Patient-Safety-Learning

Kerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in two months. In March 2021 she complained of having per vaginal bleeding for six weeks and she was referred for an ultrasound. Due to her underlying ill health, she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. There were a number of missed appointments and a colonoscopy took place on 20 October 2021. The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged. The CT scan on 28 October 2021 demonstrated a large pelvic mass and she was referred to the gynaecology team in early December and a multidisciplinary team meeting discussion on 17 December 2021 led to a request for an MRI scan. Appointments were made for 31 December 2021, 25 January 2022 and again in February but not attended and she eventually underwent an MRI on 1 May 2022 which revealed a large mass. She was again discussed at the multidisciplinary team meeting on 6 May 2022 and referred to the gynae-oncology surgeons at Maidstone hospital. She was seen on 1 June 2022 and booked for surgery on 27 June 2022. She was, however, far too unwell for surgery on 27 June 2022 and further investigations revealed brain metastases. She was admitted to hospital and treated with steroids and referred to the Oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but she was, by now, too unwell to receive even palliative radiotherapy. She was taken to Medway Maritime hospital on 19 August 2022 and was struggling as she had been so unwell at home. Whilst plans were being made to provide some care at home she remained overnight but sadly died on 20 August 2022 as she was so unwell she could not return home.

This report from Public Policy Projects (PPP) calls for changes in the use of approved medicines to improve diabetes care in the UK. It is the first in a series looking at specific areas of diabetes care in the UK.

Despite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic quality, and many diagnostic safety events are not recognised. Without methods to identify, measure, investigate and analyse events, healthcare organisations cannot understand causes of diagnostic errors, identify contributing factors or create solutions. One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error. 

The National Diabetes Foot Care Audit (NDFA) has published a State of the Nation report for 2018 to 2023. Based on data from England and Wales from 1 Apr 2018 to 31 Mar 2023, it details the findings and recommendations relating to the assessment, outcomes and participation in the NDFA for this period. Ulceration of the foot in people living with diabetes presents significant challenges, including emotional, physical and financial costs, and is associated with increased risk of both amputation and death. It affects between 1 and 2% of all people with diabetes each year and its management accounts for approximately 1% of the total NHS budget. The overall aim of the NDFA is to measure factors associated with increased risk of ulcer onset and adverse ulcer outcomes, and to share information relating to best clinical practice. This report contains three key findings: The time to first expert assessment (FEA) is key to achieving the positive outcomes of being alive and ulcer free (AAUF) at 12 weeks There is a marked variation between foot care services both in terms of assessment and outcomes There are wide ranging differences between regions, integrated care boards and services in ulcer registration rates, and also the percentage of those registered that are classified as severe.

Women with learning disabilities are less likely to access cervical and breast cancer screening when compared to the general population. In this study, the Social Ecological Model (SEM) was used to examine the inequalities faced by women with learning disabilities in accessing cervical and breast cancer screening in England. The study highlighted the following barriers to access for women with learning disabilities:Women with learning disabilities may lack knowledge of cancer symptoms and cancer screening, as well as being scared about the process and getting the results. The attitudes of family and paid carers towards screening may influence women with learning disabilities' decisions as to whether screening is seen as favourable; support and training may ensure unbiased perspectives. Barriers associated with how cancer screening programmes are designed, such as postal invitations which assumes an ability to read. Screening staff need to be aware of the general needs of people with learning disabilities, such as the benefits of easy-to-read documents. Multidisciplinary working is required so reasonable adjustments can be embedded into cancer screening pathways.The authors suggest that multiple methods to reduce the inequalities faced by women with learning disabilities are needed, and that these can be achieved through reasonable adjustments. Embedding reasonable adjustments can support women with learning disabilities in making an informed decision and accessing screening if they choose to. This may result in women with learning disabilities getting a timely cancer diagnosis.

The NHS Health Check is a free check-up of your overall health. It can tell you whether you're at higher risk of getting certain health problems, such as heart disease, diabetes, kidney disease and stroke. Local authority commissioners have a statutory responsibility for delivering the NHS Health check to the eligible population within their area. All the information collected through NHS Health Checks is sent through to the relevant GP practice, and results in either no action required, lifestyle and behaviour advice and information to reduce CVD risk, or clinical intervention if needed. The Professional Records Standards Body (PRSC) is running a survey to gain views form healthcare professionals and IT system suppliers on the information recorded through NHS Health Checks. The results of the survey will inform the development of an information standard that will ensure that the information collected is recorded and communicated in a standardised format, using recognised clinical coding wherever possible. The government is also undertaking the development of a digital version of the NHS Health Check as a delivery option for the future, where a person can choose to complete the health check questions online and carry out biometric tests at home, before the results are written back to the GP record–therefore some questions in the survey may reflect this new development by way of future proofing the information standard once a digital option is available.

Suicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, examples of optimal practice that help to keep patients safe also often important learning for organisations and healthcare professionals. This study in BMC Psychiatry aimed to explore clinicians’ views of what constitutes good practice in mental healthcare services in the context of suicide prevention. The study highlighted clinicians’ views on good practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. The authors concluded that clinicians possess important understanding of optimal practice, but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.

In this blog, Kristy Widdicombe-Dutch shares her decades-long experience of harmful healthcare that has left her with a complete loss of trust in the system. She describes how, starting in her 20s, she has experienced disbelief, gaslighting and poor care in relation to her vascular issues, which has left her with long-term physical harm and psychological trauma.

The Royal College of Nursing (RCN) is developing a professional framework for nursing which will encompass the whole nursing workforce, from the nursing support worker through to the consultant nurse. Beyond the point of registration, the work of the registered nurse increases in its complexity, and as part of this framework, the RCN has developed definitions of the levels of nursing practice beyond registration. This webpage provides definitions and standards for enhanced, advanced and consultant levels of nursing. These definitions will help those who aspire to practice at these levels, as well as giving greater clarity to employers and higher education institutions. They can be applied across all fields of nursing and in all settings.

This cohort study in JAMA Network Open aimed to determine the prognostic performance of the simplified Geneva score and other validated risk assessment models (RAMs) to predict venous thromboembolism (VTE) in medical inpatients. The study provided a head-to-head comparison of validated RAMs among 1352 medical inpatients. It found that sensitivity of RAMs to predict 90-day VTE ranged from 39.3% to 82.1% and specificity of RAMs ranged from 34.3% to 70.4%. The authors concluded that the clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

Worldwide, more than 99% of the burden of measles infections and deaths affects populations in low-income and middle-income countries. Measles accounts for 3% of the global mortality of children younger than five years, constituting 90% of deaths from measles, and rubella is the main vaccine-preventable cause of birth defects. Vaccine coverage, both through routine immunisation and supplementary immunisation activities, remains below targets for measles elimination, with considerable heterogeneity between and within countries. This Lancet article looks at how microneedle patches (MNPs) could potentially improve coverage of childhood vaccinations by providing a more thermostable, individual-dose, injection-free vaccine delivery device suitable for administration by local, non-medical personnel. MNPs could also reduce wasted vaccine doses, needle-stick injuries and breaks in the cold chain, as well as making waste management easier.