Through its core work to review recorded patient safety events, the National Patient Safety Team identified an issue related to reactivation of Hepatitis B following chemotherapy.
A reported incident described concerns relating to the processes by which a patient who had previously had a hepatitis B viral (HBV) infection, was prescribed chemotherapy treatment, without the recommended prophylactic anti-viral treatment. Exploration of this issue identified inconsistencies in how organisations manage the requirements of different medicines, as well as variations in the electronic systems used to prescribe and administer immunosuppressive systemic anti-cancer treatment (SACT).
SACT has the potential to cause flares and reactivation of HBV in patients with current infection or previous exposure to the virus. In some cases, HBV reactivation can lead to acute liver failure, deterioration in liver function and potentially death. Many patients are unaware they have or have ever been exposed to HBV therefore screening is essential prior to commencement of treatment with some forms of SACT.
The team asked the UK Chemotherapy Board to develop guidance for practitioners to support consistency and management of these concerns. In February 2022, the UK Chemotherapy Board published their position statement on Hepatitis B Virus Screening and Reactivation.
The team also asked the British Oncology Pharmacy Association to incorporate specific guidance into the revised standards for the safe use of electronic prescribing systems in SACT.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.
In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.