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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    NHS staff are carrying out the equivalent of one 'never-event' every day, figures show. This is despite the Government ordering a crackdown on the mistakes, which cost hospitals an estimated £800million in compensation each year. Experts today demanded further action on 'unacceptable' levels of never-events, blaming inadequate staffing levels and a lack of investment in the NHS. A MailOnline audit of a decade's worth of NHS data found a colossal 4,328 never-events have occurred in England since 2013. This equates to roughly eight a week. Shocking incidents uncovered include women getting parts of their reproductive anatomy cut out instead of an appendix, men getting unwanted circumcisions and laser procedures to the wrong eye. The Royal College of Surgeons said the level of never-events was 'unacceptable' and blamed NHS staffing levels for increasing the risk to patients. "Surgeons will be working hard to do their best for patients, but they do so in difficult circumstances," a spokesperson said. "The NHS is overstretched, with staff shortages, a workforce suffering from burn-out and pressure to get record waiting times down. "This increases the risk of mistakes happening." Read full story Source: MailOnline, 10 October 2023
  2. News Article
    A growing number of doctors plan to leave the profession due to burnout and dissatisfaction, the General Medical Council has said, highlighting fears that the government’s long-term strategy for the NHS may have come too late. The GMC’s annual report on the medical workforce said the benefits of measures announced by the government in the NHS long-term workforce plan in June, such as the ambition to create more medical school places, “will only start to be seen a decade from now”. The report found that the number of licensed doctors increased in 2022, with 23,838 joining and 11,319 leaving. However, it said there were “still high vacancy rates and workforce pressure”, and that the rate of doctors leaving the profession was returning to pre-pandemic levels, at 4% last year. The GMC warned there were “worrying signs” that a growing number “plan to leave the profession as a result of high levels of dissatisfaction and high risk of burnout”. It added that there may be “a limited window of opportunity to address current issues” before more medics leave. Read full story Source: The Guardian, 12 November 2023
  3. News Article
    A woman who suffered traumatic complications from a vaginal mesh implant has been awarded a record settlement of at least £1m from the NHS. Yvette Greenway-Mansfield, 59, was given a mesh implant at Coventry’s University Hospital in 2009 and went on to suffer serious complications. Her medical negligence claim against the hospital trust found that the surgery was carried out prematurely and unnecessarily and that her consent form had been doctored to include additional risks after Greenway-Mansfield had signed it. Greenway-Mansfield said that being awarded the compensation was a “huge relief”, but added that many other women who have suffered similar damage had received little or no compensation, and criticised the government’s failure to establish a financial redress agency for victims. “I’m not the only one. There are thousands of mes,” she said. “There should be a pot of money to provide damages for these women and a care plan in place as an automatic response to mesh-damaged people. It comes down to a perception of women and women’s health problems. We’ve all had enough of it.” Read full story Source: The Guardian, 13 November 2023
  4. Content Article
    Through a data sharing agreement, the Faculty of Intensive Care Medicine can access a record of incidents reported to the National Reporting and Learning System (NRLS). Available information is limited and from a single source; all that is know about these incidents is presented in this report. The safety bulletin aims to highlight incidents that are rare or important, and those where the risk is perhaps something we just accept in our usual practice. It is hoped that the reader will approach these incidents by asking whether they could occur in their own practice or on their unit. If so, is there anything that can be done to reduce the risk?
  5. Content Article
    In October 2021 the government announced plans for new community diagnostic centres (CDCs) across England. The ambition was that these centres would provide people with increased and more convenient access to diagnostics tests, and would lead to earlier diagnosis and reduce pressure on hospitals. Two years on, with 127 centres open and 1,563,400 patients waiting for a diagnostic test as of the end of August 2023, how are community diagnostic centres getting on and what challenges are they facing?  
  6. Content Article
    During the bleak early years of the Covid pandemic, if there was one thing we were all doing, it was “following the science”. This, we were repeatedly assured, was what was driving all the government’s tough decisions. We might not like all its policies but we shouldn’t, it was implied, argue. After all, it was – always – just “following the science”. But was it really? In her evidence to the Covid inquiry, former civil servant Helen MacNamara revealed that in April 2020, the then prime minister, Boris Johnson, asked the former chief executive of the NHS in England, Simon Stevens, about reports that female frontline healthcare workers were struggling with PPE that had been designed for men. Stevens is said to have “reassured” the prime minister that there was “no problem”. However, as Caroline Criado Perez highlights, report after report over decades has found that while PPE is usually marketed as gender-neutral, the vast majority has in fact been designed around a male body, and therefore neither fits nor protects women. In fact, more often than not, it’s a hindrance.
  7. Content Article
    Medicines optimisation looks at the value which medicines deliver, making sure they are clinically-effective and cost-effective. It is about ensuring people get the right choice of medicines, at the right time, and are engaged in the process by their clinical team.  
  8. Content Article
    Nurses are at the heart of care across a wide range of services, with people and other professionals often reliant on their expertise. The Professional Record Standards Body (PRSB) worked with the NHS and social care to create a new nursing standard for use across different health and social care settings.
  9. Content Article
    Internationally, there is a growing awareness on diagnostic errors as a major – and too often overlooked – patient safety problem. According to analyses conducted by the Danish Society for Patient Safety, diagnostic errors are not only common, but they also have major consequences for patients and the healthcare system’s finances. In this article, Charlotte Frendved and Siri Tribler hope that by raising awareness of the diagnostic process and possible vulnerabilities can help improve patient safety.
  10. Content Article
    The Greater Manchester Major Trauma Network recognise that many older patients self-present to emergency departments and the ‘Meet Harry’ infographic was produced as an aide memoire to triage nurses and clinicians to assist in assessment. You can view the ‘Meet Harry’ infographic by clicking on the image or download it from the attachment below.
  11. News Article
    The UK faces an ageing crisis and healthcare must step in, England's chief medical officer, Prof Sir Chris Whitty, warns in his annual report. People are living longer but some spend many of their later years in bad health - and that has to change, he said. Based on projections, the elderly boom will be in rural, largely coastal, areas and these places are often poor cousins when it comes to provision. In deprived regions, age-related issues emerge 10 years earlier, on average. "We've really got to get serious about the areas of the country where ageing is happening very fast, and we've got to do it now. "It's possible to compress the period of time that people spend in ill health...because otherwise we will end up with large numbers of people leading much more dependent lives." Providing services and environments suitable for older adults in these areas is an absolute priority, the report says. Read full story Source: BBC News, 10 November 2023
  12. News Article
    New data suggests around 700,000 cases on the elective waiting list relate to patients who are on at least four different pathways, and NHS England says personalised care plans must be developed to treat them more efficiently. NHSE has published new data that reveals the overall referral to treatment waiting list, of 7.8 million cases, is made up of 6.5 million individual patients. The difference is due to some patients waiting for more than one treatment. Stella Vig, NHSE’s clinical director for secondary care, told HSJ around 2-3% of the individual patients on the waiting list are on four to five pathways or more. Read full story (paywalled) Source: HSJ, 9 November 2023
  13. News Article
    Community clinics credited with easing pressure on A&E and GP practices nationally last winter have not yet been funded for this year, and many may not be able to open, HSJ has learned. Several local and regional sources said they were concerned no funding had been announced for acute respiratory hubs, despite respiratory illness already starting to rise. Last year national funding was announced in December and – despite the late notice – NHS England collected evidence showing that, once they were opened, ARI hubs reduced acute respiratory infection attendances by up to two-thirds, and released GP appointments. The hubs, normally held at community clinics, offer urgent same-day appointments for those with suspected ARI problems to patients referred in by other services. David Bramley, deputy director in NHSE’s NHS@Home team, said on a webinar on Tuesday: “This year, perhaps unsurprisingly, we are seeing ARI rates beginning to climb… but we’re also not expecting any additional funding for ARI hubs this year.” Read full story (paywalled) Source: HSJ, 10 November 2023
  14. Content Article
    Chief Medical Officer Professor Chris Whitty's annual report recommends actions to improve quality of life for older adults and prioritise areas with the fastest growth in older people.
  15. Content Article
    In the windowless room where he spends 24 hours a day, lying in the bed he cannot leave, Nicholas Thornton reaches for his laptop and begins to type. It is the only way he can communicate. For more than 10 years, this 28-year-old has been trapped in dementia care units and A&E wards, abused by nurses and held in padded rooms. In all this time, he’s never had the care he needs. The 28-year-old is bedbound, unable to move and unable to speak, the effects of more than 10 years trapped in hospitals and units that cannot care for his needs. Nicholas, who is autistic and has a learning disability, has been moved again and again since he was first sectioned aged 16, ferried between units hundreds of miles from his family’s home in Essex. His story comes as a four-year-long independent inquiry, led by House of Lords peer Sheila Hollins, condemns the government for failing to address the “systemic” failures that have led to people with learning disabilities being locked away in hospitals in solitary confinement for up to 20 years.
  16. News Article
    New NHS England guidance has advised line managers to ‘remain calm’, ‘not panic’, and ‘show kindness’ when handling staff resignations. The Expectations of Line Managers in Relation to People Management framework, published on the NHS England website, contains guidelines on several areas for line managers, including equality, diversity and inclusion, recruiting and flexible working. In the “managing exits” section, managers are told they are expected to: “Support your colleague by showing kindness to them, respect their decision, and wish them well for the future”; “Lead by example and remain calm, ie do not panic when key colleague leaves”; “Use opportunity to reflect and innovate, ie should services be redesigned?”; and “Be mindful that the colleague may have mixed emotions about leaving. Include them in planning any leaving event”. Managers are also told they should “undertake an exit interview, or ask another manager if appropriate, to understand the employee’s experience of working in your organisation” and “consider skills gaps and risks of someone leaving”. Read full story Source: HSJ, 9 November 2023
  17. Content Article
    NHS England has launched this framework on the expectations of NHS line managers in relation to people management. The report contains a recommendation to create a clear view on the expectations of line managers in the service in relation to people management and the implications for provision of people services.
  18. News Article
    Black babies in England are almost three times more likely to die than white babies after death rates surged in the last year, according to figures that have led to warnings that racism, poverty and pressure on the NHS must be tackled to prevent future fatalities. The death rate for white infants has stayed steady at about three per 1,000 live births since 2020, but for black and black British babies it has risen from just under six to almost nine per 1,000, according to figures from the National Child Mortality Database, which gathers standardised data on the circumstances of children’s deaths. Infant death rates in the poorest neighbourhood rose to double those in the richest areas, where death rates fell. The mortality for Asian and Asian British babies also rose, by 17%. The annual data shows overall child mortality increased again between 2022 and 2023, with widening inequalities between rich and poor areas and white and black communities. Most deaths of infants under one year of age were due to premature births. Karen Luyt, the programme lead for the database and a professor of neonatal medicine at Bristol University, said many black and minority ethnic women were not registering their pregnancies early enough and the “system needs to reach them in a better way”. “There’s an element of racism and there’s a language barrier,” Luyt said. “Minority women often do not feel welcome. There’s cultural incompetence and our clinical teams do not have the skills to understand different cultures.” Read full story Source: The Guardian, 9 November 2023
  19. News Article
    AstraZeneca is facing legal action over its Covid vaccine, by a man who suffered severe brain injury after having the jab in April 2021. Father-of-two Jamie Scott suffered a blood clot that left him with brain damage and unable to keep working. The action, taken under the Consumer Protection Act, alleges the vaccine was "defective" as it was less safe than individuals were entitled to expect. Studies suggest Covid vaccines have saved millions of lives. In June 2022, the World Health Organization said the AstraZeneca vaccine was "safe and effective for individuals aged 18 and above". A further claim from about 80 people who say they were injured by the AstraZeneca vaccine is also due to be launched later this year but Mr Scott's case is expected to be heard first. AstraZeneca said: "Patient safety is our highest priority and regulatory authorities have clear and stringent standards to ensure the safe use of all medicines, including vaccines. "Our sympathy goes out to anyone who has lost loved ones or reported health problems. "From the body of evidence in clinical trials and real-world data, Vaxzevria [the vaccine against Covid] has continuously been shown to have an acceptable safety profile and regulators around the world consistently state that the benefits of vaccination outweigh the risks of extremely rare potential side effects." Read full story Source: BBC News, 9 November 2023 Related reading on the hub: Interview with Charlet Crichton, founder of UKCVFamily
  20. Content Article
    The depleting effect of repeated decision making is often referred to as decision fatigue. Understanding how decision fatigue affects medical decision making is important for achieving both efficiency and fairness in health care. In this study, Persson et al. investigate the potential role of decision fatigue in orthopaedic surgeons' decisions to operate, exploiting a natural experiment whereby patient allocation to time slots is plausibly randomised at the level of the patient. The results show that patients who met a surgeon toward the end of his or her work shift were 33 percentage points less likely to be scheduled for an operation compared with those who were seen first. In a logistic regression with doctor-fixed effects and standard errors clustered at the level of the doctor, the odds of operation were estimated to decrease by 10.5% for each additional patient appointment in the doctors' work shift. This pattern in surgeons' decision making is consistent with decision fatigue. Because long shifts are common in medicine, the effect of decision fatigue could be substantial and may have important implications for patient outcomes.
  21. Content Article
    The Independent Sector Complaints Adjudication Service (ISCAS) provides independent adjudication on complaints about ISCAS subscribers. ISCAS is a voluntary subscriber scheme for the vast majority of independent healthcare providers.
  22. News Article
    Hospital-acquired infections, which became substantially more common during the pandemic, have returned to pre-pandemic levels, according to a new report from a US patient safety watchdog group. It's key to note, researchers say, that infection rates before March 2020 were nothing to celebrate. On top of that moderately good news, the Leapfrog Group found other metrics that measure patient safety and satisfaction have fallen significantly, likely because of hospital staffing shortages and other pandemic-era challenges. "We're encouraged and relieved to see that infections are rapidly decreasing in hospitals following the spike during the pandemic, but we remain very concerned about a number of major problems in hospitals," said Leah Binder, president and CEO of Leapfrog, an independent, national nonprofit founded by large employers and other purchasers. Patient surveys following hospital visits found declines in experiences for the second year in a row in all states. Particularly significant drops were reported in “communication about medicines” and “responsiveness of hospital staff." Preventable errors have been linked to these problems. "Hospitals need to take a hard look at what they are unnecessarily continuing post-pandemic that are not helping patients," Binder said. Read full story Source: USA Today News, 6 November 2023
  23. News Article
    Three in five foreign doctors in the NHS face “racist microaggressions” at work, such as patients refusing to be treated by them or having their abilities doubted because of their skin colour. The widespread “thinly veiled, everyday instances of racism at work” experienced by medics trained overseas has been uncovered by a survey of more than 2,000 UK doctors and dentists. Almost three in five (58%) said they had encountered such behaviour, from colleagues as well as patients, although most did not report it because they thought that no action would be taken. Doctors affected can feel upset, humiliated, marginalised and not taken seriously as a result. The findings have raised fears that international medical graduates may choose not to work in the NHS, which is increasingly reliant on their skills given the service’s shortage of doctors. Dr Naeem Nazem, the head of medical at the medical defence organisation MDDUS, which acts for doctors accused of wrongdoing, said: “These findings show us that a worryingly large number of overseas-trained doctors working in the NHS face racist microaggressions in the course of their work, from both patients and colleagues, and that many do so regularly.” Read full story Source: The Guardian, 8 November 2023
  24. News Article
    A doctor who worked for the same private healthcare company as rogue surgeon Ian Paterson performed unnecessary shoulder operations for financial gain, a medical tribunal has heard. Orthopaedic consultant Michael Walsh worked at a Spire Healthcare hospital in Leeds from 1993 until 2018, when he was suspended after concerns were raised about his work. Spire, which runs 38 hospitals around the UK, reported him to the General Medical Council (GMC) after an investigation found he carried out operations unnecessarily or badly, with many patients left suffering pain or trauma. Mr Walsh, who also worked at another private hospital in Leeds run by Nuffield Health but is now retired, is facing dozens of medical negligence claims from patients, with some already having received payouts. Read full story Source: Medscape, 8 November 2023
  25. News Article
    A report highlights that maternity and neonatal services are often regular agenda items at board meetings, but the quality and quantity of information that is presented and the subsequent discussion (or lack thereof) doesn’t lead to effective oversight. The shocking and distressing stories emerging from the Lucy Letby case in August 2023 shone a light on the “cover-up culture” in the NHS. Although deliberate harming of babies is thankfully exceedingly rare, some of the issues raised in this case echo concerns that trusts are failing to react to signs of poor performance in maternity and neonatal services. Responsibility ultimately lies with trust boards which have a statutory duty to ensure the safety of care. However, the actions (or inactions) of leadership have come up frequently in inquiries and reviews. Read full story (paywalled) Source: HSJ, 7 November 2023
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