Risk of death from unintended administration of sodium nitrite

NHS England | August 2020 | Risk of death from unintended administration of sodium nitrite

A National Patient Safety Alert has been issued on the risk of death from unintended administration of sodium nitrite.

About this alert

Sodium nitrite has one licensed indication: as an antidote to cyanide poisoning. It can cause significant side effects and is categorised as highly toxic. It should only be available in Emergency Departments.

Incidents have been reported where sodium nitrate was inadvertently administered instead of sodium bicarbonate, and other sodium containing injections. As the packaging and labelling of sodium bicarbonate ampoules are similar to unlicensed sodium nitrite ampoules, mis-selection errors are likely to be due to the inadvertent supply of sodium nitrite outside of Emergency Departments.

NHS acute trusts are asked to remove sodium nitrate injections from all clinical areas except Emergency Departments, and replace unlicensed sodium nitrite ampoules with licensed sodium nitrite vials. Pharmacies and Emergency Departments are also asked to change procedures and storage policies for all ‘specialist antidotes’.

Full details from NHS England

First do no harm. The independent medicines and medical devices safety review

Wide-ranging and radical recommendations call for widespread improvement across health system 

This report comes after a two-year review, chaired by Baroness Julia Cumberlege, of harrowing patient testimony and a large volume of other evidence concerning three medical interventions: Primodos, sodium valproate and pelvic mesh.

The report sets out nine major recommendations to bring much-needed help and support to those who have suffered as a result of these interventions, and to reduce the risk of avoidable harm from medicines and medical devices in the future.

Full report: First do no harm. The independent medicines and medical devices safety review

How to ensure safe and effective resuscitation for patients with Covid-19 #covid19rftlks

Jevon P et al (2020). How to ensure safe and effective resuscitation for patients with Covid-19. Nursing Times [online]; 116| 7 | 26-30.

Resuscitation of patients with Covid-19 presents a number of challenges to health professionals in hospitals and the community. This article discusses recent guidance and the controversy surrounding the use of PPE

Abstract

Caring for patients who are critically ill with Covid-19 presents a number of complex challenges including decisions regarding resuscitation and concerns about use of personal protective equipment while undertaking chest compressions. This article explores these issues, summarises recent guidance and provides an overview of what nurses should do when patients with confirmed or suspected Covid-19 require resuscitation.

Key points

  • The coronavirus pandemic poses serious health risks to health workers when resuscitating patients with Covid-19
  • Health professionals must discuss Do Not Attempt Cardio-pulmonary Resuscitation (DNACPR) decisions with the patient, or those close to the patient if the patient lacks mental capacity
  • Care for people with Covid-19 should aim to identify those who are deteriorating, treat them effectively and prevent
    cardiac arrest
  • There is confusion around guidance on personal protective equipment for the resuscitation of patients with Covid-19
  • The Resuscitation Council (UK) advises that chest compressions are an aerosol-generating procedure requiring level 3 PPE

Full article is available from Nursing Times

NHS England: NHS Roadmap To Safely Bring Back Routine Operations #covid19rftlks

NHS England | May 2020| NHS Roadmap To Safely Bring Back Routine Operations

Health leaders have set out a series of measures to help local hospitals plan to increase routine operations and treatment, while keeping the necessary capacity and capability to treat future coronavirus patients.

Over the coming weeks patients who need important planned procedures – including surgery – will begin to be scheduled for that care, with specialists prioritising those with the most urgent clinical need.

But, in line with measures currently in place to protect staff and patients who have been receiving urgent treatment during the pandemic, they will be required to isolate themselves for 14 days and be clear of any symptoms before being admitted.

Testing will also be increasingly offered to those waiting to be admitted to provide further certainty for patients and staff that they are COVID-free.

This approach will help to protect patients from potentially catching the virus in hospital, and help staff to ensure they are using the correct infection control measures and protective equipment.

Those requiring urgent and emergency care will continue to be tested on arrival and streamed accordingly, with services split to make the risk of picking up the virus in hospital as low as possible.

Those attending emergency departments and other ‘walk-in’ services will be required to maintain social distancing, with trusts expected to make any adjustments necessary to allow this.

As well as the requirements for those needing operations, as many outpatient appointments as possible will be conducted remotely, and those who do need a face to face consultation will be asked not to attend if they have COVID symptoms.

Those requiring a long hospital stay will be continuously monitored for symptoms and re-tested between 5 and 7 days after admission, and those who are due to be discharged to a care home will be tested up to 48 hours before they are due to leave.

Read the full piece from NHS England 

CQC: Safety and speaking up during the COVID-19 emergency #covid19rftlks

Care Quality Commission | April 2020 | Safety and speaking up during the COVID-19 emergency

The Care Quality Commission (CQC) has released a news release thanking  health and care staff all over England for their heroic responses to the many challenges facing them and the people they are caring for. The CQC recognises that this is an extremely stressful and difficult time for everyone and that many of you will have concerns about increased risks of unintentional harm to you, your colleagues and to people who use services.

So, now more than ever, safety remains a priority for the whole system. Everyone who has a role in providing care, or who receives care in England, needs to be more vigilant so that we can reduce the risk of avoidable harm to people. You can do this by following safety systems, guidance and recommendations that ensure the right care is provided, as intended, every time and continuing to report safety incidents locally using your professional and clinical judgement. The CQC need to continue to learn from what works as well as what does not.

All leaders of health and care services can support this by encouraging a supportive culture where people are able to speak up about risks and adverse outcomes, without fear of blame or repercussions. A psychologically safe culture provides a compassionate, inclusive, and trusting environment – one that shares safety insights and empowers people who use services and staff with the skills, confidence, and mechanisms to improve safety. This culture means we will hear more, learn more, and act more to improve care.

Importantly, the CQC want to encourage workers to speak up about anything that gets in the way of providing good care so that potential harm is prevented. The freedom to speak up has never been more important.

There are many ways to speak up. Please continue to report anything concerning you through your local risk management system. You can also speak up through a discussion with your line manager, a suggestion for improvement, a matter raised with a Freedom to Speak Up Guardian or bringing a matter to the attention of a regulator. Speaking up is an essential element of a safe culture and should be ‘business as usual’ for everyone working in care, regardless of their role.

But speaking up is only effective if listening happens. That’s why it’s so important that leaders understand that a Speak Up culture is not just about encouraging workers to raise concerns: it is about listening to what they are saying, acting on the information and providing feedback.

CQC provides information and guidance for all health and care staff about how to speak up, and a quick guide on raising concerns on this site.

The National Guardian for the NHS supports workers to speak up through a network of Freedom to Speak Up Guardians and provides information and guidance,as well as a list of organisations that can provide support and the directory of Freedom to Speak Up Guardians.

Finally, the CQC want to thank you for everything you are doing to encourage a safe culture and to make sure that you, your colleagues, and the people you care for are safer as a result.

Further information from the CQC

 

Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

Full reference: Panagioti, M. et al. | 2019| Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis| 

The BMJ has published  a systematic review and meta-analysis of  preventable patient harm across a range of settings, the review is available to read in full from the BMJ

Abstract

Objective To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.

 

Design Systematic review and meta-analysis.

 

Data sources Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.

 

Review methods Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.

 

Results Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6%. A pooled proportion of 12%  of preventable patient harm was severe or led to death. Incidents related to drugs and other treatments  accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties.

 

Conclusions Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.

 

The Healthcare Safety Investigation Branch launch online feedback form

Healthcare Safety Investigation Branch | August 2019 | Online feedback form launched so you can ‘tell us what you think’

The Healthcare Safety Investigation Branch (HSIB) have launched an online feedback form so that anyone involved in their healthcare safety investigations can tell HSIB what they think.

  • National investigations in general
  • Specific national investigations
  • Maternity investigations
  • HSIB in general

Full details from HSIB

BMJ study: 5 % of patients exposed to preventable harm across medical settings

BMJ | 2019| Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis

A systematic review with meta analysis observes that the prevalence of preventable patient harm across a range of settings, their analysis indicates that approximately 1 in 20 patients are exposed to preventable harm. The study findings suggest that preventable patient harm was more prevalent in advanced specialties such as intensive care or surgery. 

Abstract

Objective To systematically quantify the prevalence, severity, and nature of preventable patient harm across a range of medical settings globally.

Design Systematic review and meta-analysis.

Data sources Medline, PubMed, PsycINFO, Cinahl and Embase, WHOLIS, Google Scholar, and SIGLE from January 2000 to January 2019. The reference lists of eligible studies and other relevant systematic reviews were also searched.

Review methods Observational studies reporting preventable patient harm in medical care. The core outcomes were the prevalence, severity, and types of preventable patient harm reported as percentages and their 95% confidence intervals. Data extraction and critical appraisal were undertaken by two reviewers working independently. Random effects meta-analysis was employed followed by univariable and multivariable meta regression. Heterogeneity was quantified by using the I2 statistic, and publication bias was evaluated.

Results Of the 7313 records identified, 70 studies involving 337 025 patients were included in the meta-analysis. The pooled prevalence for preventable patient harm was 6% (95% confidence interval 5% to 7%). A pooled proportion of 12% (9% to 15%) of preventable patient harm was severe or led to death. Incidents related to drugs (25%, 95% confidence interval 16% to 34%) and other treatments (24%, 21% to 30%) accounted for the largest proportion of preventable patient harm. Compared with general hospitals (where most evidence originated), preventable patient harm was more prevalent in advanced specialties (intensive care or surgery; regression coefficient b=0.07, 95% confidence interval 0.04 to 0.10).

Conclusions Around one in 20 patients are exposed to preventable harm in medical care. Although a focus on preventable patient harm has been encouraged by the international patient safety policy agenda, there are limited quality improvement practices specifically targeting incidents of preventable patient harm rather than overall patient harm (preventable and non-preventable). Developing and implementing evidence-based mitigation strategies specifically targeting preventable patient harm could lead to major service quality improvements in medical care which could also be more cost effective.

The article is available to read in full from the BMJ 

In the news: OnMedica One in 20 patients exposed to preventable harm in medical care

Patient Safety Strategy

The NHS patient safety strategy | NHS Improvement 

This strategy sets out what the NHS will do to achieve its vision to continuously improve patient safety.  To do this the NHS will build on two foundations: a patient safety culture and a patient safety system.

Three strategic aims will support the development of both:
• improving understanding of safety by drawing intelligence from multiple
sources of patient safety information (Insight)
• equipping patients, staff and partners with the skills and opportunities to
improve patient safety throughout the whole system (Involvement)
• designing and supporting programmes that deliver effective and sustainable
change in the most important areas (Improvement).

Full document: The NHS Patient Safety Strategy. Safer culture, safer systems, safer
patients

See also: How data can shape a safer NHS|  Nuffield Trust blog