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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The UK government's commitment to implement “Martha’s rule,” is good news for patients. It will give patients and their families an explicit right to request a second opinion if a patient’s health condition is getting worse and they feel their concerns are not being taken seriously. However, all patients are familiar with the power imbalance when they encounter health professionals.  Patients and carers are key partners in the quest to make care safer, argues Tessa Richards in this BMJ opinion piece. Although actively co-designing research and policy on patient safety with patients and carers is now widely seen as best practice, there is still a long way to go. In her article, Tessa highlights two recent webinars with Henrietta Hughes, Patient Safety Commissioner, who is responsible for implementing Martha’s rule in NHS hospitals, and discusses patient advocacy and the new Patient Safety Partners. Watch the Patient Safety Learning webinar with Henrietta Hughes.
  2. News Article
    The NHS has too few staff to prepare for a pandemic surge, while its ageing buildings and social care’s weak ‘resilience and capacity’ would also undermine its response, NHS England has warned. A new NHSE submission to the Covid-19 public inquiry says funding pressure from 2010 has undermined the health service’s “resilience” and that “resilience and capacity issues in social care are national issues which must be addressed from the centre”. The document was posted unnoticed on the inquiry website last month. No current or former NHSE leaders have so far given evidence to the inquiry. It is the first time NHSE has clearly set out that understaffing and underinvestment compromised the service’s readiness to deal with the pandemic. Referring to the NHS’s ability to create “surge capacity [with] flexible staff and equipment which can be pivoted into different roles”, it goes on: “It is only possible to train staff to work more flexibly into different roles/environments if they can be freed up to attend training and refreshers. “This requires ‘surplus’ staff numbers on rotas, which is not currently possible in relation to many staffing groups across the NHS.” Read full story (paywalled) Source: HSJ, 3 October 2023
  3. News Article
    Transgender people may be banned from single-sex hospital wards under plans to restore "common sense" in the NHS, the health secretary says. Speaking at the Conservative party conference, Steve Barclay announced a consultation on strengthening the protections in place for women. NHS guidance issued in 2021 said trans people may be placed on wards according to the gender they identify as. The change would stop that with trans people given their own rooms and areas. But doctors have questioned whether there are the facilities available to achieve that. And the move would have to meet the legal threshold set by the Equality Act, which allows trans people to be excluded from single-sex spaces if there is a proportionate means of achieving a legitimate aim, such as privacy or safety. Mr Barclay said he wanted to make sure the "dignity, safety and privacy" of all patients was respected, while the rights of women are protected. Read full story Source: BBC News, 3 October 2023
  4. Content Article
    Aortic valve replacement (AVR) is a life-saving procedure for symptomatic severe aortic stenosis (AS), which relieves symptoms, increases life expectancy and improves quality of life. Little is known about the rate of AVR provision by gender, race or social deprivation level in the NHS across England. However, a large analysis examining AVR on the health service in England – the first of its kind – reveals striking inequalities in its provision. Women, black and Asian people, and those living in the poorest parts of the country are much less likely to receive the life-saving procedure, the study shows. “In this large, national dataset, female gender, black or south Asian ethnicities and high deprivation were associated with significantly reduced odds of receiving AVR in England,” the authors wrote. Dr Clare Appleby, a consultant cardiologist at the Liverpool Heart and Chest hospital NHS foundation trust and an author of the study, said public health initiatives to understand and tackle these inequalities should be prioritised. “Severe symptomatic aortic stenosis is a serious disease that causes mortality and reduces quality of life for patients,” she said. “Left untreated it has a worse prognosis than many common metastatic cancers, with average survival being 50% at two years, and around 20% at five years.” Further research and public health initiatives to understand and address inequalities in the timely provision of AVR are important and should be prioritised in England.
  5. News Article
    The impact of successive doctors’ strikes is now ‘causing significant disruption and risk to patients’, including to those needing urgent heart and cancer treatment, NHS England leaders have told the BMA in their strongest warnings yet. A letter to the union’s council chair on Tuesday evening, leaked to HSJ, said: “We are increasingly concerned that the cumulative impact of this action is causing significant disruption and risk to patients… “We are extremely concerned that Christmas Day cover is insufficient to ensure appropriate levels of patient safety are being maintained across local health systems. This is particularly the case in the current period of industrial action, with three consecutive Christmas Day levels of service.” Although Christmas Day includes cover for emergency care, the officials said that in practice – with demand above Christmas Day levels, and with successive days and repeated strikes – it was not protecting patients needing urgent care. The letter, signed by NHSE leaders including chief medical officer Sir Steve Powis, and chief nurse Dame Ruth May, goes on: “Secondly, we are becoming increasingly concerned that combined periods of industrial action are impacting on our ability to manage individuals who require time-sensitive urgent treatment, for example cardiac, cancer or cardiovascular patients, or women needing urgent caesarean sections.” Read full story (paywalled) Source: HSJ, 3 October 2023
  6. Content Article
    Despite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework.
  7. Content Article
    Martha’s Rule is currently a topic of intense discussion and debate. Behind the rule is a sad and tragic story which strikes at the heart of NHS care delivery – clinical failures and the death of a 13-year-old girl. In this blog, John Tingle argues there is a need to formalise the right of patients and their families/carers to obtain an urgent clinical review, second opinion.
  8. Event
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    This upcoming webinar from the Care Quality Commission will focus on quality statements and evidence categories. It will talk through where these two elements fit in the wider new regulatory approach and what guidance is available to help you understand them. The webinar will focus on example quality statements to explore how CQC will use evidence categories to identify specific sources of evidence to use in their assessments. Alongside the provider guidance, this webinar will give you the information you need to understand the evidence that CQC use to assess each of their new quality statements. This one-hour webinar will be an opportunity for providers and professionals who work in health and social care services, organisations who represent them and other stakeholders to hear the latest updates about CQC's new regulatory approach. The webinar will be led by Dave James, Head of Policy – Adult Social Care and Amanda Hutchinson, Head of Regulatory Change. Register
  9. Event
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    An online half day conference from the Legal Training Consultancy with a panel of seven speakers, including five KCs. Who should attend? The conference will appeal to solicitors, barristers, medical professionals, expert witnesses, NHS Trusts and Private Health Providers, insurers and associations. Topics Causation and divisible vs indivisible injuries. Scope of the Duty of Care. The law on consent to medical treatment following McCullough v Forth Valley Health Board in the Supreme Court. A medical perspective on proposals for reform of medical litigation. Case law update. CCC v Sheffield Teaching Hospitals and “lost years” compensation. Early investigation of cerebral palsy claims: The lessons learned. Speakers: Alexander Hutton KC, Hailsham Chambers Ben Collins KC Old Square Chambers Richard Booth KC, 1 Crown Office Row Richard Baker KC, 7BR Owain Thomas KC 1 Crown Office Row Jeremy Pendlebury, 7BR Hugh Whitfield , Consultant Urological Surgeon Register
  10. Content Article
    Throughout October’s Speak Up Month, the National Guardian for the NHS, Dr Jayne Chidgey-Clark will be in conversation with guests who have their own speaking up stories and reflecting on how we can break the barriers they faced to make a better and safer speaking up culture across healthcare in England.
  11. News Article
    A group of 67 women from Greenland are seeking compensation from the Danish government over a campaign of involuntary birth control in the 1960s. At least 4,500 women, some of them teenagers, were fitted with coils under a programme intended to limit birth rates among the indigenous population. An inquiry is due to conclude in 2025, but the women, some of whom are in their 70s, want compensation now. They are seeking 300,000 kroner (£34,880; $42,150) each. Records from the national archives showed that, between 1966 and 1970 alone, intrauterine devices (IUDs) were fitted into the women, some as young as 13, without their knowledge or consent. A commission set up by the Danish and Greenlandic governments to investigate the programme is not due to deliver its findings until May 2025. "We don't want to wait for the results of the inquiry," said psychologist Naja Lyberth, who initiated the compensation claim. "We are getting older. The oldest of us, who had IUDs inserted in the 1960s, were born in the 1940s and are approaching 80. We want to act now." Ms Lyberth said that, in some cases, the devices fitted had been too big for the girls' bodies, causing serious health complications or even infertility, while in others the women had been unaware of the devices until they were discovered recently by gynaecologists. She accused the Danish government of the time of wanting to control the size of Greenland's population in order to save money on welfare. "It's already 100% clear that the government has broken the law by violating our human rights and causing us serious harm," she said. Read full story Source: BBC News, 3 October 2023
  12. News Article
    A trust has been reprimanded by the Information Commissioner’s Office (ICO) for exposing a domestic abuse victim to risk by disclosing their address to an ex-partner. University Hospitals Dorset Foundation Trust is one of only seven organisations in the UK – and the only NHS organisation – to have received a reprimand since July 2022 for a data breach involving a victim of domestic abuse. According to new details released by the ICO, University Hospitals Dorset received a reprimand in April this year over a procedure it had in place that, when sending correspondence by letter, would include the full addresses of all recipients of that letter without their consent to do so. In the case that was referred to the ICO, the subject of the data breach had their full address revealed to their ex-partner despite previous allegations of abuse, which has created a “risk of unwanted contact which will remain”. The ICO concluded that, while the subject did not request their address be withheld, it would not be a reasonable expectation that personal information would be shared without prior consent. The report raised concerns that UHD did not have a clear policy in place for managing situations where there are parental disputes and that no formal training was provided to administrative staff for dealing with such circumstances. Read full story (paywalled) Source: HSJ, 2 October 2023
  13. News Article
    The mother of a four-year-old boy with complex needs said she fears he could die waiting for life-changing surgery. Collette Mullan made the claim to BBC Spotlight as it examined the scale of hospital waiting lists. Northern Ireland has the worst waiting times in the UK, with more than half a million cases queued for an outpatient or inpatient appointment. The Department of Health has described current waiting lists as "entirely unacceptable". Óisín, from County Londonderry, has a number of health conditions including cerebral palsy, and is currently waiting for two procedures. He is fed with a tube that carries his food through his nose into his stomach, but since it was inserted six months ago, his mum Collette said he has struggled to breathe. Óisín is now waiting to have the nasogastric tube removed and replaced by a different feeding system which goes directly to his stomach. Collette said she was told it could be a three-year wait for the procedure. She is concerned that Óisín's cerebral palsy puts him at a greater risk of complications, saying she had been warned there was a danger he could aspirate. "He could die. Anything going into his lung really, it could be very dangerous," she said. Read full story Source: BBC News, 3 October 2023
  14. Event
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    B Braun will be hosting a free ESSIG sustainability day. There will be a full programme of talks and discussion plus the chance to catch up with Barema/ESSIG colleagues. Sustainability impact on Industry. Sustainability impact on the NHS. Sustainability impact on the environment. Register
  15. Content Article
    Previously well, Gaia died aged 25 years of an unexplained brain condition hours after admission to University College Hospital London. Her death has been the subject of hospital investigations and an inquest. Over one year later her death remains unexplained. Why? This is her mother’s (Dorit) search for the truth: information is provided to stimulate medical crowd thinking – to ask the right questions and to get the right answers. Read the narrative of Gaia’s final illness in her mother’s story and in the memorandum from the link below. See also: Serious Incident Report: Unexpected deterioration of a young woman on the Acute Medical Unit: updated report (February 2022)
  16. News Article
    Former police officers, including a murder detective, have been hired by NHS hospitals in a move that campaigners have warned risks discouraging whistleblowers. The Sunday Telegraph has revealted that retired officers have been employed by a trust currently under scrutiny for its treatment of doctors who raise patient safety concerns. One of them has taken up a patient safety incident investigator role worth up to £57,349 a year. Meanwhile a senior detective has been called into multiple trusts on an ad hoc basis to conduct investigations. Last night a leading patient group called on the NHS to be transparent about exactly how such personnel are being used, “given the ongoing concerns about how such roles interact with whistleblowers”. Paul Whiteing, chief executive of the charity Action Against Medical Accidents (AvMA), said: “We at AvMA welcome any steps taken by Trusts to professionalise the investigation of patient safety incidents. This is long overdue. “But given the on-going concerns about how such roles interact with whistleblowers, to maintain trust and confidence of all of the staff, trusts need to be clear, open and transparent about why they are making such appointments and the role and duties of those they employ to fulfil them, whatever their backgrounds.” Campaigners have warned that some NHS trusts deliberately seek to conflate patient safety issues with staff workplace investigations. Read full story (paywalled) Source: The Telegraph, 30 September 2023
  17. News Article
    Thousands of women may be missing out on a diagnosis of type 2 diabetes because the thresholds are geared towards men, research suggests. Scientists assessed test results from more than one million patients across the country and concluded that the bar for diagnosis might be set too high for women. They calculated that, if thresholds were lowered slightly, an extra 35,000 women under the age of 50 in England would be diagnosed with type 2 diabetes — increasing the number in this age group with the condition by 17%. Under the present guidelines, those 35,000 women would be given the all-clear and would miss out on the chance of earlier treatment and lifestyle advice, increasing their risk of complications in later life. The team, led by doctors at the University of Manchester and including researchers from hospitals nationwide, stressed that their findings were preliminary, and needed further assessment before their hypothesis was confirmed. But, if proved correct, they believe that about 65 young women may be dying of diabetes each year without a diagnosis. Read full story (paywalled) Source: The Times, 1 October 2023
  18. News Article
    An NHS hospital trust in Nottingham failed to send more than 400,000 digital letters and documents to GPs and patients, BBC News can reveal. A former employee has told of "a lack of responsibility" over a new computer system. Patient body Healthwatch said it was "deeply concerned" by the scale of the incident and the impact on care. The trust says a full investigation took place in 2017 and found no significant harm to patients. But it has now said it will carry out a review of that investigation and take any further action needed. The healthcare regulator the Care Quality Commission (CQC) said it was not aware of the incident and would be following up with the trust. This is the second major incident in England involving unsent NHS letters uncovered by the BBC recently. Read full story Source: BBC News, 30 September 2023
  19. News Article
    NHS trusts are sharing intimate details about patients’ medical conditions, appointments and treatments with Facebook without consent and despite promising never to do so. An Observer investigation has uncovered a covert tracking tool in the websites of 20 NHS trusts which has for years collected browsing information and shared it with the tech giant in a major breach of privacy. The data includes granular details of pages viewed, buttons clicked and keywords searched. It is matched to the user’s IP address – an identifier linked to an individual or household – and in many cases details of their Facebook account. Information extracted by Meta Pixel can be used by Facebook’s parent company, Meta, for its own business purposes – including improving its targeted advertising services. Records of information sent to the firm by NHS websites reveal it includes data which – when linked to an individual – could reveal personal medical details. It was collected from patients who visited hundreds of NHS webpages about HIV, self-harm, gender identity services, sexual health, cancer, children’s treatment and more. It also includes details of when web users clicked buttons to book an appointment, order a repeat prescription, request a referral or to complete an online counselling course. Millions of patients are potentially affected. Read full story Source: The Guardian, 27 May 2023
  20. News Article
    Prescribers should not start any new patients on some ADHD medicines because of a national shortage, the Department for Health and Social Care has warned. GPs are also being asked to identify and contact all patients currently prescribed the medicines to ensure they have supplies to last. A national patient safety alert said there were ‘supply disruptions’ of various strengths of methylphenidate, lisdexamfetamine and guanfacine. It follows a previous alert about shortages of atomoxetine capsules in August which is set to resolve next month, DHSC said. The shortages are due to a combination of manufacturing issues and an increased global demand, the alert explained. With the latest issues expected to continue to December for some medicines, new patients should not be started on the products affected by shortages until the supply issue resolves, the guidance sent to healthcare professionals said. Where patients do not have enough to last until the re-supply date – which differs depending on the medicine in question – GPs are being asked to contact pharmacies to find out about stocks and reach out to the patient’s specialist team for advice if a product cannot be sourced. Read full story Source: Pulse, 28 September 2023
  21. Content Article
    There are supply disruptions affecting various strengths of the following medications which are licensed for the treatment of attention deficit hyperactivity disorder (ADHD): methylphenidate (Equasym® XL) capsules, methylphenidate (Xaggitin XL® , Concerta XL® , Xenidate XL® ) prolonged-release tablets, lisdexamfetamine (Elvanse® ) capsules, and guanfacine (Intuniv® ) prolonged-release tablets. This is a safety critical and complex National Patient Safety Alert. Implementation should be co-ordinated by an executive lead (or equivalent role in organisations without executive boards) and supported by clinical leaders in pharmacy, community pharmacy, GP practices, mental health services and those working in the health and justice sector.
  22. Content Article
    Commercial aviation practices, including the role of the pilot monitoring, the sterile flight deck rule, and computerised checklists, have direct applicability to anaesthesia care. Checklists are commonly used in the operating room, especially the World Health Organization surgical safety checklist. However, the use of aviation-style computerised checklists offers additional benefits. In this editorial, Jelacic et al. discuss how these commercial aviation practices may be applied in the operating room.
  23. Content Article
    In this BMJ article, Anna Tylor describes the assumptions she faces as someone who is visually impaired, and how healthcare professionals can make information accessible for blind and partially sighted people.
  24. Content Article
    Incident investigation remains a cornerstone of patient safety management and improvement, with recommendations meant to drive action and improvement. However, there is little empirical evidence about how—in real-world hospital settings—recommendations are generated or judged for effectiveness.
  25. Content Article
    The National Early Warning Score (NEWS2) is calculated using routine vital sign measures of temperature, pulse and so on. It is used by ambulance staff and emergency departments to identify sick adults whose condition is likely to deteriorate.  NEWS2 has been shown to work among the general population. However, it has been unclear if it could monitor the condition of care home residents because of their age, frailty, and multiple long-term conditions. New research from the National Institute for Health and Care Research (NIHR) shows that, among care home residents admitted to hospital as an emergency, NEWS2 can effectively identify people whose condition is likely to get worse.
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