He faces charges of performing procedures that were not "clinically indicated", failing to carry out tests and investigations and failing to obtain consent from patients. It followed complaints many had suffered pain or trauma after having pelvic floor surgery using artificial mesh, a technique known as laparoscopic ventral mesh rectopexy (LVMR). Giving evidence, he was asked why he did not consider waking up one female patient who underwent an LVMR, to get her consent to surgery. Mr Dixon said it would have meant giving her more drugs for pain relief and could have "multiplied the risks" to her. He is also accused of failing to advise patients about the risks of procedures, failing to discuss non-surgical options and dismissing patients' concerns when they experienced pain or other symptoms following surgery. Read full story Source: BBC News, 23 November 2023 Related reading on the hub: Woman’s mesh consent form was changed after signing – how can patients be better protected?
  21. Content Article
    Hospital and health system CEOs have a lot of issues dominating their thoughts, including questions about navigating financial, operational and workforce challenges in the industry. Some of these problems may not have an obvious or immediate solution, leaving leaders with unanswered questions.  To gain more insight into executives' top concerns, Becker's asked hospital and health system leaders to share the questions they need answered right now. 
  22. Content Article
    The COVID-19 pandemic highlighted systemic weaknesses in the healthcare system. This survey of 3,067 registered nurses working in New Jersey used the Donabedian framework to identify challenges related to providing safe care during the pandemic. Respondents identified several organisational factors, including inadequate resources and staffing, which adversely impacted their ability to adhere to patient safety and infection prevention and control protocols during the pandemic.
  23. Content Article
    A NIHR-funded study has reached an agreement amongst researchers and patients on how best to measure improvement in Long Covid. Researchers have identified a Core Outcome Measure Set (COMS). This is designed to help researchers and clinicians measure the severity and impact of Long COVID. COMS specify key things that should be measured in all patients. This improves how data can be compared and summarised. Researchers say this will speed up the development of treatments for Long Covid. 
  24. Content Article
    The healthcare workplace is a high-stress environment. All stakeholders, including patients and providers, display evidence of that stress. High stress has several effects. Even acutely, stress can negatively affect cognitive function, worsening diagnostic acumen, decision-making, and problem-solving. It decreases helpfulness. As stress increases, it can progress to burnout and more severe mental health consequences, including depression and suicide. One of the consequences (and causes) of stress is incivility. Both patients and staff can manifest these unkind behaviours, which in turn have been shown to cause medical errors. The human cost of errors is enormous, reflected in thousands of lives impacted every year. The economic cost is also enormous, costing at least several billion dollars annually. The warrant for promoting kindness, therefore, is enormous. Kindness creates positive interpersonal connections, which, in turn, buffers stress and fosters resilience. Kindness, therefore, is not just a nice thing to do: it is critically important in the workplace. Ways to promote kindness, including leadership modelling positive behaviours as well as the deterrence of negative behaviours, are essential. A new approach using kindness media is described. It uplifts patients and staff, decreases irritation and stress, and increases happiness, calmness, and feeling connected to others.
  25. Content Article
    Following on from the care failures highlighted in the 2021 report, 'No one's listening', the Sickle Cell Society have published a new report taking a deeper look at sickle cell nursing care. The findings show the need for vastly more resources, training and support in this critical area of care. The report highlights that not only is no-one listening, but that lives are still being put at risk.
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