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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    The true picture of A&E waiting times in Wales has been seriously under-reported for a decade, the BBC can reveal. The Royal College of Emergency Medicine (RCEM) has established thousands of hours are missed from monthly figures. Senior A&E doctors have been raising the issue for months. The Welsh government said it would ask health boards for assurances they were following the guidance "to ensure the data is absolutely transparent". The RCEM said it could not measure "how bad" things were because thousands of patients subject to so-called "breach exemptions" were not included in the overall A&E waiting times. The Welsh government initially disputed the RCEM's claim, but after seeing detailed figures - which were obtained through freedom of information (FOI) requests to health boards - it changed its position. Wales' health minister has repeatedly claimed A&E waiting times in Wales have "bettered English performance". But once the missing data is taken into account, it suggests the performance in Wales is worse. Read full story Source: BBC News, 16 October 2023
  2. Content Article
    In this webinar, Chloe from the Getting It Right First Time (GIRFT) programme and Raj, a patient who had had surgery at a surgical hub an hour and half away from his home, talk about a project to improve the elective surgical hub programme based on patients' experiences and feedback. They were joined by the Patients Association project manager, Hannah.  Elective hubs are surgical centres on existing hospital sites, separated from emergency services, which means the facilities can be kept free for patients waiting for planned operations, reducing the risk of short-notice cancellations. Raj speaks candidly of his experiences in the early days of the project, and Chloe explains how patient experiences have enabled the NHS to improve the service. 
  3. Content Article
    The case of Lucy Letby has dominated recent headlines and caused widespread shock. Much of the early discussion in the media after the verdict has focused on whether NHS managers mishandled concerns and suspicions raised by doctors about the sudden deaths of babies and potential criminal actions—and has labelled the doctors raising those concerns as the problem. But a polarised narrative of doctors versus managers won’t help resolve many underlying systemic issues in the NHS, writes David Oliver in this BMJ opinion piece. Many managers are themselves current or former clinical practitioners, so the divide isn’t sharp. Many of the serious problems currently affecting culture and morale in the NHS workforce happen with doctors, nurses, and other clinical staff in influential leadership and management roles. Simplistic and politicised talk of “pen pushers,” “bureaucrats,” and “too many managers” ignores the fact that many of the people in charge have clinical qualifications.
  4. Content Article
    Clinical trial documents are complex and may have inconsistencies, leading to potential site implementation errors and may compromise participant safety. This study characterises the frequency and type of administrative and potential patient safety interventions (PPSIs) made during the review of oncology trial documents for clinical trial implementation by centralized clinical content specialists. The study demonstrates a gap in patient safety when assessing trial documents for clinical trial implementation. One solution to address this gap is the utilisation of a centralised team of clinical specialists to preemptively review trial documents, thereby enhancing patient safety during clinical trial conduct.
  5. Content Article
    Much has been written recently about Martha’s rule—the proposal to allow patients in hospitals in England and their families the right to demand an urgent second opinion if their condition is deteriorating. In this BMJ opinion piece, Helen Haskell outlines some principles for creating an effective family activated system, including breadth, urgency, continuity, independence and feedback.
  6. News Article
    The mother of a patient at Muckamore Abbey Hospital has described how her son contracted tuberculosis (TB) while at the hospital. She said he had been left severely disabled after a series of associated strokes. Patient P116 is now 40 years old and has suffered from severe epilepsy since he was a baby. His mother told the inquiry into abuse at the hospital that her concerns over her son's health were ignored. She said that even after he began developing symptoms - including losing six stone (38kg) of weight - staff seemed "not to care". In the end, he was only diagnosed with TB after his mother took him to hospital herself. Due to the delay in the diagnosis and the way the family's complaint was handled, a serious adverse incident review was carried out and P116's mother received a letter of apology from the then permanent secretary at the Department of Health, Richard Pengelly, and Theresa Villiers, who was Northern Ireland secretary at the time. His mother told the inquiry her son's time in Muckamore remained a "major trauma" for the family and she still found it very difficult to talk about. She told the inquiry she felt strongly that "independent expert support" should be given to patients abused or neglected in Muckamore, including specialist counselling for the patients and their families. Read full story Source: BBC News, 12 October 2023
  7. News Article
    Weight management is a sensitive topic. Nevertheless, the measurement is often used as a marker to inform medical decisions or for someone's personal interest. But for many wheelchair users, accessing scales has proved near impossible. "The last time I was weighed was about 22 years ago, " Lizzie tells the BBC podcast, Access All. "I think I was about 15." As a result, now aged 37, Lizzie has been through three successful pregnancies, all without knowing how her body was adapting or how her baby was growing. Based in Devon, she has a degenerative muscle-related impairment and uses a wheelchair. This makes weighing herself on traditional bathroom scales, which require you to stand still and independently on a small platform, a challenge. There is equipment out there to help wheelchair users, like Lizzie. Chair scales enable someone to sit on a seat which records their weight and there are similar bed and hoist versions too. There are also wheel-on scales which are very large and involve subtracting the weight of the chair afterwards. But none of these seem widely available. Dr Georgie Budd, who is based in Merthyr Tydfil, says this worries her. A wheelchair user herself she appreciates how difficult it can be for people to access scales. "There's a lot of things that we use weight for in health - anaesthetics and drug dosing - and just to keep an eye on it as well for someone's general health. During pregnancy for example, if someone was losing weight I, as a GP, would actually be really quite concerned," she says. Neither NHS England nor the government have guidance for doctors nor advice on what equipment to use and no figures are kept on how many hospitals have access to such equipment and where they are. The National Institute for Health and Care Excellence (NICE) previously considered the issue in 2014 and requested more research be carried out. But so far nothing has been started. Read full story Source: BBC News, 13 October 2023
  8. News Article
    The community services waiting list has risen sharply to more than 1 million, with children suffering the longest waits, new data has revealed. NHS England figures published today show the adult community waiting list increased from 704,000 to 781,000 between October 2022 – the first published data available – and August. The children and young people’s list rose from 207,000 to 221,000. This means the overall community waiting list for England has exceeded 1 million for the first time since figures were first published in October last year. Waits for musculoskeletal services dropped to a low of 255,000 in January. But this progress has since reversed – and, in July, the number of people waiting for care climbed to a high point of 319,000. The waiting for podiatry and podiatric services, meanwhile, has climbed by 7% since October from 117,000 to 126,000, adding an extra 8,000 people to the waiting list. These services also account for 46 per cent – or 5,635 – of the waiting list over 52 weeks. Waiting lists for smaller adult specialties have also significantly worsened. For example, nursing and therapy support for long-term conditions saw large increases in three areas: continence and colostomy, rising by 16%; respiratory and COPD, rising by 27%; and diabetes, rising by 37%. Read full story (paywalled) Source: HSJ, 12 October 2023
  9. News Article
    Three patients have died after being given a bowel test by a doctor who failed to ensure treatment needed was carried out, a health board has said. NHS Greater Glasgow and Clyde (NHSGGC) said three more patients suffered harm. The six patients were identified in a clinical review the health board carried out of 2,700 people the consultant carried out a colonoscopy on between 2020 and 2022. The consultant, who has not been named, was suspended in November 2022 and has since left the health board. NHSGGC deputy medical director Professor Colin McKay said: “We would like to offer our sincere apologies to patients who were not followed up appropriately and our condolences to the families of those patients who have died." “Our investigations found that the doctor did not consistently follow up the results of investigations that had been completed or requested and therefore missed the opportunity for patients to be treated, including a number of patients who went on to develop malignancy." Read full story Source: The Independent, 11 October 2023
  10. News Article
    Valproate-containing medicines will be dispensed in the manufacturer’s original full pack, following changes in regulations coming into effect on Wednesday 11 October 2023. The Medicines and Healthcare products Regulatory Agency (MHRA) has published new guidance for dispensers to support this change. Following a government consultation, this change to legislation has been made to ensure that patients always receive specific safety warnings and pictograms, including a patient card and the Patient Information Leaflet, which are contained in the manufacturer’s original full pack. These materials form a key part of the safety messaging and alert patients to the risks to the unborn baby if valproate-containing medicines are used in pregnancy. The changes follow a consultation on original pack dispensing and supply of medicines containing sodium valproate led by the Department of Health and Social Care (DHSC), in which there was overwhelming support for the introduction of the new measures, to further support safety of valproate-containing medicines. Minister for Public Health, Maria Caulfield, said: “This safety information will help patients stay informed about risks of valproate, and I encourage all dispensers of valproate to consult the new guidance carefully. “This continues our commitment to listening and learning from the experiences of people impacted by valproate and their families and using what we hear to improve patient safety.” Read full story Source: MHRA, 11 October 2023
  11. Content Article
    This is guidance for dispensing of valproate-containing medicines in the manufacturer’s original full pack, following amendments to the Human Medicines Regulations (HMRs). These amendments currently apply in England, Scotland and Wales. This guidance should be regarded as good practice by pharmacists in Northern Ireland. The change comes into force in England, Scotland and Wales from 11 October 2023. 
  12. News Article
    The daughter of a man who took his own life after experiencing years of pain linked to botched dental surgery said she had "lost faith in the system". Clive Worthington, from Harlow, Essex, travelled to Hungary for dental implants in 2008. Several follow-up procedures from the same dentist back in the UK over the next seven years were unsuccessful. The government said it was addressing a so-called loophole which meant the 81-year-old missed out on compensation. Last week, an inquest concluded Mr Worthington's death in 2022 was a suicide. Senior Essex coroner Lincoln Brookes said the "long-term consequences" of Mr Worthington's unsuccessful dental surgery "impacted significantly on his mental health and ability to cope with daily life". In 2017, the General Dental Council (GDC) found Dr Eszter Gömbös, who was employed by Perfect Profiles, at fault for the work. Mr Worthington was awarded £117,378 in damages and legal costs at Chelmsford County Court in November 2019 - one of the highest pay-outs for dental negligence in the UK. But the insurer which covered Dr Gömbös - the Dental Defence Union (DDU) - argued "discretionary indemnity" and refused to pay. Read full story Source: BBC News, 12 October 2023 Related hub content “I’ve been mocked, scolded and gaslighted”: a harmed patient’s experience of orthodontic treatment A patient harmed by orthodontic treatment shares their story We want to hear from patients with experience of NHS and/or private orthodontists and dentists in any healthcare setting, including community practices and hospitals. Did the orthodontist/dentist give you the treatment and support you needed? If you had ongoing problems, how did the orthodontist/dentist and other healthcare professionals respond? Have you tried to make a complaint? Share your experience of orthodontist and dentistry services
  13. News Article
    The NHS waiting list in England has hit a new record high, with almost 7.8 million people waiting for treatment, data shows. An estimated 7.75 million people were waiting to start treatment at the end of August, up from 7.68 million in July. It is the highest number since records began in August 2007. The waiting list for treatment has been growing for much of the last decade, passing three million in 2014, four million in 2017, five million in 2021 and seven million in 2022. As the NHS waiting list grows A&E pressures are “ running red hot”, a major think tank has warned, with new figures showing 123,000 patients waited more than 12 hours in emergency departments last month. Some 8,998 people in England are estimated to have been waiting more than 18 months to start routine hospital treatment at the end of August, up from 7,289 at the end of July, according to data. A total of 396,643 people in England had been waiting more than 52 weeks to start routine hospital treatment at the end of August, up from 389,952 at the end of July. The Government and NHS England have set the ambition of eliminating all waits of more than a year by March 2025. Read full story Source: The Independent, 12 October 2023
  14. News Article
    NHS England plans to reduce follow-up appointments is leading to patient safety risks and causing waiting lists to grow, an acute trust has warned. The NHSE plans were set out in the 2023-24 planning guidance which says trusts must cut outpatient follow-ups by 25% against 2019-20 levels by March, to increase capacity for new patients. But North Cumbria Integrated Care Foundation Trust has raised concerns that adhering to the policy will “exacerbate” its follow-up backlogs, warning that the delays “potentially… pose a risk of harm to patients whose condition may deteriorate when follow-up is late”. NHS Confederation told HSJ it thought the policy “has risks” because it could mean that patients needing follow-ups will wait for longer, although the organisation also saw benefits. It said hospital leaders had “mixed feelings” about the policy. The Patients Association also raised concerns that cancelling follow-ups for some patients “will exacerbate health inequalities”. Read full story (paywalled) Source: HSJ, 12 October 2023
  15. News Article
    Two companies supplying staff to the NHS saw large growth in income and profits last year, annual accounts reveal. Independent Clinical Services, owned by a Canadian private equity firm, saw a growth in turnover of more than 40%, with income growing from £273m to £399m, year on year. A smaller company specialising in recruiting overseas healthcare staff to the UK also saw a bumper year, according to data released last month. Your World Recruitment Ltd’s income increased by nearly a third, going from £50.5m to £66.8m (up 32%), with a similar rise in profits. The company’s strategic report said: “Demand for agency staff and healthcare services in the first half of 2023 has remained strong principally due to staff shortages in the NHS and high waiting lists. “The board expects the challenging market conditions to continue for the remainder of 2023, although demand is expected to remain due to an acute shortage of healthcare workers in the UK and worldwide.” The NHS has been pushing hard for increased overseas recruitment in recent years, to fill domestic gaps." Read full story (paywalled) Source: HSJ, 10 October 2023
  16. Content Article
    Getting the president of the United States to consider enacting your policy proposals is a major achievement. Having him actually implement them is an accomplishment that can change lives. The patient safety movement reached that first milestone with a recent report by the President’s Council of Advisors on Science and Technology entitled, A Transformational Effort on Patient Safety. Whether advocates achieve the second, crucial goal remains very much an open question. The PCAST casts a wide net, examining everything from nanotechnology to the public health workforce. It appears until now to have addressed patient safety only tangentially, when in 2014 it was a small part of a larger report on accelerating health system improvement through systems engineering.  The good news for patient safety advocates is that President Joe Biden has shown a genuine understanding of the issue. Leah Binder, president of the Leapfrog Group, hailed the report in a statement that singled out two of the recommendations. The first one was to publicly report Never Events (medical errors that never should have happened) by individual facility. The second was a recommendation to establish a National Patient Safety Team. A major barrier standing between recommendation and implementation is the patient safety movement’s paltry political power. At present, patient safety has little public awareness and no grassroots constituency. Hospitals, on the other hand, are an integral part of almost every Congressional district, have a largely positive public image and are facing tough financial pressures. The White House will think long and hard about taking any actions hospitals see as unreasonable.
  17. News Article
    The UK’s rapidly growing number of specialist, associate specialist, and specialty (SAS) doctors and “locally employed” (LE) doctors need targeted and specific support to make the most of their expertise, the General Medical Council has said. SAS and LE doctors are the fastest growing part of the medical workforce, increasing by 40% in four years, from 45 578 in 2017 to 63 740 in 2021, said the regulator.1 This was largely driven by doctors from overseas coming to work in UK hospitals. SAS doctors are specialty and specialist grade doctors with at least four years of postgraduate training, including two in a specialty relevant to their area of work. Read full story (paywalled) Source: BMJ, 9 October 2023
  18. News Article
    The number of NHS-funded hip replacements carried out last year remained well below pre-covid levels, while the total funded privately nearly doubled to cover the shortfall, new data reveals. The National Joint Registry annual report, which tracks orthopaedic activity across the NHS, showed the number of NHS-funded elective hip replacements carried out at NHS facilities in 2022 was at its lowest level since 2007. However, the number of procedures performed in independent hospitals – both funded by the NHS and funded privately – has increased sharply. Orthopaedics is the biggest single elective specialty, with 847,000 of the current waiting list of 7.7 million on a trauma and orthopaedics pathway. As of July, 43% of these patients had been waiting longer than 18 weeks. The NJR report said: “The independent sector provision has increased hugely [since 2007] particularly in the last few years of covid recovery and there are now more hip replacements carried out in the independent sector than in the NHS. “Despite the cost-of-living crisis the number of hip replacements paid for privately has almost doubled since 2019.” Read full story (paywalled) Source: HSJ, 10 October 2023
  19. News Article
    The UK’s largest mental health charity, Mind, has published previously unseen data laying bare the full scale of the emergency in mental healthcare, with staff reporting 17,340 serious incidents in 12 months. The Care Quality Commission (CQC) figures shows mental healthcare staff across England reported an incident two times every hour in the last year, where people are treated for issues including self-harm, eating disorders and psychosis. Incidents included: injuries to patients that caused likely long term sensory, movement or brain damage, or physically damaged their body prolonged physical pain or psychological harm, or shortened life expectancy cases of abuse, including those involving the police injuries for which the patient needed treatment to prevent them dying. All of these incidents involved care providers raising concerns with the CQC under their statutory duty under Regulation 18. Dr Sarah Hughes, Chief Executive of Mind, says: “It is deeply worrying that healthcare staff across the country are so concerned about the situation in mental health settings that they are reporting a serious incident once every half an hour. We knew this was a crisis – now we know the scale of this crisis. People seek mental healthcare to get well, not to endure harm. Families are being let down by a system that’s supposed to protect their loved ones when they are most sick. The consequences can be and have been fatal". Read full story Source: Mind, 10 October 2023
  20. Content Article
    Simulation for non-pedagogical purposes has begun to emerge. Examples include quality improvement initiatives, testing and evaluating of new interventions, the co-designing of new models of care, the exploration of human and organisational behaviour, comparing of different sectors and the identification of latent safety threats. However, the literature related to these types of simulation is scattered across different disciplines and has many different associated terms, thus making it difficult to advance the field in both recognition and understanding. This paper, therefore, aims to enhance and formalise this growing field by generating a clear set of terms and definitions through a concept taxonomy of the literature.
  21. Event
    Medication errors are a leading cause of patient harm globally. Look-alike, sound-alike (LASA) medicines are a well-recognised cause of medication errors that are due to orthographic (look-alike) and phonetic (sound-alike) similarities between medicines, which can be confusing. Look-alike medicines appear visually the same with respect to packaging, shape, colour and/or size, while sound-alike medicines are similar in the phonetics of their names, doses and/or strengths. Confusions can occur between brand-brand, brand-generic or generic-generic names. Organisations need to prospectively design and implement strategies to identify LASA medication errors and build a robust system that intercepts them before they result in patient harm. At this webinar, WHO will launch their publication “Medication Safety for Look-alike, Sound-alike Medicines”, as part of the WHO technical series on “Medication Safety Solutions”. Preventive strategies that can be implemented by healthcare professionals and organizations will be discussed on how to prevent LASA errors to reduce the risk of medication-related harm. Register
  22. Content Article
    Information from ADHD on the elvanse and atomoxetine drug shortage and what you should do.
  23. Content Article
    It is important that people who work in health and care are trained, skilled and treat patients and service users well. Regulators and accredited registers help to keep you safe by ‘registering’ health and care practitioners - you should check a practitioner’s registration when you: Pay for private services from a health or care practitioner. Employ a health or care practitioner. Commission services from a health or care practitioner. Have concerns about a practitioner. The link below allows you to search for a practitioner.
  24. News Article
    Peter Marshall was delighted when he finally got an appointment after calling his GP surgery for several days. On the day, he saw a young medic who said his excruciating stomach pain was caused by irritable bowel syndrome (IBS) and suggested over-the-counter peppermint tablets to ease the discomfort. And off the 69-year-old retired IT specialist went, happy to have a diagnosis and treatment. In fact, Peter hadn't had an appointment with a GP — he had been seen by a physician associate (PA). This is a type of healthcare worker whose numbers are about to soar in the NHS in order to reduce the pressure on doctors so that they can concentrate on the most complex and seriously ill patients. It all sounds like a great idea. Indeed, PAs are now being employed across areas that are particularly stretched, with around a third of PAs working in GP surgeries and 10% in A&E departments, according to the latest census by the Royal College of Physicians. But they are actually spread across 46 NHS specialties, from urology and surgery to cardiology and mental health. In this role, they are permitted to carry out a range of medical tasks, from performing physical examinations, diagnosing patients and analysing test results to running clinics and performing minor procedures — as well as doing home visits — all under the supervision of a doctor. However, in the case of Peter Marshall, although he was reassured by his diagnosis, his symptoms were, in fact, a sign of bowel cancer — and he died nine months later, in January this year. His sister, who has told Good Health his story, says: 'My brother had no idea that he had seen a PA and not a qualified doctor — he didn't know the word physician associate even existed, no one does.' The family, from London, later received an apology from the PA. 'Patients are so desperate to get an appointment with their GP, you are grateful to see anyone and whatever they say, you accept,' she says. Read full story Source: Daily Mail, 9 October 2023
  25. News Article
    An NHS hospital has been accused of posing a continuing risk to patients by “covering up” leadership failures, including not properly investigating the deaths of two babies. Dr Max Mclean, chairman of Bradford Teaching Hospitals trust, has quit in protest at the conduct of the trust’s chief executive, Professor Mel Pickup, after no action was taken over serious concerns about her performance. In a blistering resignation letter, Mclean said he “cannot, in good conscience, work with a CEO who has fallen so short of the standards expected of her role that there is a genuine safety risk to patients and colleagues”. He is calling for senior national NHS figures to establish new leadership at the trust, and has written to the head of NHS England to share his concerns about Pickup, who has been in post since 2019. Mclean told The Times there were parallels with the Lucy Letby scandal, when management ignored the concerns of whistleblowers. “Patients are at risk, babies are at risk, and there could be avoidable deaths unless there is a change of leadership,” he said. The former detective chief superintendent who has chaired the trust since 2019, raised nine serious issues about Pickup’s performance, which he said were confirmed by an independent investigation that concluded last month. However, the trust’s board met on October 2 and decided there would be no further action against Pickup, leaving Mclean with “no option” but to resign and speak publicly. Read full story (paywalled) Source: The Times, 10 October 2023
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