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  1. Today
  2. News Article
    Female health monitoring apps are putting women at risk by "coercing" them into disclosing - and then poorly handling - highly sensitive data, according to new research. The study examined the privacy policies and data safety labels of 20 of the most popular of these kind of apps, which are commonly used to help women conceive. It found a host of poor data-management practices, including some apps not having a delete function, even for highly personal information such as menstrual cycles and miscarriages. Its authors say it is the most extensive evaluation its kind completed to date. They say the apps are used by hundreds of millions of people. The BBC has contacted a number of app providers - none have responded to a request for comment. "While female health apps are vital to the management of women’s health worldwide, their benefits are currently being undermined by privacy and safety issues," the lead author of the study, Dr Ruba Abu-Salma, from King's College London, told the BBC. Other key findings from the study include: 35% of apps claimed not to share personal data with third parties but contradicted this in their privacy policies 50% assured users that health data would not be shared with advertisers, but were ambiguous about other data collected 45% of privacy policies denied responsibility for third-party practices, despite claiming to vet them. Female-focused technology has boomed in recent years, with the market expected to exceed $75 billion by 2025. But Lisa Malki, another of the study's authors, said the industry needed to get better at protecting the women whose data it was using. Read full article on the BBC here.
  3. Content Article
    Medicines waste is a significant problem in the NHS, with an estimated £300m wasted annually on unused or partially used medicines. In hospitals, this waste is added to when patients do not take their medicines home or when their medicines are not transferred with them as they change wards. In this blog for The Pharmaceutical Journal, Claire Williams, deputy clinical pharmacy manager at Hampshire Hospitals NHS Foundation Trust describes how her Trust reduced its medicines waste by moving patients’ medication with them and returning unused medication to the pharmacy in a timely manner. The Trust was participating in the Centre for Sustainable Healthcare ‘Green Team’ competition, and Claire and her colleagues saw it as an opportunity to showcase the impact that pharmacy can have in supporting the green agenda. This article is free to read but you will need to sign up for a Pharmaceutical Journal account to access it.
  4. Content Article
    Large language models (LLMs) are a form of artificial intelligence that can generate human-like text and functions as a form of an input–output machine. They bring great potential to help the healthcare industry centre care around patients’ needs by improving communication, access and engagement. However, LLMs also present significant challenges associated with privacy and bias that also must be considered. This blog looks at three major patient-care advantages of LLMs, as well as the potential risks associated with using them in healthcare.
  5. Content Article
    This report commissioned by the US Agency for Healthcare Research and Quality aims to identify major themes related to the current state of diagnostic safety and highlight key gaps in knowledge. Through a rapid narrative review methodology to evaluate multiple resources in the literature and interviews with experts, it presents several findings that have implications for future resource investments to reduce harm from diagnostic errors. The report looks at the following key themes: Incidence and Contributing Factors Measurement: Data and Methods Cognitive Processes Culture, Workflow, and Work System Issues Disparities Health Information Technology Patients and Families Testing Interventions Implementation
  6. Content Article
    FebriDx® is a single-use, analyser-free, point-of-care test with markers for bacterial and viral infection, measured on a finger-prick blood sample. As part of a larger feasibility study, this study explored the views of healthcare professionals (HCPs) and patients on the use of FebriDx® to safely reduce antibiotic prescriptions for lower respiratory tract infections (LRTI) in primary care. The authors concluded that the tool was perceived as a useful in guiding antibiotic prescribing and supporting shared decision making. Initial practical problems with testing and communicating results are potential barriers to use. Training and practice on using the test and effective communication are likely to be important elements in ensuring patient understanding and satisfaction and successful adoption.
  7. News Article
    More than 30 of the most common antidepressants used in the UK are to be reviewed by the UK’s medicines regulator, as figures point to hundreds of deaths linked to suicide and self-harm among people prescribed these drugs. The medicines, which include Prozac and are prescribed to millions of patients, will all be looked at by the Medicines and Healthcare products Regulatory Agency (MHRA). It follows concerns raised by families in Britain over the adequacy of safety measures in place to protect those taking the drugs, such as warnings about potential side effects. The regulator will look into the effectiveness of the current warnings, according to a letter from mental health minister Maria Caulfield, which has been seen by The Independent. There has been a huge rise in the use of antidepressants in England, with 85 million prescriptions issued in 2022-23, up from 58 million in 2015-16, according to NHS figures. Nigel Crisp, a crossbench peer and chair of the Beyond Pills all-party parliamentary group, told The Independent: “Overprescribing of antidepressants has an enormous cost in terms of human suffering, because so many people become dependent and then struggle to get off them – and it wastes vital NHS resources.” The review comes as it emerged that: More than 515 death alerts linked to these drugs, involving suicidal ideation and self-harm, have been made to the MHRA since the year 2000 (these alerts don’t directly confirm the cause of a person’s death) Some antidepressants have been given to children as young as four, and the total cost of the medication to the NHS in 2022-23 was more than £231m Read full story Source: The Independent, 11 May 2024
  8. News Article
    Giving teenagers the HPV vaccine is cutting cases of cervical cancer by 90%, figures for England show. Scientists say it works so well that this type of cancer could be eradicated in the near future. The study shows the vaccine is most effective when offered to Year 8 students - those aged 12 to 13. The vaccine also provides protection against genital warts by preventing human papillomavirus (HPV) infections. The study, funded by Cancer Research UK and led by experts at Queen Mary University of London, shows the HPV vaccine combined with cervical screening can dramatically reduce cervical cancer incidence to the point where almost no-one develops it. More cases were prevented in the most deprived socio-economic groups in society - those often hit hardest by the disease. Prof Peter Sasieni, lead author of the work that is published in the British Medical Journal,, external said: "Our research highlights the power of HPV vaccination to benefit people across all social groups. Historically, cervical cancer has had greater health inequalities than almost any other cancer and there was concern that HPV vaccination may not reach those at greatest risk. This study captures the huge success of the school-based vaccination programme in helping to close these gaps and reach people from even the most deprived communities." Read full story Source: BBC News, 16 May 2024
  9. Yesterday
  10. Content Article
    In this blog, Kristy Widdicombe-Dutch shares her decades-long experience of harmful healthcare that has left her with a complete loss of trust in the system. She describes how, starting in her 20s, she has experienced disbelief, gaslighting and poor care in relation to her vascular issues, which has left her with long-term physical harm and psychological trauma.
  11. Event
    An After Action Review (AAR) is a facilitated discussion following an event to understand what happened and why. AARs involve key stakeholders involved in the incident and provide insight into how improvements could be made to help deliver safer care for patients. The AAR process emphasises the importance of a facilitated approach with all participants encouraged to work collaboratively to identify possible changes and improvements. AARs provide all participants with an opportunity to reflect and consider opportunities for self-learning. AARs are gathering momentum within healthcare particularly since the approach was identified as one of the national learning response methods within NHS England’s Patient Safety Incident Response Framework (PSIRF) documentation. The workshop will commence by looking at a brief history of AAR across the globe and its recent transition as an approach to help healthcare teams better understand their patient safety incidents. The core part of the day will focus on the four questions involved in conducting an effective AAR and learners will be given the chance to put learning into practice by looking at relevant case studies and scenarios in small groups. The day will conclude with an honest assessment of AARs and consider the challenges and benefits of utilising this team approach in a healthcare setting. This course is aimed at those who wish to lead and conduct AAR reviews plus those who are likely to take part in AAR investigations. The facilitators for this course will continue the journey beyond the course itself to support and enable you to develop your skills in AAR when you return to your organisation. This masterclass will enable you to: Understand history of AARs and why they are gathering momentum in healthcare Appreciate what an AAR is and how it differs from other incident investigation methods Identify when it is appropriate to conduct an AAR Examine what skills effective AAR conductors require Understand the four fundamental questions involved in conducting an AAR Develop your AAR skills via a number of case studies and scenarios Consider how human factors can play a part in the AAR process Examine why AAR can be an effective mechanism for change and improvement Discuss the strengths and weaknesses associated with AARs Evaluate where you consider you can gain the most from undertaking AAR. Register hub members receive a 20% discount. Email info@pslhub.org for the discount code.
  12. Event
    This National Virtual Summit focuses on the New PHSO National NHS Complaint Standards which are now being used and embedded into the NHS. Through national updates, practical case studies and in depth expert sessions the conference aims to improve the effectiveness of complaints handling within your service, and ensure that complaints are welcomed and lead to change and improvements in patient care. The conference will also reflect how involving people and their families in complaints and integrating the process with the new Patient Safety Incident Response Framework (PSIRF) to ensure patient safety actions and learning. https://www.healthcareconferencesuk.co.uk/virtual-online-courses/nhs-complaints-summit or email frida@hc-uk.org.uk for further information. Follow the conference on Twitter @HCUK_Clare #NHSComplaints hub members receive a 20% discount. Email info@pslhub.org for the discount code.
  13. Event
    This conference brings together leading experts at the forefront of Martha’s Rule implementation and offers a comprehensive and practical guide for clinical staff to seamlessly integrate Martha’s Rule into their daily practice. The conference delves into the caregiver’s perspective, principles and implications of Martha’s Rule, legal and patient safety considerations, effective communication strategies, and the use of technology in the adoption of Martha’s Rule. Throughout the day, there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/marthas-rule-patient-safety or email aman@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for the discount code. Follow on X @HCUK_Clare #MarthasRule
  14. Content Article
    Despite growing awareness of diagnostic error, most healthcare systems do not track or record diagnostic quality, and many diagnostic safety events are not recognised. Without methods to identify, measure, investigate and analyse events, healthcare organisations cannot understand causes of diagnostic errors, identify contributing factors or create solutions. One of the best ways to collect information about diagnostic errors is through self-reporting by patients and healthcare professionals. This issue brief from the Agency for Healthcare Research and Quality looks at how to foster psychological safety and organisational safety culture in order to reduce harm from diagnostic error. 
  15. Event
    Aimed at Clinicians and Managers, this national virtual conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process, and safety. The conference delves into integrating human factors into healthcare systems and processes, clinical decision making, healthcare system design, quality of patient experience, medication safety, and workload, fatigue and stress management. Throughout the day there will be interactive sessions, small breakout groups, and collaborative exercises, fostering a dynamic learning experience. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/virtual-online-courses/a-practical-guide-to-human-factors-in-healthcare or email frida@hc-uk.org.uk hub members receive a 20% discount. Email info@pslhub.org for discount code. Follow on Twitter @HCUK_Clare #HumanFactors
  16. Content Article
    Suicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, examples of optimal practice that help to keep patients safe also often important learning for organisations and healthcare professionals. This study in BMC Psychiatry aimed to explore clinicians’ views of what constitutes good practice in mental healthcare services in the context of suicide prevention. The study highlighted clinicians’ views on good practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. The authors concluded that clinicians possess important understanding of optimal practice, but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.
  17. Content Article
    This report, commissioned by Alzheimer’s Society from Carnall Farrar, sets out estimates of current and future economic and healthcare costs of dementia in the UK. It breaks down this data by cost type, dementia severity and the regions of England and the devolved nations.
  18. Content Article
    This BMJ long-read article argues that health is going in the wrong direction in the UK, and reversing the trend requires political and societal commitment to deal with the underlying causes. It proposes evidence-based solutions to the worsening health and widening inequalities in the UK through action on the social determinants of health.
  19. Event
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    Telemetry monitors are patient-worn devices that allow the patient's heart rate, heart rhythm, and other physiologic conditions to be assessed without restricting the patient to a bed. These devices allow cardiac patients to move around the facility while still being monitored. Monitors are designed to transmit an alarm signal to nursing staff if the patient develops a concerning heart rhythm or other condition that requires attention. The safety and effectiveness of a telemetry monitoring program depends heavily on the organization's alarm management strategy. Any failure to recognize or delay in responding to a potentially life-threatening change in the patient's condition could lead to severe harm. As with any physiologic monitoring system, healthcare organizations must scrutinize all aspects of how telemetry alarms are initiated, how they are communicated, and how staff respond. The use of inappropriate alarm settings or notification processes can prevent staff from learning about a change in the patient's condition or may lead to frequent false alarms or nuisance alarms that overwhelm, distract, or desensitize staff—a phenomenon known as alarm fatigue. Either situation can result in valid alarm conditions being missed by staff, and thus a patient's deterioration going unnoticed. Improvements in the way that telemetry systems are implemented and managed can help combat alarm fatigue and reduce the risk of alarm-related adverse events. During this lab webcast, we will discuss: Alarm fatigue: what it is, why it is a concern, and how telemetry implementation decisions can contribute to this hazard Criteria for selecting patients for telemetry monitoring Policies and procedures for setting and disabling alarms Alarm escalation processes and secondary alarm notification systems Strategies to optimize the monitor watching function Register for the webcast The webcast will take place at 12:00 ET, 17:00 BST
  20. Content Article
    The Safe Learning Environment Charter supports the development of positive safety cultures and continuous learning across all learning environments in the NHS. It is underpinned by principles of equality, diversity and inclusion. It has been developed by over 2482 learners, educators and key stakeholders in health education. The Charter was created by NHS England in response to healthcare learners’ feedback on their clinical experiences in maternity services, set out in the Kirkup (2015 and 2022) and Ockenden (2020 and 2022) reports. The Charter is designed for learners and those responsible for supporting placement learning across all learning environments and all professions within them. It is aligned to the NHS People Promise in recognition that learners are vital to the workforce and are included in the promises NHS staff and leaders must all make to each other, to improve everyone’s experience of working in the NHS. The Charter sets out the supportive learning environment required to allow learners to become well-rounded professionals with the right skills and knowledge to provide safe and compassionate care of the highest quality.
  21. News Article
    More than 50 NHS whistleblowers claim to have lost their jobs—with some driven to the brink of suicide—after standing up to protect patients’ lives as bosses bury their concerns. The group of doctors and nurses said that they had been targeted after raising concerns about more than 170 patient deaths and nearly 700 cases of poor care. One consultant said that it was the “biggest scandal within our country” and claimed the true number of avoidable deaths was “astronomical”. Instead of addressing the problems, the whistleblowers claim that NHS bosses are spending millions of pounds of taxpayers’ money on hiring law firms and private investigators to investigate them instead. Last year Rob Behrens, the health ombudsman, warned The Times Health Commission that patient safety was at risk due to “toxic” and hierarchical behaviour among NHS doctors. Professor Phil Banfield, the chairman of the council of the British Medical Association, which represents doctors, wrote in The Daily Telegraph that whistleblowing “is not welcomed by NHS management… NHS trusts and senior managers are more concerned with protecting personal and organisational reputations than they are with protecting patients.” In one case, the NHS spent more than £4 million on legal action against a single whistleblower, which included £3.2 million in compensation. Among the clinicians interviewed, 40 said that their employer took “no positive action” to address patient safety concerns; 36 said that patients remained at risk at their place of work; 19 said that NHS trusts covered up the problems, and ten said that their employers had denied there was a problem. Whistleblowers’ representatives are urging the government to require independent medical assessments for claims and to ban the suspension or exclusion of doctors for speaking out about patient safety. Dr Naru Narayanan, president of the hospital doctors’ union, has called for an independent national whistleblowing body outside of the NHS to register protected disclosures and protect individuals against recriminations. The Times Health Commission recommended that a no-blame compensation scheme should be introduced for medical errors, with settlements determined according to need. Backed by Jeremy Hunt, the chancellor, the scheme would help end the deadly cycle of NHS scandals and cover-ups and ensure families receive timely support. Read full story (paywalled) Source: The Times, 15 May 2024
  22. News Article
    A trust is experiencing severe problems with its electronic patient record system two years after it was installed, HSJ research has revealed. A “preliminary review” into the Oracle Cerner electronic patient record – called Surrey Safe Care – at Ashford and St Peter’s Hospitals (ASPH) Foundation Trust in Surrey found the emergency department was still spending “significant time” using the system, an electronic bed board was not updated in real-time, and there were booking and workflow errors in clinics. The review, which was released to HSJ after a Freedom of Information Act request and carried out in recent months, found problems stemming from limited system training, configuration issues and insufficient technology available on wards and in clinics. The EPR went live in May 2022. The trust also had “insufficient analysts” to provide comprehensive management information. Also, performance, utilisation and management information were described as still being “under construction.” In a statement, ASPH said, “Annual reviews will be carried out to monitor the continual progress of this project. A new working group of clinical, operational, and digital staff will agree how we use existing resources to improve staff training, add extra functionality to the EPR, invest in appropriate technology and additional analysts.” Read full story (paywalled) Source: HSJ, 15 May 2024
  23. Content Article
    In this blog, Miqdad Asaria, Assistant Professor at the Department of Health Policy at LSE, argues that AI could lead to a paradigm-shift in healthcare systems likes the NHS. He outlines how AI could help personalise medical treatments, enhance research and development of new drugs and help with the administrative burden currently undermining the productivity and efficiency of healthcare providers.
  24. Content Article
    This is the second ‘saving babies’ lives’ progress report from the Joint Policy Unit. When the first report was published in May 2023, the Unit committed to reassessing progress each year. Through this process it aims to hold government and decisionmakers to account, helping to ensure that saving babies’ lives and tackling inequalities in pregnancy and baby loss are the political priorities they deserve to be. This years report highlights that maternity services need a much more transformative approach from government, that matches the scale and impact of the issue. Maternity services are not on course to meet government ambitions to reduce rates of stillbirth, neonatal death or preterm birth, and there continue to be stark and persistent inequalities in rates of pregnancy and baby loss by ethnicity and deprivation. View a summary version of the report
  25. News Article
    A mother of five died of endometrial cancer hours after being admitted to A&E following preventable delays in her diagnosis. An inquest was told that a private clinic identified the cancer by ultrasound but the report was never sent to her GP. Kerri Mothersole, 44, from Swale in Kent, had a complex medical history including decades of depression and chronic back pain. Her 21-year-old son, Jordan Dighton, said: “My mum should have been taken more seriously—if she were, maybe she’d still be alive.” In May 2020 Mothersole presented with symptoms of early menopause. Blood tests showed that she had low iron levels and her symptoms persisted. In March 2021 she told her GP at Green Porch Medical Centre that she had had vaginal bleeding for six weeks. She could not attend her ultrasound appointments because she was the family’s only driver, and was removed from the waiting list despite rescheduling two appointments. In June of that year her GP referred her for an NHS scan at HEM Clinical Ultrasound Service in Sittingbourne. A radiographer, who was new to the private clinic, found a suspected ovarian mass. However, the clinical lead deemed the scan results inaccurate so they were never returned to the GP. Instead Mothersole was asked to attend a second pelvic and abdominal scan. She was losing weight and in persistent pain. Despite her symptoms being gynaecological, she underwent what turned out to be a clear colonoscopy. According to the coroner, had the first scan report been seen this would have led to an urgent referral to gynaecology. Mothersole was eventually admitted to A&E, where she remained under the care of oncology until she was discharged home to the care of hospice nurses. Dighton told The Times, “The system was so siloed and her case was passed around from department to department. It’s only after her death that we’ve started to make sense of what pathways she should have been on.” Read full story (paywalled) Read the Prevention of Future Deaths Report for Kerri Mothersole Source: The Times, 15 May 2024
  26. Content Article
    Kerri Mothersole was a 44 year old woman who had a past medical history of asthma, labyrinthitis, depression and back pain. In May 2020 she was seen with symptoms of possible early menopause and blood tests requested. In October 2020 she was noted to be suffering from tiredness and had irregular periods and again blood tests were requested. Blood tests taken in January 2021 noted a low haemoglobin and ferritin so iron was prescribed as well as follow up in two months. In March 2021 she complained of having per vaginal bleeding for six weeks and she was referred for an ultrasound. Due to her underlying ill health, she had difficulty in attending appointments and missed a number of different appointments. She was seen in the surgery on 21 June 2021 by her General Practitioner who noted abdominal tenderness and weight loss and he again referred her for an ultrasound. An ultrasound was undertaken by a private firm HEM Clinical Ultrasound on 28 June 2021 but the report was never sent to her General Practitioner. A second ultrasound on the 1 July 2021suggested a diagnosis of adenomyosis but noting that serious pathology could not be ruled out. Only the second report was sent to the General Practitioner which led to a routine gynaecology referral, she had however already been referred to the colorectal team on the urgent two week wait pathway. Had the earlier scan report been seen this would have led to an urgent referral to gynaecology. There were a number of missed appointments and a colonoscopy took place on 20 October 2021. The procedure was negative but the endoscopist thought he could feel something in the pelvis and a CT scan was arranged. The CT scan on 28 October 2021 demonstrated a large pelvic mass and she was referred to the gynaecology team in early December and a multidisciplinary team meeting discussion on 17 December 2021 led to a request for an MRI scan. Appointments were made for 31 December 2021, 25 January 2022 and again in February but not attended and she eventually underwent an MRI on 1 May 2022 which revealed a large mass. She was again discussed at the multidisciplinary team meeting on 6 May 2022 and referred to the gynae-oncology surgeons at Maidstone hospital. She was seen on 1 June 2022 and booked for surgery on 27 June 2022. She was, however, far too unwell for surgery on 27 June 2022 and further investigations revealed brain metastases. She was admitted to hospital and treated with steroids and referred to the Oncologists as surgery was deemed no longer appropriate. She was prescribed hormone treatment but she was, by now, too unwell to receive even palliative radiotherapy. She was taken to Medway Maritime hospital on 19 August 2022 and was struggling as she had been so unwell at home. Whilst plans were being made to provide some care at home she remained overnight but sadly died on 20 August 2022 as she was so unwell she could not return home.
  27. Content Article
    This report from Public Policy Projects (PPP) calls for changes in the use of approved medicines to improve diabetes care in the UK. It is the first in a series looking at specific areas of diabetes care in the UK.
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