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Royal Cornwall Hospital deploys AI tool for secure surgical videos

Royal Cornwall Hospital has deployed an artificial intelligence (AI) tool that allows clinicians to view case videos safely and securely.

Touch Surgery Enterprise enables automatic processing and viewing of surgical videos for clinicians and their teams without compromising sensitive patient data. These videos can be accessed via mobile app or web shortly after the operation to encourage self-reflection, peer review and improve preoperative preparation.

James Clark, consultant upper gastrointestinal and bariatric surgeon at the trust, said: “Having seamless access to my surgical videos has had an immense impact on my practice both in terms of promoting patient safety and for educating the next generation of surgeons."

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Source: Digital Health, 28 November 2019

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How safe is our care?

All healthcare leaders, providers, patients and the public should wrestle with a fundamental question:  How safe is our care? The typical approach has been to measure harm as an indicator of safety, implying that the absence of harm, is equivalent to the presence of safety. But, are we safe, or just lucky?  

Jim Reinertsen, a past CEO of complex health systems and a leader in healthcare improvement, suggests that past harm does not say how safe you are; rather it says how lucky you have been. After learning about the Measurement and Monitoring of Safety (MMS) Framework, Reinertsen found the answer to his question, “Are we safe or just lucky?”

“The Measurement and Monitoring of Safety Framework challenges our assumptions in terms of patient safety,” says Virginia Flintoft, Senior Project Manager, Canadian Patient Safety Institute. “The Framework helps to shift our thinking away from what has happened in the past, to a new lens and language that moves you from the absence of harm to the presence of safety.”

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Source: Hospital News, 3 December 2019

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Sepsis: getting the balance right

Public and professional understanding of sepsis has increased greatly in recent years. This has led to campaigns to diagnose sepsis early in the clinical course of the illness and to start treatment with antibiotics and fluid replacement promptly. But could this pressure to improve sepsis management be counterproductive and lead to overdiagnosis of sepsis? This was the argument made by the authors of a recent letter to the Lancet.

One problem arising from overdiagnosis of sepsis is the overuse of broad spectrum antibiotics, says Paul Morgan in an Editorial to the BMJ. Another concern is that the emphasis on the early treatment of sepsis detracts from the recognition, diagnosis, and treatment of other acute illnesses. 

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Source: BMJ, 28 November 2019

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Health strike: Nurses start industrial action on pay and staffing

Industrial action by healthcare workers is intensifying as Northern Ireland's nurses take part in 24 hours of action. Health workers are staging industrial action in protest at pay and staffing levels which they claim are "unsafe".

In an unprecedented joint statement, the five health trusts said the action was likely to result in "a significant risk to patient safety".

Last week, the Royal College of Surgeons warned NI's healthcare system was "at the point of collapse". On Tuesday, members of the Royal College of Nursing (RCN) are refusing to do any work that is not directly related to patient care.

Full details and advice on current health care services can be found on the Health and Social Care Board website.

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Source: BBC News, 3 December 2019

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Fewer than half of pharmacists issue warning cards for patients using valproate

It is a requirement that patient cards detailing information on the risks are issued every time valproate is dispensed, under Medicines and Healthcare products Regulatory Agency (MHRA) guidance.

Only 40% of pharmacists are meeting a patient safety requirement when dispensing valproate to women, an audit carried out by the Company Chemists’ Association (CCA) has found.

The drug can cause birth defects in women who take it when pregnant.

In April 2018, the Medicines and Healthcare products Regulatory Agency (MHRA) stated that valproate must not be used by women and girls of childbearing age unless a pregnancy prevention programme (PPP) is in place.

Duncan Rudkin, Chief Executive of the General Pharmaceutical Council (GPhC), said pharmacies must do more to ensure the safe dispensing of valproate.

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Source: The Pharmaceutical Journal

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Six hospitals plummeted to ‘inadequate’ in wake of Whorlton Hall

The Care Quality Commission (CQC) has rated six mental health hospitals “inadequate”, just months after describing them as either “good” or “outstanding”, since the Whorlton Hall scandal was revealed.

HSJ analysis shows that of the 13 mental health hospitals admitting people with learning disabilities or autism which have been rated “inadequate” by the CQC since May this year, six of them dropped at least two ratings in a short space of time. The six hospitals which dropped at least two ratings include Whorlton Hall — the County Durham hospital closed following a BBC Panorama report in May showing residents being mistreated — which the CQC rated as “good” in December 2017 before revising this to “inadequate” in May.

The BBC investigation prompted the CQC to investigate all similar mental health hospitals run by Cygnet, which took over the running of Whorlton Hall in January 2019. 

Cygnet Newbus Grange in Darlington — which was rated “outstanding” in a report published in February 2019 – was judged “inadequate” by September, while Cygnet Acer Clinic in Chesterfield fell from “good” in November 2018 to “inadequate’ in a report published 12 months later.

The other three hospitals were the Breightmet Centre for Autism in Bolton, Kneesworth House in Hertfordshire and The Woodhouse Independent Hospital in Staffordshire.

It comes as the CQC prepares to publish independent reports on its role in relation to the Whorlton Hall scandal. NHS England — one of the commissioners, along with local authorities and clinical commissioning groups, of learning disability inpatient care — also last month initiated a “taskforce” on the issue.

The CQC has acknowledged it needed to “strengthen” its assessments of this type of care and said it had begun to do so, and was reviewing them further “from a human rights perspective”.

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Source: HSJ, 2 December 2019

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Health strike: Action could delay cancer diagnoses

Patients are facing a week of disruption, with more than 10,000 outpatient appointments and surgeries cancelled in Belfast.

Some people referred by their GPs on suspicion of cancer could have their diagnosis delayed, the head of the Belfast Trust has said. The trust apologised, blaming industrial action on pay and staffing.

Martin Dillon said outpatient cancellations "could potentially lead to a delay in treatment" for cancer.

The Department of Health said the serious disruption to services was "extremely distressing".

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Source: BBC News, 2 Decmeber 2019

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'We try our best as nurses, but it's not enough'

Georgina Day works as an A&E nurse in a London hospital. Every shift, her team of just over 20 starts four nurses short because there are posts it cannot fill.

"It can be worse - if people are sick or agency staff don't turn up. It makes providing good patient care difficult."

She says the demands are huge - her department sees more than 400 patients a day. But the shortages mean patients face delays or have to be given care, such as intravenous antibiotics, in corridors instead of in cubicles.

She says that can make patients angry, recounting the experience of one father shouting at her and saying she didn't care about his sick son.

"I care massively," she says. "When patients are angry it makes me really sad. I want more for them."

Georgina's experience is not unique. A survey by the Royal College of Nursing found six in 10 nurses felt they could not provide the level of care they wanted to.

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Source: BBC News, 2 December 2019

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Australia needs to “get real on medicine safety”

Australia needs to “get real on medicine safety”, Federal Parliament heard this week.

Speaking in the House of Representatives, Julian Hill (ALP, Vic) said “too many Australians are being seriously injured, sometimes with lifelong impacts or dying, because of the weakness in our pharmacovigilance system”.

Mr Hill, Deputy Chair of the Parliamentary Joint Committee of Public Accounts and Audit, referred to a recent study by the Pharmaceutical Society of Australia which “estimated the extent of the problem at 250,000 annual hospital admissions as a result of medication related problems and 400,000 additional presentations to emergency departments, likely because of medicine related problems.

There’s an annual cost of $1.4 billion, and yet 50 per cent of this harm is estimated to be preventable,” he said.

“I have spoken before about my concerns in this area, and so have many other advocates, but the  government is still not taking these issues seriously. Every day of inaction means Australians are at risk of death or serious harm from medicines when it could be avoided”.

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Source: AJP.com.au, 28 November 2019

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NHS Trust introduces artificial intelligence for monitoring eye health

East Kent Hospitals University NHS Foundation Trust has adopted artificial intelligence (AI) to test the health of patient’s eyes. In collaboration with doctors at the trust, the University of Kent has developed AI computer software able to detect signs of eye disease.

Patients will benefit from a machine-based method that compares new images of the eye with previous patient images to monitor clinical signs and notify the doctor if their condition has worsened.

Nishal Patel, an Ophthalmology Consultant at the Trust and teacher at the University said: “We are seeing more and more people with retinal disease and machines can help with some of the capacity issues faced by our department and others across the country."

“We are not taking the job of a doctor away, but we are making it more efficient and at the same time helping determine how artificial intelligence will shape the future medicine. By automating some of the decisions, so that stable patients can be monitored and unstable patients treated earlier, we can offer better outcomes for our patients.” 

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Source: National Health Executive, 22 November 2019

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Nursing shortages forcing NHS to rely on less qualified staff

The NHS is relying on less qualified staff to plug workforce gaps because of a huge shortage of nurses, according to a new report.

Support staff, such as healthcare assistants and nursing associates, have been used to shore up staffing numbers, said the Health Foundation charity.

The NHS has relied upon overseas recruitment, but a lack of EU nurses because of Brexit means it is now taking more nurses from countries such as India and the Philippines.

At present, there are almost 44,000 nursing vacancies across the NHS (12% of the nursing workforce), but this could hit 100,000 in a decade, the report said.

The report said most changes to the skill mix – meaning the ratio of fully qualified to less qualified staff – are implemented well and led by evidence, but added: “It is important that quality and safety are at the forefront of any skill mix change.”

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Source: The Guardian, 28 November 2019

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New legislation to provide for mandatory open disclosure

Hospitals will face penalties if staff do not notify patients of serious adverse incidents under proposed new legislation.

Due to be brought to Cabinet by the Minister for Health Simon Harris in early December, it will provide for mandatory open disclosure of patient safety issues. It is understood that the new Bill would mean that where a hospital or health service provider was satisfied that a notifiable patient safety incident had occurred, information in its possession on the issue should be disclosed. A doctor or practitioner would be obliged to inform the patient and hospital of the incident.

Under the proposals, failure to comply with this requirement on disclosure would mean the health service provider would be penalised. The nature or extent of the proposed penalties is unknown.

The department is preparing a list of notifiable patient safety incidents for the mandatory open disclosure proposals.

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Source: The Irish Times, 25 November 2019

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CervicalCheck: Review finds hundreds of previously missed abnormal results

Large numbers of previously missed abnormalities have been uncovered in the biggest review of smear tests undertaken since cervical cancer screening began in Ireland.

The review led by the Royal College of Obstetricians and Gynaecologists in the UK has found hundreds of “discordant” results after re-examining the slides of over 1,000 women who had been tested for the disease under CervicalCheck, were given the all-clear and later developed cancer, according to an informed source.

Discordant means the re-examination of the smear test by Royal College reviewers has produced a result that is different from the original finding by CervicalCheck.

The extent of the individual divergences from the initial results is not yet known, but the review has found some cancers could have been prevented, it is understood.

The college is due to submit an aggregate report on its findings to Minister for Health Simon Harris shortly.

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Source: The Irish Times

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Reflecting on To Err is Human: 20 Years of Patient Safety Work

It’s been 20 years since the Institute of Medicine — known now as the National Academy of Medicine — published the groundbreaking report, To Err is Human. And in that time, the healthcare industry has seen vast changes, bringing patient safety and healthcare quality to the forefront.

The notion that patient safety issues are not only common, but they are preventable, challenge previously held industry beliefs, Craig Clapper, a partner in strategic consulting at Press Ganey, said during a recent interview with PatientEngagementHIT.com. 

In this article he discusses the progress that has been made and what still needs to be done.

Looking into the future, Clapper sees an industry that integrates patient safety as a key element of everything it does. While clinicians focus on boosting patient satisfaction, delivering good clinical outcomes, and fulfilling other obligations, they should feel and see the connection with patient safety.

“We should talk less about safety culture in isolation and more about how to make it about the entire patient experience,” Clapper concluded. “That'll be our biggest single advantage in the next decade. Instead of having a subculture for every outcome, we must have one seamless performance culture that can emphasize the safety, quality, and experience of care.”

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Source: PatientEngagementHIT, 26 November 2019

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A third of maternity doctors 'burnt out' and at risk of losing empathy for women in their care

More than a third of maternity doctors are “burnt out,” and at risk of lacking empathy for the women in their care, researchers have warned.

The study of more than 3,000 obstetricians and gynaecologists found high levels of long-term stress and overwork, especially among trainee medics. 

Researchers said the findings – from the largest UK study on the topic – were “very worrying,” with serious implications for patients. 

Overall, 36% of those surveyed met the criteria for “burnout,” which is associated with emotional exhaustion, lack of empathy and connection with others, researchers said. 

Medics who met the criteria for burnout were three times as likely to report anxiety, irritability and anger. They were also four times more likely than colleagues to practice “defensively”- meaning they tried to avoid difficult cases, or else carried out more interventions than necessary, for fear of error. 

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Source: The Telegraph, 26 November 2019

 

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Hundreds of families come forward in Shropshire maternity scandal

More than 200 new families have contacted an inquiry into mother and baby deaths at a hospital trust in Shropshire.

Investigators were already looking at more than 600 cases where newborns and mothers died or were left injured while in the care of the Shrewsbury and Telford Hospital Trust. One expert says the scandal, spanning decades, may be the tip of the iceberg.

Dr Bill Kirkup says it suggests failure might be more widespread in the NHS.

The surge in new cases follows the leak of an interim report last week.

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Source: BBC News, 27 November 2019

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Breast cancer: Patient creates app to help with treatment

A mobile app designed by a patient is helping people with breast cancer prepare for the start of radiotherapy.

The treatment requires them to raise their arm above their head, but patients often find that difficult or painful after breast surgery. Exercises are important but Karen Bonham said leaflets giving details did not help her enough.

So she helped create the app to offer exercise videos and medics say it is helping more women be ready on time. Staff at Velindre Cancer Centre in Cardiff say they have noticed fewer patients needing urgent referral for physiotherapy ahead of the treatment since the "Breast Axilla Postoperative Support app", or BAPS App, was launched in February.

Kate Baker, clinical lead physiotherapist at Velindre, who helped devise the app, said: "Previously, we've always handed out information on exercises in a leaflet, that patients would be given by a physiotherapist and taken home. But often these pieces of paper get lost and they're not followed through.

"What we wanted to do was provide exercises, physical activity advice and further information in an app format, which would allow individuals to have it with them at all times."

Donna Egbeare, breast surgeon at Cardiff and Vale University Health Board, who was also involved in developing the bilingual app, said the impact of being able to start radiotherapy on schedule was significant.

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Source: BBC News, 27 November 2019

 

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New hospital tech disrupts doctors' and nurses' jobs, forces improvisation to ensure patient safety

Doctors and nurses must adapt their routines and improvise their actions to ensure continued patient safety, and for their roles to be effective and to matter as new technology disrupts their working practices.

Research from Lancaster University Management School, published in the Journal of Information Technology, found electronic patient records brought in to streamline and improve work caused changes in the division of labour and the expected roles of both physicians and nursing staff.

These changes saw disrupted working practices, professional boundaries and professional identities, often requiring complex renegotiations to re-establish these, in order to deliver safe patient care. Managers implementing these systems are often quite unaware of the unintended consequences in their drive for efficiency.

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Source: EurekAlert, 25 November 2019

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GP who downplayed symptoms of boy who died from Addison’s disease is suspended

A GP who gave wrongly dated and misleading medical notes to police inquiring into the death of a 12 year old boy from undiagnosed Addison’s disease has been suspended from the UK medical register for nine months.

Ryan Morse died in the early hours of 8 December 2012, hours after his mother rang the local Blaenau Gwent surgery twice in a day, reporting high temperature, extreme drowsiness, and involuntary bowel movement. The second time, she spoke to GP Joanne Rudling, telling her that the boy’s genitals had turned black.

But Rudling failed to check the notes of the first call or give adequate weight to the fact that the mother was calling again, the tribunal found. She failed to obtain an adequate history or reach an appropriate conclusion about the change in genital colour.

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Source: BMJ, 25 November 2019

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Hospital alarms prove a noisy misery for patients

When Kea Turner’s 74-year-old grandmother checked into Virginia’s Sentara Virginia Beach General Hospital in the US, with advanced lung cancer, she landed in the oncology unit where every patient was monitored by a bed alarm.

“Even if she would slightly roll over, it would go off,” Turner said. Small movements — such as reaching for a tissue — would set off the alarm, as well. The beeping would go on for up to 10 minutes, Turner said, until a nurse arrived to shut it off.

Tens of thousands of alarms shriek, beep and buzz every day in every US hospital. All sound urgent, but few require immediate attention or get it. Intended to keep patients safe by alerting nurses to potential problems, they also create a riot of disturbances for patients trying to heal and get some rest.

Alarms have ranked as one of the top 10 health technological hazards every year since 2007, according to the research firm ECRI Institute. That could mean staffs were too swamped with alarms to notice a patient in distress, or that the alarms were misconfigured. The Joint Commission, which accredits hospitals, warned the nation about the “frequent and persistent” problem of alarm safety in 2013. It now requires hospitals to create formal processes to tackle alarm system safety, but there is no national data on whether progress has been made in reducing the prevalence of false and unnecessary alarms.

The commission has estimated that of the thousands of alarms going off throughout a hospital every day, an estimated 85-99% do not require clinical intervention. Staff, facing widespread “alarm fatigue,” can miss critical alerts, leading to patient deaths. Patients may get anxious about fluctuations in heart rate or blood pressure that are perfectly normal, the commission said.

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Source: The Washington Post, 24 November 2019

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Let’s do our duty: Top nurse leads NHS staff flu jab drive

England’s most senior nurse has called on the NHS’ million-plus frontline workers to protect themselves and their patients this year by taking up their free flu jab.

Ruth May, the Chief Nursing Officer for England, is spearheading this year’s drive to ensure that as many NHS staff as possible get vaccinated against seasonal flu – meaning they are both less likely to need time off over the busy winter period, and less likely to pass on the virus to vulnerable patients.

Since September, hospitals and other healthcare settings across the country have been laying on special activities designed to highlight the importance of the flu vaccine, and celebrate those staff who choose to protect themselves and their patients. A record 70% of doctors, nurses, midwives and other NHS staff who have direct contact with patients took up the vaccine through their employer last year, with most local NHS employers achieving 75% or higher.

Ruth has been joined in writing an open letter to NHS staff by other heads of professions like the NHS National Medical Director, Professor Stephen Powis, Chief Allied Health Professions Officer, Suzanne Rastrick, Chief Midwifery Officer, Professor Jacqueline Dunkley-Bent, and Chief Pharmaceutical Officer, Dr Keith Ridge. In it they urge every member of the NHS’ growing frontline workforce to work together to achieve even higher level of coverage this year.

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Source: NHS England, 25 November 2019

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Latest NHS maternity scandal is product of toxic 'can't happen here' mentality

Shrewsbury and Telford hospital NHS trust has uncovered dozens of avoidable deaths and more than 50 babies suffering permanent brain damage over the past 40 years. But how many more babies must die before NHS leaders finally tackle unsafe, disrespectful, life-wrecking services? The NHS’s worst maternity scandal raises fundamental questions about the culture and safety of our health service.

Too many hospital boards complacently believe “it couldn’t happen here”. Instead of constantly testing the quality and reliability of their services, they look for evidence of success while explaining away signs of danger.

Across the NHS there are passionate clinicians and managers dedicated to building a culture that delivers consistently high quality care. But they are undermined by a pervasive willingness to tolerate and excuse poor care and silence dissent. Until that changes, the scandals will keep coming.

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Source: The Guardian, 2 November 2019

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Hancock rejects GP vote to remove home visits from contracts

Health Secretary Matt Hancock has ruled out scrapping home visits by GPs, describing the idea as “a complete non-starter”.

Doctors argued that they were no longer able to provide home visits as part of their core work and voted at a conference on Friday to remove them from their NHS contract. Under the proposals GPs would negotiate a separate service for urgent visits to patients. However, the health secretary said he was strongly opposed to the plans and insisted that they would not come to fruition.

“The idea that people shouldn’t be able, when they need it, to have a home visit from a GP is a complete non-starter and it won’t succeed in their negotiations,” he told BBC Radio 4’s Today programme.

He admitted that most home visits were done by nurses but said that on some occasions a GP was needed.

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Source: The Independent, 24 November 2019

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No safety switch: How lax oversight of EHRs puts patients at risk

Back in 2009, healthcare experts, including mainly members of the American Medical Informatics Association, envisioned creating a national databank to track reports of deaths, injuries and near misses linked to issues with the move to have computerised medical records.

The experts at that September 2009 meeting agreed that safety should be a top priority as federal officials poured more than $30 billion into subsidies to wire up medical offices and hospitals nationwide. However, it never happened. Instead, plans for putting patient safety first — and for building a comprehensive injury reporting and reviewing system — have stalled for nearly a decade, because manufacturers of electronic health records (EHRs), health care providers, federal health care policy wonks, academics and Congress have either blocked the effort or fought over how to do it properly, an ongoing investigation by Fortune and Kaiser Health News (KHN) shows.

Meanwhile, patients remain at risk of harm. In March, Fortune and KHN revealed that thousands of injuries, deaths or near misses tied to software glitches, user errors, interoperability problems and other flaws have piled up in various government-sponsored and private repositories. One study uncovered more than 9,000 patient safety reports tied to EHR problems at three pediatric hospitals over a five-year period.

Despite such incidents, experts believe EHRs have made medicine safer by eliminating errors due to illegible handwriting and in some cases speeding up access to vital patient files. But they also acknowledge they have no idea how much safer, or how much the systems could still be improved because no one — a decade after the federal government all but mandated their adoption — is assessing the technology’s overall safety record.

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Source: Kaiser Health News, 21 November 2019

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Older people dying for want of social care at rate of three an hour, claims charity

At least 74,000 older people in England have died, or will die, waiting for care between the 2017 and 2019 general elections. A total of 81 older people are dying every day, equating to about three an hour, research by Age UK has found.

In the 18 months between the last election and the forthcoming one, 1,725,000 unanswered calls for help for care and support will have been made by older people. This, said the charity, was the equivalent of 2,000 futile appeals a day, or 78 an hour.

Age UK’s director, Caroline Abrahams, said: “This huge number of requests for help did not lead to any support actually being given for three main reasons: because the older people died or will die before services were provided, because of a decision that they did not meet the eligibility criteria as interpreted by their local authority, or because their local authority signposted them to some other kind of help than a care service.”

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Source: The Guardian, 22 November 2019

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