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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The performance of one of the NHS’s flagship strategies to reduce demand on over-stretched hospitals has collapsed, HSJ can reveal. Internal NHS figures show the number of processed advice and guidance requests (A&G) from GPs to hospital consultants fell by 28% between June and August, alongside a 32% fall in the number of processed cases where patients were diverted away from secondary care. This comes despite the overall number of A&G requests from GPs only falling by 5% in the same period. A&G services allow GPs to contact hospital consultants before making a referral in order to ensure only clinically appropriate patients are referred to secondary care. The model is described by NHS England as a ”a key part of the National Elective Care Recovery and Transformation Programme’s work.” The data showing the fall in processed requests and diversions from secondary care came from NHSE’s specialist advice activity dashboard, which HSJ has seen. Read full story (paywalled) Source: HSJ, 26 October 2023
  2. News Article
    Women affected by a review of cervical smears in the Southern Health Trust have said they are "angry, frustrated and scared" for their future. About 17,500 patients in the trust are to have their previous smears re-checked as part of a major review of cervical screening dating back to 2008. Some of these women will be recalled to have new smear tests carried out. But the process has not started yet and will take at least six months to complete. Letters were sent out by the trust earlier this month to those affected. The Southern Trust says it expects to recall around 4,000 women for a new smear test after it reviews 17,368 historic slides. The Trust's medical director, Dr Steve Austin, told its board meeting that the review of slides was expected to start next week. It also emerged that the number of calls from concerned women has increased with many asking for more "specialist" answers. Read full story Source: BBC News, 27 October 2023
  3. News Article
    Rishi Sunak is “highly unlikely” to meet his promise to cut NHS waiting lists, health leaders have warned, as a “sobering” analysis suggests the backlog will rise to 8 million and won’t begin to fall until next summer. The prime minister vowed in January that “NHS waiting lists will fall” as he outlined five pledges upon which he staked his premiership. The backlog was 7.2 million at the time. It is now 7.75 million, the highest since records began in 2007. But a grim report published today by the Health Foundation, an independent thinktank, will pile further pressure on Sunak over the NHS. The 15-page analysis predicts that the waiting list for hospital treatment in England will continue to rise for at least 10 months and ultimately top 8 million, regardless of whether or not strikes continue. The thinktank modelled four different scenarios and concluded that, based on current trends, NHS waiting list figures could peak by August 2024 if there was no more strike action by healthcare workers, before starting to come down. If strikes were to continue, the list could increase a further 180,000, it said. Matthew Taylor, the chief executive of the NHS Confederation, said: “This analysis all but confirms that the prime minister’s pledge to reduce the size of the waiting list is increasingly unlikely to be met.” He added: “As the Health Foundation report rightly says, the root cause of the delays to treatment that patients are now experiencing is a decade of underinvestment in the NHS.” Read full story Source: The Guardian, 27 October 2023
  4. Content Article
    Trevor Stevens daughter, Tobi, took her own life in December 2020 whilst in the care of the Norfolk and Suffolk NHS Foundation Trust. Trevor recently attended the HSJ Patient Safety Congress. In this blog, he reflects on his experience at the Congress. Related reading on the hub: Time for a reset on safety? Highlights from day one of the HSJ Patient Safety Congress
  5. Content Article
    Reducing inequalities in maternal healthcare in England is an important policy aim. One part of achieving that is to ensure that women from Black, Asian and minority ethnic communities, as well as women from the most deprived areas, see the same midwife or midwifery team throughout their pregnancy and postnatal period. Emma Dodsworth takes a closer look at the data to reveal what progress is being made on this.
  6. Content Article
    The US Department of Health & Human Services was directed in the Patient Safety and Quality Improvement Act of 2005 to create and maintain a Network of Patient Safety Databases (NPSD) to provide an interactive, evidence-based management resource for healthcare providers, Patient Safety Organisations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ), and others. AHRQ, the lead agency for patient safety in the USA implements the NPSD. Initially, the NPSD contains non-identifiable data derived from patient safety work product submitted by PSOs from across the country. This rich data source makes it possible to identify and track patient safety concerns for the purpose of learning how to mitigate patient safety risks and reduce harm across healthcare settings nationally. 
  7. Content Article
    Patient initiated follow up and remote clinical reviews show promise in alleviating capacity issues and ensuring timely care, with positive patient feedback and early intervention benefits Media interest regularly reports on the three headline performance measures of the NHS; 18-week target, cancer wait targets, and four hour waits in emergency departments. There is, however, another large group of patients that we do not have any targets for and receive no media attention, who Peter Towers, NHS service manager, has termed the “fourth group”. These are the patients who have started their treatment but cannot be discharged back to primary care as they require continued secondary outpatient care.
  8. News Article
    Several people have been admitted to hospital in Austria after using suspected fake versions of Novo Nordisk’s diabetes drug Ozempic, the country’s health safety body has said, the first report of harm to users as a European hunt for counterfeiters widened. The patients were reported to have suffered hypoglycaemia and seizures, serious side-effects that indicate that the product contained insulin instead of Ozempic’s active ingredient semaglutide, the health safety regulator Bundesamt für Sicherheit im Gesundheitswesen (BASG) said on Monday. The European Medicines Agency (EMA) warned last week that pens falsely labelled as Ozempic were in circulation, and Austria’s criminal investigation service said on Monday that the fake injection pens could still be in circulation. The Danish maker of the drug, Novo Nordisk, has warned of a rise in the online offers of counterfeit Ozempic as well as its weight-loss drug Wegovy, both based on semaglutide. “It appears that this shortage is being exploited by criminal organisations to bring counterfeits of Ozempic to market,” said BASG. Read full story Source: The Guardian, 24 October 2023
  9. News Article
    The NHS has launched an investigation after it sent “priority” letters to people who died years ago, in some cases decades, urging them to book flu and Covid-19 jabs to reduce their risk of serious illness. The health service is asking eligible patients to arrange appointments for both vaccines to avoid a potential “twindemic” of flu and coronavirus this winter, which would pile further pressure on hospitals and GP surgeries. “You are a priority for seasonal flu and Covid-19 vaccinations,” the two-page letter tells recipients. “This is because you are aged 65 or over (by 31 March 2024). However, some of the letters, which contain personal information such as NHS numbers, have been sent to people who died years ago. Others have been sent to people who are not eligible for the vaccines, with no connection to the addressee. In a statement, NHS England told the Guardian it was investigating. It declined to answer questions about when the error was first discovered, what had caused it and how many people had been affected. “We have been made aware of some letters sent in error and appreciate this may have been upsetting for those who received it – we are working as quickly as possible to investigate this,” a spokesperson for NHS England said. Read full story Source: The Guardian, 24 October 2023
  10. News Article
    More than a quarter of ‘critical incidents’ have been declared by just four trusts since the start of the crisis in urgent and emergency care. Data obtained by HSJ shows 241 critical incidents have been declared by organisations due to “operational” or “system pressures” between April 2021, when long waits for urgent care began to surge upwards, and last month. Four trusts account for 68 of these (28%). Critical incidents are declared when the level of disruption “results in an organisation temporarily or permanently losing its ability to deliver critical services, or where patients and staff may be at risk of harm”. These incidents may require “special measures and support from other agencies, to restore normal operating functions,” according to the NHS England definition. Most critical incidents were only in place for a few days before being stood down by the trust or system, but some were in place for much longer – sometimes for several months at a time, the data suggests. Read full story (paywalled) Source: HSJ, 25 October 2023
  11. News Article
    A coroner has found neglect contributed to a baby's death at the hospital where he was born. Jasper Brooks died at the Darent Valley Hospital in Kent on 15 April 2021. The coroner found gross failures by midwives and consultants at the hospital and says Jasper's death was "wholly avoidable". Jasper was a second child for Jim and Phoebe Brooks. Due to a complication during pregnancy of her first child, Phoebe was booked in to have an elective Caesarean section to deliver Jasper. But in April 2021 those plans changed overnight. A check-up found Phoebe had raised blood pressure. She was told to remain in hospital and that the C-section would happen the following morning - nine days earlier than planned - when there were more staff on duty. Jasper's parents say the midwives caring for Phoebe repeatedly failed to listen to her and Jim's concerns - that she was shaking violently, feeling sick, and thought she was bleeding internally. "We felt like an inconvenience - no-one wanted to deal with me that night," Phoebe says. "The doctor didn't want to do my C-section, the midwife that's meant to be looking after me, she just doesn't really care. "I remember saying clearly to her, 'my whole body is shaking - something's happening, and no-one's taking the time to listen to what I'm saying or listen in on my baby'." At the inquest hearing, midwife Jennifer Davis was accused by the family's barrister, Richard Baker KC, of "failing to act on signs of blood loss, failing to determine if Phoebe was in active labour, and failing to call a senior doctor when necessary". Jasper was born without a heartbeat, so a resuscitation team was called. But during the inquest, the family learned that further errors were made because the correct people failed to attend the resuscitation. There was no consultant neonatologist on site - a doctor with expertise in looking after newborn infants or those born prematurely. Intubation, the process of placing a breathing tube into the windpipe - which should only take a few minutes - did not occur for 18 minutes. There was also a delay in administering adrenaline to try to stimulate Jasper's heart. Read full story Source BBC News, 24 October 2023
  12. News Article
    The medical regulator has told NHS England to ‘directly tackle’ a perception there is a plan to replace doctors with physician associates amid an ‘intense’ debate about their future. General Medical Council chief executive Charlie Massey wants NHS England and health systems in the devolved nations to address several issues surrounding the expansion of medical associate roles. This follows intense debate over recent weeks, including multiple media reports of safety incidents where the involvement of physicians and anaesthesia associates has been questioned. The debate has been partially prompted by ambitions in the long-term workforce plan to increase their numbers, and the impact this would have on post-graduate medical training. Last week almost 90% cent of Royal College of Anaesthetists members voted to pause the rollout of anaesthesia associates, after an extraordinary general meeting. This prompted NHSE leaders to stress to trusts that associates should be working within established guidelines and have appropriate supervision. In response, Mr Massey has written to NHSE, calling for it to: “Directly tackle the perception that there is a plan for the health services to ‘replace’ doctors with PAs or AAs by convening and leading a system-wide discussion on an agreed vision for these roles.” Read full story (paywalled) Source: HSJ, 25 October 2023
  13. News Article
    Sepsis is still killing too many patients due to the same hospital failings that occurred a decade ago, a damning report by the NHS ombudsman has warned. Avoidable mistakes include delays in spotting and treating the condition, poor communication between health staff, sub-standard record keeping and missed opportunities for follow-up care, according to Rob Behrens, the parliamentary and health service ombudsman (PHSO). Despite some progress since a previous report on sepsis by the ombudsman in 2013, lessons are not being learned and repeated mistakes are putting people at risk, Behrens said. Major improvements are urgently needed to avoid more fatalities, he added. “I’ve heard some harrowing stories about sepsis through our investigations, and it frustrates and saddens me that the same mistakes we highlighted 10 years ago are still occurring,” said Behrens. “It is clear that lessons are not being learned. Losing a life through sepsis should not be an inevitability.” Melissa Mead, whose one-year-old son, William, died from sepsis in 2014 after concerns were dismissed by doctors, said: “I think this report, nine years on from William’s death, really lays bare the incidences of sepsis cases.” Mead, who peer-reviewed the study, added: “Too many lives are being lost in preventable circumstances.” Read full story Source: The Guardian, 25 October 2023 Further reading on the hub: Top picks: Six resources about sepsis
  14. Content Article
    Sepsis is a life-threatening reaction to an infection. It can affect anyone of any age. It happens when your immune system overreacts to an infection and starts to damage your body’s own tissues and organs. Sepsis is sometimes called septicaemia or blood poisoning. According to the UK Sepsis Trust, 48,000 people in the UK die of sepsis every year. This number can and should be reduced. It is often treatable if caught quickly. This report from the Parliamentary and Health Service Ombudsman(PHSO) looks at some of the sepsis complaints people have brought to PHSO, to shine a light on their experiences and encourage others to let their voices be heard. It shares case summaries and guidance to help people complain and help NHS organisations understand and learn from the issues raised Further reading on the hub: Top picks: Six resources about sepsis
  15. Content Article
    NHS England wants to find out how people would choose to tell the NHS about things that go wrong in healthcare, to help the NHS do things better. NHS England wants to hear from people of all ages and backgrounds, who use all kinds of NHS services. They want to know how people would choose to give feedback if something went wrong in their care, or in the care of someone they look after, so the NHS can learn. NHS England will use what you tell them to help design a new online service to make care better. Click on the link below to find out more and take the survey. Closing date:  31 December 2023
  16. Event
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    Musculoskeletal (MSK) problems are a leading cause of disability and sick leave in the working population. The purpose of this meeting is to assist participants in developing and implementing effective strategies in their practice to address these issues. A panel of experts from various disciplines, including occupational health, orthopaedics, psychology, and policy steering groups, will provide comprehensive and practical information on the prevention, treatment, and rehabilitation of MSK problems. By attending, you will: Learn about the latest innovations in ergonomic settings at workplace. Understand supportive psychological factors for management of MSK pain. Learn about the state of art therapeutic interventions in some MSK conditions affecting workers. Gain insights into national policies/strategies for prevention and rehabilitation of the MSK problems. Register
  17. Content Article
    Medication errors are a leading cause of patient harm globally. WHO launched the Global Patient Safety Challenge: Medication Without Harm, with the objective of preventing severe medication related patient harm globally. This publication is one of the documents in the WHO Technical Series on “Medication Safety Solutions” that the WHO is publishing, to address important aspects pertaining to medication safety.
  18. Content Article
    Modern health systems must embrace digital technologies to address challenges like ongoing shortages in the global health and care workforce, significant diagnostic backlogs and the requirements of diverse and ageing populations. The COVID-19 pandemic and the exceptional advances in artificial intelligence (AI) and machine learning (ML) have accelerated the drive towards digitalisation of health systems. However, making digital health technologies work in practice remains challenging in terms of how these technologies are designed, how their performance and safety in operation are assured and how their impact on staff and on patients is assessed, writes Mark Sujan in this BMJ Editorial.
  19. News Article
    The Health and Social Care Select Committee have commissioned an Expert Panel to consider the Government’s progress against accepted recommendations from public inquiries and reviews on patient safety. The Panel will consider a range of recommendations made by public inquiries and reviews on both patient safety and whistleblowing and subsequently select a number of these for evaluation. The Panel will in its final report provide a rating of the Government’s progress against each of these recommendations. Panel members are: Professor Dame Jane Dacre (Chair). Sir Robert Francis KC Anita Charlesworth Professor Stephen Peckham Sir David Pearson Professor Emma Cave Read full story Source: House of Commons Health and Social Care Select Committee, 24 October 2023
  20. News Article
    You might not have heard of a ‘physician associate’ - and that’s not your fault. They probably won’t tell you. A physician associate walks and talks like a doctor, but they are no replacement for one. To become a physician associate you need to complete a two-year postgraduate course or three-year apprenticeship. But despite much less learning than the five years a junior doctor must undergo to be qualified, they are often paid more than them. Which is why the government’s plan to flood the NHS with 10,000 more of them over the next 15 years doesn’t make any sense. There’s certainly no money-saving aspect. This is simply another corner-cutting exercise to quickly plug gaps in a struggling NHS that will put patients at risk. Far from saving doctors work (their original purpose), they often create more. Physician associates are unregulated so cannot be held accountable for their mistakes, meaning doctors must recheck any critical decisions they make. Critical decisions are made quite frequently in hospitals. But they’re not just overstretching doctors and creating more work; they’re harming patients. A recent Daily Mail investigation has found brain bleeds misdiagnosed as inconsequential headaches and lung disease mistaken for a chest infection. Doctors say they are “increasingly concerned” by this. Read full story Source: LBC, 16 October 2023
  21. News Article
    Eighteen more hospitals in England contain potentially crumbling concrete, bring the total affected to 42, the Department of Health and Social Care has confirmed. The reinforced autoclaved aerated concrete (Raac) has also been found in 214 schools and colleges in England as well as thousands of other buildings. NHS Providers, which represents hospitals, said the concrete "puts patients and staff at risk". Full structural surveys are taking place at all newly confirmed sites. The government said it was committed to eradicating Raac from NHS buildings completely by 2035. Seven of the worst-affected hospitals will be replaced by 2030 as part of the programme to build 40 new hospitals in England, it added. Read full story Source: BBC News, 21 October 2023
  22. Content Article
    A dementia diagnosis is a fundamental first stage of the dementia pathway. Missing out on an early and accurate diagnosis can have a significant negative impact, for example limiting access to symptom management interventions, ultimately leading to poorer outcomes and increased health and social care costs.  This inquiry focuses on understanding the scale of impact of regional health inequalities on access to a dementia diagnosis and developing solutions to reduce their influence.
  23. Content Article
    This is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
  24. Content Article
    Physician associates (PAs) work alongside doctors and form part of the multidisciplinary team. They work across a range of specialties in general practice, community and hospital settings. Anaesthesia associates (AAs), sometimes also known as physicians’ assistants (anaesthesia), work as part of the anaesthetic team. They provide care for patients before, during and after their operation or procedure. This General Medical Council (GMC) page outlines the roles of PAs and AAs and what the regulation will look like.
  25. Content Article
    Historically, patient safety efforts have focused mostly on measuring and responding to harm. However, safety is much more than the absence of harm. Instead, patient safety includes looking at the whole system: its past, present and future in all its complexity. Healthcare Excellence Canada and Patients for Patient Safety Canada held many conversations with users of the health system, people who work in healthcare and safety scientists. The ideas collected suggest a new way of approaching patient safety – where everyone can contribute to creating safe conditions and where harm is more than physical. This discussion guide summarises what has been learned so far and captured in this key statement: Everyone contributes to patient safety. Together we must learn and act to create safer care and reduce all forms of healthcare harm.
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