Urgent need for safer devices for injecting drugs into the spine and not mixing them up with other drugs.

BBC News reports that the NHS, prompted by the National Patient Safety Agency, is threatening to stop using current drug equipment in a bid to get firms to start making safer devices. They want to see an end to universal syringe connectors which can be used for jabs into both the vein and spine.

Wayne Jowett's parents have been campaigning about this since the terrible suffering and death of their son, reported here. See also here. Since Wayne's agonising and avoidable death, after the highly toxic drug vincristine was injected into his spine when it should have been injected into a vein, staff have been given extra training and there are now strict rules governing the separate storage of spinal and intravenous drugs. But despite improvements in safety, mistakes are still occurring.

Hospitals that botch a list of eight treatments causing patient harm or deaths, will not be paid under new guidelines.

List of eight blunders the NHS must never commit released by watchdog
article in the Telegraph

Extract:

"The list includes operating on the wrong side of the body, such as removing the wrong kidney, administering cancer treatment incorrectly which can be fatal and leaving surgical instruments inside a patient after surgery has been drawn up as 'never events' by the National Patient Safety Agency.

The events are potentially harmful or even fatal to patients and are largely preventable.

Health minister Lord Darzi proposed last year that primary care trusts, which pay hospitals for the treatments carried out on patients from their areas, should monitor how often these event occur and from next year block payments for botched care.

A similar system is used in America and has led to a reduction in healthcare blunders.

The Government's chief medical officer, Sir Liam Donaldson, has reported that 350 errors in surgery are reported every day, including implanting hearing aids in the wrong ear, replacing the wrong knee joint and drilling holes in the wrong side the head.

The never events also include inpatient suicide using bed rails that do not collapse, escape from a medium or high secure mental health service by patients and the deaths of a woman due to haemorrhage after a planned caesarean birth.

How often never events occur will be monitored and reported publicly each year."

No doubt many of us wish the list could be extended! - Let us hope it does some good and that some needless suffering is avoided. The oxygen of publicity should help.

Airline-style checklist is to be introduced in NHS operating theatres after a worldwide study shows it cuts deaths and complications after surgery.

Airline-style checklist to be introduced in NHS operating theatres
article in the Telegraph

Extract:

"The checklist, drawn up by experts at the World Health Organisation, involves stopping all work at three points in an operation, where the staff present confirm they have the right patient, equipment is working, they are about to do the correct surgery, and all needles and swabs are counted before and after to ensure none have been left in the wound.

Eight hospitals around the world recorded surgical complications and deaths before implementing the checklist and afterwards with a total of 7,688 patients involved.

The results, published in the prestigious New England Journal of Medicine, showed that major complications reduced from 11 per cent to seven per cent – a reduction of one third – and deaths dropped from 1.5 per cent to 0.8 per cent – a 40 per cent reduction.

St Mary's Hospital in London, where Health Minister Professor Lord Darzi still works as a surgeon, took part in the study between October 2007 and September 2008.

During the time the hospital was piloting the checklist surgeons removed the gall bladder of the wrong patient, which is exactly the kind of mistake the checklist is designed to stop. The error was made in an operating theatre that was not involved in the study.

A spokesman for Imperial College Healthcare NHS Trust which runs the hospital, said: "The international pilot was undertaken in a limited number of operating theatres, which did not include the one in which the incident took place. Ensuring effective trust-wide implementation of the checklist is a key part of our response to the incident."

Lord Darzi said: "The beauty of the surgical safety checklist is its simplicity and – as a practising surgeon – I would urge surgical teams across the country to use it. "Operating theatres are high-risk environments. By using the checklist for every operation we are improving team communication, saving lives and helping ensure the highest standard of care for our patients. The amazing results from the global pilot puts this beyond any doubt."

The National Patient Safety Agency alerted all NHS trusts to the checklist and will require all relevant organisations to implement a modified version of it by February 2010."

Reducing avoidable deaths and complications would certainly be welcome. - Bearing in mind my own recent experience, I'd recommend also ensuring that bandages are not put on too tightly on patients with thin, delicate skin and weak veins, and are changed for dressings as soon as possible, to avoid unnecessary bruising, swelling, pain and further skin-thinning.

Thousands of patients are the victims of medical errors that could have been avoided if safety were given a higher priority in the NHS

Thousands of NHS patients suffer avoidable medical errors, says Healthcare Commission
article in the Telegraph

Extract 1:

"The report said only half of NHS trusts comply with all safety standards and there has been little improvement.

Errors that have led to patients being harmed include incorrect diagnosis, wrong doses of medication, surgeons operating on the wrong part of the body and paperwork going missing.

The wide ranging report covers all aspects of healthcare in England and highlights a number of areas of significant improvement in the NHS, particularly around deaths from cancer and heart disease and huge reductions in waiting times.

Demand for healthcare has increased dramatically, the NHS has higher levels of funding than ever before, and the health of the nation is improving, the report said.

However, the last annual report before the Healthcare Commission is subsumed by the Care Quality Commission, the report focuses on patient safety and the lack of progress in the last five years.

The report said too few incidents are reported to the National Patient Safety Agency with particular problems in primary care where doctors and nurses report almost no errors although the majority of patient care is delivered by GPs."

"Dr Hamish Meldrum, Chairman of Council at the British Medical Association said: "The overall picture in this report is of major improvements to standards of care. We applaud the efforts of NHS staff in reducing the amount of time patients have to wait, and improving the quality of the care they receive.

Extract 2:

"Any errors are regrettable but there are millions of contacts between the NHS and patients every day. It is inevitable that, in a very small proportion of these, care falls below the highest standards. Doctors want to get rid of unacceptable variations in quality, but we need to be careful to analyse and learn from the causes of low performance rather than jumping to conclusions or simply adopting a blame culture."

Martin Fletcher, Chief Executive at the National Patient Safety Agency, said: “Good reporting is the cornerstone of patient safety. Safety cannot be improved without a range of valid reporting, analytical and investigative tools that identify the sources and causes of risk in a way that leads to preventative action. The National Reporting and Learning System has a vital role to play in supporting NHS organisations to identify risks to safe patient care. Patient safety needs to be everyone’s responsibility.”"

If you read the whole article you will see that the foolish Dr Meldrum's response is so glaringly at variance with the contents of the report as to be gross lies.

Couple the reluctance of doctors and hospital trusts to admit to errors and to report them, with the long-standing culture of cover-up by the medical profession as a whole, and add to that the widespread practice of further victimising the victims of medical negligence and you may begin to comprehend the vast scale of medical malpractice and avoidable suffering in this country. Then add further the difficulties of even getting a complaint acknowledged/received by the system: the Healthcare Commission has 'gatekeepers' who prevent Prof Sir Ian Kennedy and his fellow Commissioners from even seeing many of the complaints submitted by those who have suffered/are suffering from the mistakes/negligence of the system...

We are very badly served by the expensive, poorly performing NHS and our vastly overpaid doctors, and the NHS Complaints Procedures routinely add to the suffering of complainants/victims and are a national scandal.

Three patients have died after being given large doses of a commonly used sedative, a health watchdog has warned.

Three patients died 'after being given too high a dose of sedative'
article in the Telegraph

Extract:

"The National Patient Safety Agency (NPSA) said that almost 500 patients in total have received the wrong dose of the drug, called midazolam, over the past four years.

Midazolam is used to sedate patients before minor procedures, including setting broken wrists and dentistry.

The medication hit the headlines in 2000 when a male nurse was convicted of killing a colleague after drugging her with midazolam.

As well as the three deaths another 48 patients had been "moderately" harmed by receiving large doses of the drug in the past four years, the NPSA said.

The watchdog, part of the NHS, also warned that health professionals were frequently relying on a reversing agent to bring people around after they had been over-sedated.

The drug works by slowing down both the heart and lung rate, and can cause a heart attack or lung problems if given in very high doses.

The NPSA said that it had received 498 reports of patients being given the wrong dose of midazolam between November 2004 and November 2008.

It warned that patients were being given whole containers, or ampoules, of the drug instead of just a small amount.

"The presentation of high strength midazolam as a 5mg/ml (2ml and 10ml ampoules) or 2mg/ml (5ml ampoule) exceeds the dose required for most patients," the watchdog warned in a statement.

"There is a risk that the entire contents of high strength ampoules are administered to the patient when only a fraction of this dose is required.

"There is frequent reliance on injectable flumazenil (antagonist/reversing agent) for reversal of sedation in patients that have been over-sedated."

The NPSA called for high-strength midazolam to be removed from many parts of hospitals."

Holes drilled in the wrong side of heads during surgery. - It's not Brain Surgery, is it?

Holes drilled in the wrong side of heads during surgery NHS watchdog warns
article in the Telegraph

Extract:

"So-called wrong site surgery has been a consistent problem in the NHS and in some cases patients have died as result of having the wrong organ removed.

In 2005 the National Patient Safety Agency issued an alert to all neurosurgical units after an audit found there was no standard method of identifying which side the patient was to have surgery with some units marking with pen the side to be operated on and others marking the side not to.

Since the alert the NPSA have had another 15 reports of incidents in nine of the 36 neuro centres where surgeons have begun brain surgery on the wrong side of the head.

Another alert has now been issued saying it is still a problem.

The brain surgery incidents are among 56 wrong site surgical mistakes reported to the NPSA during 2007 and another 654 reports related to operating list errors where the wrong patient or the wrong operation had been planned."

Getting the right side? - It's a no-brainer!

An article today in the Telegraph says that nine out of ten preventable deaths in the NHS are not reported

Nine out of ten preventable deaths in the NHS are not reported
article in the Telegraph

Extract:

"Of the estimated 72,000 annual deaths in the NHS, just 3,200 are recorded by the National Patient Safety Agency, MPs were told.

The Commons Health Select Committee heard evidence from experts in its first evidence session on its investigation into patient safety.

The NPSA runs a system where all NHS staff can report incidents or near misses so patterns can be spotted and the wider health community warned.

Incidents can include drugs administered in the wrong way or the wrong dose, medicines mixed up, the wrong operation carried out, a patient wrongly identified and broken or malfunctioning equipment.

Howard Stoate, a practising GP and Labour MP for Dartford, said the National Patient Safety Agency's own estimates suggest there are 72,000 preventable deaths in the NHS each year.

However, the incident recording database had collected just 3,200 reports of patient deaths, in 2007/8.

He said: "That is not just under-reporting, that is an extra-ordinary figure.

"If the public realised that only between five and ten per cent of preventable deaths are being reported they would have something to say about that.

"For example if only ten per cent of airline crashes were reported we'd have some concerns about that."

NPSA chief executive Martin Fletcher replied that while there were 'issues' around under-reporting, reporting rates were continually improving.

Sir Bruce Keogh, medical director of the NHS, said no-one was 'comfortable' with under-reporting but he said people could not be 'forced' to report incidents.

He said it was the staff member's personal, moral and professional duty to report incidents.

In 2004 the NPSA produced a report that said one in ten patients admitted to hospitals will suffer a patient safety incident - almost one million people in 2002/3 - and up to half of these could have been prevented. It added that 72,000 of these incidents may have contributed to the death of the patient."

It's clear that there's not a lot of "personal, moral and professional duty" among the staff then, isn't it, despite the much vaunted medical ethics that health professionals are always prating about? - I note that the categories of 'incidents' listed above do not include completely disregarding the pain and other serious symptoms some patients report and therefore failing to investigate and do anything about them beyond trying to bully them into taking pain-killers. - This was my situation last year in hospital with a very complicated and painful fracture of my right humerus, immeasurably worsened by the splint I was forced to wear for nearly a fortnight, because the agony I reported and the pins and needles (indication 0f nerve damage) and the massive blue swelling (lymphoedema) of my hand unrelieved by elevation of the hand were ignored, apart from the bullying I have already mentioned.

I had explained to every doctor and every nurse that I was a steroid victim and that my hands were already delicate and painful and that the splint was causing terrible pain because of pressure on the arm and on my right breast. - Steroid victims need to be dealt with quickly because their skin and veins are so vulnerable to further damage... - There was a shocking lack of knowledge about the health problems of steroid victims and although some of the staff were very kind there was a deplorable ignorance and lack of understanding/compassion in others, and a total and lamentable failure to take seriously my need for unsalted food, since salt is extremely harmful to steroid victims, compounding their pain/symptoms.

Even after the operation and my return home, having to have carers to help me because of the damage done to my hand (it was completely unusable for months) by the hospital's negligence re the long delay in removing the splint and doing the operation, my pain and the pins and needles continued to be uninvestigated for nearly a year. When someone did look to see what was the cause of the pain he instantly realised that it was caused by ulna nerve damage and that the hand is wasting away and is on the way to becoming a hook, and the movement that I got back by such long, arduous effort, is being reduced again by this ulna nerve damage.

Well all this not bothering to take seriously the symptoms I reported has cost the NHS a lot as I was much longer in hospital - a month, rather than the few days it should have been - and the many hours of appointments with physiotherapists and occupational therapists, the transport costs et al. It has all taken a terrible toll on me in great and avoidable suffering. - And no-one ever says sorry or expresses regret or remorse and no-one really makes any effort to help with all the problems and difficulties caused to me. Making any complaint is futile because of routine defensiveness of health professionals and their cover-up culture and is highly likely to result in victimisation.

The NHS should be scrapped. It is extremely expensive and is wholly unfit for purpose.

Doctors and pharmacists are being warned by the National Patients Safety Agency to take greater care when prescribing or administering drugs.

Doctors are warned over drug deaths
Article in the Observer

Extract:

"Doctors and pharmacists are being warned by the National Patient Safety Agency to take greater care when prescribing or administering drugs. Eight NHS patients have died and 17,000 others been put at risk in 'incidents' involving powerful painkillers used by millions of Britons between January 2005 and December 2007.

On Friday the agency sent a 'rapid response report' - an official warning that is sent around the NHS when evidence emerges about a threat to patient safety - entitled 'Reducing Dosing Errors with Opioid Medicines'. It covers the 11 most common forms of opioids, such as morphine, methadone, fentanyl, diamorphine and oxycodone.

'Incidents have been reported to the National Reporting and Learning System concerning patients receiving unsafe doses of opioid medicines, where a dose or formulation was incorrect, based on the patient's previous opioid dose,' said the report.

Around 12 million prescriptions for opioids are issued every year."

If you want a drug-free way of reducing pain, try cutting down on salt and salty food. - See http://www.wildeaboutsteroids.co.uk/sodium_foods.html and

http://www.wildeaboutsteroids.co.uk/conditions.html

Hospital acquired infections or medical errors are more likely to cause death than extreme sports like high-altitude mountaineering and bungee-jumping

NHS hospitals more dangerous than bungee-jumping
Article in the Sunday Telegraph

Extract:

"The risks from infection, mistakes over drugs and failings in care mean that nearly one in 100 patients admitted to an NHS hospital will die an avoidable death, compared with one in 1,000 of those taking part in dangerous sports.

The findings define health care as a "hazardous activity" for patients and compare it unfavourably with air travel and the nuclear power industry, both of which carry a one in 100,000 risk.

The research, which was compiled by the NHS National Patient Safety Agency and the health care charity, the Health Foundation, reveals that up to 104,000 patients die each year as a result of poor infection management and basic medical errors."

I'd say this is a gross underestimate of the harm done by hospitals and by doctors.

A simple checklist which has the potential to save thousands of lives could soon be implemented in all British NHS hospitals, it has emerged.

Medical checklist could save thousands of patients
Article in the Telegraph

This is so basic and so obvious that you'd think even the arrogant medical profession would have thought of it before and been using it for years...

Extract:

"A coalition of 13 medical organisations, led by the National Patient Safety Agency and including the Royal Colleges of Surgeons, Anaesthetists, Obstetricians and Nurses, has pledged to introduce the checklist to every operating theatre in Britain.

Martin Fletcher, chief executive of the agency, said: "All these professional groups have committed to making this a reality in the UK. We are one of the first countries to get behind it."

The basic checks range from confirming which area of the body is being operated on, to counting the number of swabs and needles used to ensure none has been left inside the patient.

Another involves simply making sure each member of the surgical team is aware of who is doing what during the procedure.

Of the eight million operations carried out in the UK last year there were 129,000 reported incidents in which patients were put at risk, according to the National Patient Safety Agency.

An estimated 2,000 NHS patients die each year as a result of errors in treatment, and an inquiry by the National Audit Office in 2005 concluded that half of all incidents could have been avoided."

The National Patient Safety Agency reports that many hospital fatalities are avoidable.

Hundreds of hospital fatalities 'avoidable' - Telegraph

Extract:

"One third of deaths in hospital investigated by a patient safety watchdog could have been avoided, claims a report released today.

The National Patient Safety Agency looked into 1,804 fatal hospital incidents reported to it in 2005. It found that 576 were "potentially avoidable" if there had been better communication between staff, faster recognition of the patient's deteriorating state, improved training and more accurate interpretation of test results.

Some 425 of the deaths investigated by the NPSA in 2005 were in acute or general hospitals. Of these, 71 were reported to be related to diagnostic errors, in 64 cases the patient's deteriorating condition was not recognised or not acted upon, and 43 involved a problem with resuscitation after cardiac arrest.

The remainder were connected to medication errors, suicide or still-birth."

Many thousands of deaths both in and out of hospital are avoidable - and the suffering that precedes them. - If only the public were to be told the truth about obesity and if only the medical profession would stop giving the dangerous, futile, counterproductive advice that to lose excess weight it is necessary to eat less/to eat fewer calories/to cut down on fat/carbohydrates, etc! - Obesity is caused by fluid retention, not by overeating.

Obesity is not caused by overeating. It is caused by the conjunction of salt sensitivity and sodium intake, which leads to fluid retention.

It is over 50 years since steroids were first prescribed and it is beyond belief that most doctors are still unaware in practice of their potential for causing sodium and water retention and morbid obesity and the many other serious health problems attendant on these...

Calorie counting and advice about increasing exercise and reducing fat and carbohydrate intake to reduce obesity are ineffective, counter-productive and often damaging. - See the article in the British Medical Journal of November 2003 BMJ article for actual research on what happens when this advice is followed! - Over 800 obese adults were put on energy deficit diets, given diet sheets and plenty of instruction and help from trained staff, and apparently, visited fortnightly for a year, at the end of which they had GAINED weight! This mirrors the real experience of obese people, viz. - dieting makes you fat.

It is commonly accepted now, except by the 'experts', that less than 5% of dieters actually lose weight, and most gain weight as a result of dieting. - Even the ones who manage to lose weight do not usually improve their health. - See Overweight who diet risk dying earlier, says study for a report in The Guardian of Monday, June 27th 2005. It is about a huge research study of nearly 3000 people over a period of 18 years. The study found that overweight people who diet to reach a healthier weight are more likely to die young than those who remain fat. It also found that dieting causes physiological damage that in the long term can outweigh the benefits of the weight loss.

Contributing to the increase in obesity we have the widespread prescribing of steroids and HRT and other drugs which cause weight gain, and the failure of doctors to adhere to the protocols connected with the prescribing and monitoring of steroids. But pre-eminent, in my opinion, is the catastrophically damaging calorie-reduction advice that continues to be given despite such a wealth of evidence that it is bad advice.

Another possible factor is the increase in the amount of oestrogen in the water table.

Salt produces weight gain only in vulnerable people, i.e.

1. People whose veins are weak because of immaturity (babies, children),

2. People whose veins are relaxed or weak because of steroids, HRT, amitriptyline or certain other prescribed drugs, too readily prescribed, often in very high dose.

3. People whose natural hormone levels are altered (e.g. pregnant women).

4. 'Slimmers' - People whose blood vessel walls have been weakened by 'slimming' - i.e. eating insufficient food.


Lose weight by eating less salt! Go on! - Try it! - You will feel so much better!
How to Lose weight!

See my website http://www.wildeaboutsteroids.co.uk/.html
(The site does not sell anything and has no banners or sponsors or adverts - just helpful information.)

Read my Mensa article on Obesity and the Salt Connection

See Sodium in foods and Associated health conditions

advice for pregnant mothers

I can be contacted via my website if you need my further help. My help is free...

National Patient Safety Agency calls for standardised wristbands

Patient safety watchdog calls for standardised wristbands - Guardian

Extract:

"Nearly 3,000 hospital patients were given the wrong treatment last year because of inaccurate or confusing information on their identification wristband, according to the National Patient Safety Agency. The results, the agency said, could be potentially devastating, especially in surgery. In one mix-up a diabetic patient was given an almost fatal dose of insulin.

The agency, a special health authority established to coordinate the reporting of patient safety incidents, has told NHS trusts to standardise both the colour and data on the bands by July next year. Its survey of 62 trusts found eight different coloured bands in use and some departments within trusts using bands of different colours to signify the same condition.

Illegible writing on bands is one cause of confusion for doctors and nurses. The agency also notes that eight of the trusts could not be identified on the returned questionnaires because of "missing or illegible information". In the questionnaires, staff from nine trusts gave inconsistent replies to whether colour coding was used: seven responded "yes" and "no." One said "yes" and "don't know" and one gave all three responses. There were a small number of "don't knows" to nearly every question. The range of colour codes was illustrated by the use of four colours in different hospitals for "risk of falls": green, blue, yellow and orange. In others green and yellow are used to signify a confused person, and Jehovah's Witnesses not wanting blood products can be either red or blue.

The NPSA said the bands in future should be white with black text, carrying the last name, first name, date of birth and NHS number. Trusts will have the discretion to use red bands to denote a specific risk such as an allergy or a patient who does not want to receive blood products."

Sounds an excellent idea, though long overdue!


Lose weight by eating less salt! Go on! - Try it! - You will feel so much better!
How to Lose weight!

See my website http://www.wildeaboutsteroids.co.uk/.html
(The site does not sell anything and has no banners or sponsors or adverts - just helpful information.)

Read my Mensa article on Obesity and the Salt Connection

See Sodium in foods
and Associated health conditions

I can be contacted via my website if you need my further help. My help is free...(o:

NHS hospital patients dying as 10,000 injections are bungled...

Patients dying as 10,000 injections bungled - Sunday Telegraph

Extracts:

"Hospitals across Britain have been ordered to review how drugs are given to patients after figures revealed that almost 10,000 injections are bungled each year.

Mistakes led to the deaths of 25 patients and harmed more than 3,000 between January 2005 and June 2006, a study found.

In all, 14,000 errors were discovered during the 18 months assessed by the National Patient Safety Agency (NPSA), a watchdog created to advise the NHS on safety matters.

Most involved administering wrong dosages. Other errors included injecting drugs into the wrong part of the patient's body, incorrectly formulating medicine, wrongly storing products, giving patients drugs to which they were allergic or failing to administer prescribed drugs. As a result, the NPSA has told all hospitals to carry out a risk assessment of the products they use and ordered them not to skimp on safety on the grounds of cost."

"Six years ago, Wayne Jowett, a teenager, died in agony after the highly toxic drug vincristine was injected into his spine when it should have been injected into a vein. The lethal blunder came when two chemotherapy drugs stored in similar syringes were mixed up.

The 18-year-old, who was in remission from leukaemia, suffered irreparable nerve damage, causing excruciating pain, followed by creeping paralysis and organ failure.

His father, also called Wayne, who has campaigned for the development of a new type of connector that would make it impossible to pump drugs intended for the veins into the spine, said that neither the NPSA alert nor the pilot schemes went far enough. Mr Jowett, 47, from Nottingham, said: "We don't think enough has been done. We are just waiting for a case like Wayne's to happen again.""

Healthcare Commission found 55% of mental care inpatients have to share sleeping accommodation or bathrooms with members of the opposite sex.

Census reveals wide extent of mixed sex psychiatric wards

Extract:

"Health inspectors will today publish conclusive evidence that the government's claim to have ended the scandal of mixed-sex psychiatric wards in the NHS was false, or at best misleading. In a census of all mental health establishments in England and Wales, the Healthcare Commission found 55% of inpatients have to share sleeping accommodation or bathrooms with members of the opposite sex.

Last year ministers rejected a report from the National Patient Safety Agency that recorded at least 19 rapes of mental health patients in England, and more than 100 other improper sexual incidents in psychiatric units in the previous two years.

Lord Warner, then health minister, said the allegations of rape were unsubstantiated. He told peers in July that 99% of NHS trusts providing mental health services met "single-sex objectives" that were set out in 2000, requiring all mental health units to provide totally separate sleeping, toilet and bathing accommodation for men and women. Lord Warner said mixed sex wards were an exception that might apply to "a very small number of patients, when admitted as an emergency".

But the census - conducted by the commission and government-funded mental health agencies - found only 45% of the 32,000 inpatients in NHS or private sector psychiatric wards on March 31 last year had the benefit of single-sex accommodation."