Spread of coronavirus in hospitals a risk to patient safety


Helping the healthcare system reduce the spread of COVID-19 in hospitals is the focus of a comprehensive report by the Healthcare Safety Investigation Branch (HSIB).


The report charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital.


The aim of HSIB’s investigation was to understand the factors that could contribute to the risk of transmission, how the NHS operates to reduce that risk and where there may be opportunities to reduce that risk even further. The investigation represented the voices of those working across the health service, from strategic national planners to hospital porters. It also captured the experiences of patients and families, providing further insight into the challenges of managing the transmission of COVID-19.


The report concludes with short, medium and long term measures that support both immediate and future responses as the NHS continues to tackle the virus. The report makes eight safety recommendations, to the Department of Health and Social Care, NHS England and NHS Improvement and NHSX. The recommendations are as follows:


  1. It is recommended that the Department of Health and Social Care, working with NHS England and NHS Improvement, Public Health England, and other partners as appropriate, develops a transparent process to co-ordinate the development, dissemination and implementation of national guidance across the healthcare system to minimise the risk of nosocomial transmission of COVID- 19.
  2. It is recommended that NHS England and NHS Improvement:
    • Supports additional capacity for testing for NHS patients and staff (Pillar 1 testing).
    • Facilitates the accessibility of rapid testing for NHS trusts, as soon as an increase in rapid testing supplies becomes available.
  3. It is recommended that NHS England and NHS Improvement develops a national intensive infection prevention and control (IPC) safety support programme for COVID-19 which focuses on leadership, IPC technical support, education, practice, guidance and assurance and also develops a national IPC strategy which focuses on developing IPC capacity, capability and sustainability across the NHS in England.
  4. It is recommended that NHS England and NHS Improvement reviews the principles of the hierarchy of controls in its health building notes (HBN) and health technical memoranda (HTM) for the design of the built environment in existing and new hospital estate to reduce the risk of nosocomial transmission.
  5. It is recommended that NHS England and NHS Improvement responds to emerging scientific evidence and shared learning when reviewing guidance for NHS trusts on the role of hospital ventilation systems in nosocomial transmission.
  6. It is recommended that NHS England and NHS Improvement investigates and evaluates the risks associated with the potential impact of staff fatigue and emotional distress on nosocomial transmission of COVID-19.
  7. It is recommended that the Department of Health and Social Care reviews and identifies the mechanisms which enabled regional and local organisations to adapt and respond with agility during the pandemic. This should inform the development of a strategic approach to national leadership models at times of crisis and under normal
  8. It is recommended that NHSX considers how technology can assist in mitigating nosocomial transmission in the ward environment with regard to:
    • The use of digital communication technologies in assisting with the deployment of staff and the dissemination and circulation of key information
    • The increased use and availability of personal computing devices and electronic health record


Kathryn Whitehill, Principal National Investigator at HSIB commented:


“We were moved by stories shared and grateful for the input from families, staff and system leaders. We know the profound personal and organisational impact this virus has had; our intention is not to criticise the NHS response rather set out a prospective view of safety that supports their efforts as cases rise and we head into winter.


“The spread of coronavirus in hospitals presents a risk to patient safety. It also puts enormous strain on the workforce and the fear of contracting COVID-19 in hospital can deter patients from attending hospital who may need urgent treatment for other conditions.


“Our investigation sought to understand factors that helped or hindered efforts to manage the risk of transmission on hospital wards. We also examined the NHS response in the context of the ‘hierarchy of controls’ – a widely used approach that sets out measures to mitigate risk ranked by their effectiveness. Our report sets out 39 key findings that cover everything from hospital design and guidance to PPE and testing capacity. This detailed insight enabled us to develop safety recommendations that would aid short and long term planning and ensure that NHS trusts had measures they could implement immediately.”


You can read the full report here.



Careers in pharmacy: What is it like to be a hospital pharmacist working in oncology?

Katie Waghorn


As I have progressed through my university career, I have become interested in the idea of working as a hospital pharmacist. Although my university provided me with some mornings in Aberdeen Royal Infirmary, I still felt I did not have enough experience to make a true decision with regards to my future career path, with my pre-registration year coming near. Due to this, I decided to interview for the NHS Scotland Hospital Pharmacy Placement Scheme. I was successful and was placed at Aberdeen Royal Infirmary (ARI) for a week this summer.


Prior to my placement, I was contacted by ARI who asked me if I had a specification with regards to where I spent my week in the hospital. The options were as follows: surgical, general medical, maternity, paediatrics or oncology. I had an interest in oncology, although I was aware it was highly specialised, as I knew I would come across unfamiliar treatments I had not heard of so far at university. As a result of this, my week with the oncology team was confirmed and I was excited to begin my placement.


On arrival at ARI on my first day, I was met by a pre-registration pharmacist who took me to get a hospital ID badge and discussed my timetable for the week. I was then taken on a tour of the hospital, which showed me just how large the hospital was, with each zone being colour coded. Just before lunch, I was taken to a pharmacist who was responsible for calculating and checking doses in chemotherapy regimens for patients. To do this, the pharmacist used data such as the patient’s weight to work out their creatinine clearance. It was important that these values were accurately calculated and approved by the pharmacist, as well as the consultant, to ensure that the patient was receiving both a safe and effective therapeutic dose of chemotherapy. After lunch, I was given a small talk in the clinical trials department of the hospital, where two pharmacists discussed how they manage and run clinical trials not just in ARI, but throughout the country. I found this interesting as I realised that ARI was the main hub for new clinical trials, which also tied into my oncology placement as a substantial number of trials were being used to treat different cancers. At the end of my first day, I was shown how medicines reconciliation is carried out when a new patient arrives at the hospital. I was shown the different resources that can be used for a record of their medication and that a minimum of two is needed to have an accurate representation of this.


On my second day at the hospital, in the morning I shadowed one of the rotational pharmacists on the oncology ward. During this time, the pharmacist discussed what happens after pre-registration in the hospital and the subsequent courses that a pharmacist goes through. She explained the two-year diploma programme and independent prescribing course that follows. Before my lunch break, the quality assurance pharmacist showed me how they keep track of particle counts in an aseptic suite. He showed a scenario from last year where although the particle counts were within limits in the Grade A/B cleanroom, they were slowly increasing and became out of control. He explained that this was fixed through further training of staff and the addition of a rule to ensure staff were changing out of outdoor clothes prior to reaching the Grade C cleanroom. In the afternoon, I was timetabled to visit the radiopharmacy department, where the pharmacist went through some prescriptions for radiopharmaceutical treatments. This activity tied in well with my placement, as many of the treatments were being used for patients prior to chemotherapy. An example of this was the MUGA scan, which checks the ventricles of the heart are pumping properly if they are not then chemotherapy cannot be commenced.


On the Wednesday of my placement, I and the pre-registration pharmacist undertook the task of a mini-audit of chemotherapy prescriptions. The outpatient chemotherapy clinic did not have a regular pharmacist working there at the time, and so the department was interested to see if a pharmacist would be needed. To do this, we looked through prescriptions which went to the dispensary to see how many prescribing or legal issues arose which needed to be changed by another pharmacist, thus keeping the patient in hospital for longer than needed. Once we had sorted through all the prescriptions with issues, we then made a spreadsheet with the data and sent it to the lead pharmacist of oncology for analysis. In the afternoon, I was shown some doses of pain relief for patients in end-of-life care on the oncology ward. The pharmacist with me allowed me to check the doses were appropriate by calculating breakthrough doses needed for the patients and ensuring conversions of quantities between administration routes were correct.


On my fourth day at ARI, I spent the morning in the radiopharmacy suite with two pharmacists where we dispensed radioactive medicines for similar treatments to the ones we looked at on Tuesday. The radiopharmacy preparation room was a Grade C suite and we had to wear specialised clothing which was provided prior to entering. One medicine that we prepared was a radioactive iodine capsule, which we had to ensure had the correct activity level for the patient. The capsule was used to treat thyroid cancer as the thyroid cells absorb the iodine when it is swallowed.   Another medicine that was prepared was for a gastric emptying study. A radioactive isotope was prepared in the suite which was then to be incorporated into scrambled eggs for the patient to consume. This would allow the consultant to see how their stomach emptied the food, and if there were any issues. In the afternoon, I travelled to Roxburgh House to meet with the pharmacist who was involved in end-of-life care. Together, we looked through Kardex sheets of the patients currently staying at the house and discussed dosages of pain relief and other drugs. The pharmacist described to me the idea of a ‘just-in-case’ box which included diamorphine for pain, midazolam for agitation, levomepromazine for nausea or vomiting, and hyoscine hydrobromide for respiratory secretions. He explained that these medicines can be used to improve both out-of-hours care and make the patient comfortable when they are at the end of life in hospital.


On the final day of my oncology placement, I was first taken on a ward round with one of the senior pharmacists and the consultant, alongside two junior doctors. The ward round was fast paced and consisted of the consultant reviewing a patient whilst the pharmacist kept them up to date with current drugs the patient was taking alongside her recommendations. After the ward round, I was given a talk by one of the aseptic pharmacists with regards to the aseptic suite at ARI and how this operates. She then went through a prescription for medication for a neonate and explained how many steps must be undertaken to ensure the dose is correct and safe and won’t cause adverse effects. Before lunch, I visited the medicines information department at ARI, where the pharmacists working there discussed some interesting queries they receive throughout the day from healthcare professionals. This once again tied in well with my placement as they explained that many queries involve possible interactions between homeopathic remedies and chemotherapy. In the afternoon, one of the senior pharmacists showed me some common chemotherapy regimens that patients are given for cancer treatments, this was highly specialised as the treatments were constantly changing and new trials were being established.


Overall, I highly recommend trying to spend some time in a hospital setting if you are interested in pursuing hospital pharmacy as a career. I feel that my experience at ARI was valuable to me and has helped me understand the career further, aiding me in my decision with regards to where I would like to work in the future.


Katie Waghorn is a stage 4 MPharm student at the Robert Gordon University Aberdeen.

Three further batches losartan recalled from pharmacies


The MHRA has recalled three batches of Losartan tablets due to contamination with the nitrosamine N-nitroso-N-methylamino butyric acid.


As a precautionary measure to protect public health, the Medicines and Healthcare products Regulatory Agency (MHRA) today recalled three batches of Losartan tablets due to contamination with the nitrosamine N-nitroso-N-methylamino butyric acid (NMBA). The affected batches can be viewed here.


The recall is taking place as part of the continued investigation into potential nitrosamine contamination of sartan containing medicines, a class of medicine to treat blood pressure and heart attacks and heart failures.


Currently, there is no evidence that nitrosamine impurities can cause harm and patients are being advised to continue taking their medication.


The investigation into possible contamination of sartan medicines began in 2018, after the nitrosamine N-nitrosodimethylamine (NDMA), was identified in valsartan manufactured at a facility based in China.


Last year, the MHRA recalled batches of valsartan containing tablets to pharmacy level in July and November due to possible NDMA and N-nitrosodiethylamine (NDEA) contamination.


In January and February 2019 the MHRA recalled batches of irbesartan containing tablets after testing revealed possible contamination with NDEA.


The MHRA continues to monitor the situation in the UK and are comprehensively investigating the issue alongside the European Medicines Agency (EMA) and the European Directorate for the Quality of Medicines (EDQM).


Bernadette Sinclair-Jenkins, MHRA’s Manager, Regulatory Assessment Unit of the Inspection, Enforcement and Standards Division, commented:


“Our priority as regulator is to make sure the medicines you and your family take are effective and acceptably safe. This recall shows we are continuing to investigate potential contamination of sartan containing medicines. There is no evidence at present that medicines containing NDMA, NDEA or NMBA have caused any harm to patients and this recall is a precautionary measure. Because of the risk associated with suddenly stopping high blood pressure medication, continue to take your medicines as prescribed by your doctor.”


Podcast: Hospital pharmacy, non-clinical pharmacists, snowflakes and bullying


This week we had great fun speaking to The Hospital MPharm. The Hospital MPharm has a very interesting Facebook page on which she welcomes contributors to share experiences from their working day in hospital pharmacy. We talked all things hospital pharmacy, bullying and we sorted out what exactly a non-clinical snowflake pharmacist is.



Find her Facebook page here.


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