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Patient Safety Learning


Everything posted by Patient Safety Learning

  1. News Article
    Cancer drug information leaflets for patients in Europe frequently omit important facts, while some are “potentially misleading” when it comes to treatment benefits and related uncertainties, researchers have found. Cancer is the biggest killer in Europe after heart conditions, with more than 3.7m new cases and 1.9m deaths every year, according to the World Health Organization. Medicines are a vital weapon against the disease. But critical facts about them are often missing from official sources of information provided to patients, clinicians and the public, according to a study led by researchers from King’s College London, Harvard Medical School and the University of Sydney, among others. “Regulated information sources for anticancer drugs in Europe fail to address the information needs of patients,” the study’s authors wrote in The BMJ journal. “If patients lack access to such information, clinical decisions may not align with their preferences and needs.” Read full story Source: The Guardian, 29 March 2023
  2. News Article
    Bupa is set to cut 85 dental practices amid a national shortage of dentists, in a move that will affect 1,200 staff across the UK. The group said patients at some practices were unable to access the NHS dental service they need. Bupa, which provides NHS and private care, said the 85 practices would be closed, sold or merged later this year. The healthcare group's boss said the industry faced "systematic challenges" and the decision was a "last resort". In August the BBC revealed 9 in 10 NHS dental practices across the UK were not accepting new adult patients for treatment under the health service. Bupa has not been able to recruit enough dentists to deliver NHS care in many practices for months and in some cases years, it said. Read full story Source: BBC News, 30 March 2023
  3. Content Article
    The Prescription Charges Coalition, which brings together around 50 organisations and professional bodies to campaign to scrap prescription charges in England for people with long-term conditions, conducted the survey between February and March. It found: Nearly 1 in 10 people have skipped medication in the past year due to the cost of prescriptions. Of this group: Almost a third (30%) of those who have missed medication now have other physical health problems in addition to their original health condition. 37% now have other mental health problems in addition to their original health condition. And over half (53%) have had to take time off work as a result of worsening health. 12% of people who pay for their NHS prescription have cut medication in half to make it last longer. Over a third (35%) of survey respondents reported they had the duration of their prescription changed, meaning they’re paying more frequently for their medicines. Almost 2 in 5 (38%) people with long-term health conditions only learned about the prepayment certificate more than a year after their diagnosis. The survey shows that people with long-term health conditions that cannot afford their medication are seeing an increase in GP visits, trips to accident and emergency (A&E), and hospital stays. Some survey respondents reported they had to stay in hospital for up to 6 weeks. Not being able to afford medicine has also led to mental health is sues and increased time off work.
  4. Content Article
    Due to the scale of the pandemic, despite being in a healthcare setting, patients in hospital and other in-patient settings faced an increased risk of hospital acquired COVID-19. In its first year, the programme has supported NHS Wales organisations to assess and investigate over 5,000 cases of nosocomial COVID-19, where they meet the definition of a patient safety incident and is on track to have successfully investigated all cases of hospital-acquired COVID-19 by March 2024. Findings in the report include; The value of bereavement support and care-after-death services have for people experiencing grief and signposting to support at the earliest opportunity. The benefits of a single point of contact and support for people navigating the concerns process. The impact of visiting restrictions and visiting considerations should continue to be carefully balanced with risk. Inequities in the concerns process for people who receive healthcare via independent providers. Inconsistent approaches to the management and reporting of health care acquired infections across Wales.The need for improved application and improvement of DNACPR (Do Not Attempt Cardio-Pulmonary Resuscitation. The need for improvement in how Infection prevention and control (IP&C) guidance, is reviewed and communicated to staff. Better communication with families and carers around ward movements.
  5. Event
    This one-hour webinar will be an opportunity for providers and professionals who work in health and social care services, organisations who represent them, other stakeholders, local authorities, integrated care systems and stakeholders that represent the public to hear about CQC's approach to assessing integrated care systems and what it means for them. The webinar will be led by Amanda Williams, CQC's Interim Director of integration, inequalities and improvement. Register
  6. Event
    This one-hour webinar will be an opportunity for providers and professionals who work in health and social care services, organisations who represent them and other stakeholders to hear the latest updates about CQC's new regulatory approach. The webinar will be led by Kate Terroni, CQC's Deputy Chief Executive and Chris Day, director of engagement. There will be a presentation and time to answer your questions from the live chat. Register
  7. Event
    The Health and Care Act 2022 gives the Care Quality Commission (CQC) new powers that allow them to provide a meaningful and independent assessment of care at a local authority level. This one-hour webinar will be an opportunity for providers and professionals who work in health and social care services, organisations who represent them, other stakeholders, local authorities, and stakeholders that represent the public to hear about CQC's approach to assessing local authorities and what it means for you. Register
  8. Event
    The Health Cover Conference is the premier event for industry professionals to stay ahead of the curve in the ever-evolving healthcare landscape. Attendees will gain valuable insights from thought leaders in the field, discussing the latest trends and innovations in health insurance, including claims trends and findings, the changing role of health plans, and the integration of primary care and virtual GP providers to reduce costs. The conference will also delve into the buzzworthy topics of company-funded health cover, workplace wellness and the future of contact centre technology. Panel discussions will focus on the consumer perspective, including how to select the best health cover providers and what customers value most and least. Attendees will also hear from disruptors in the industry, such as new UK health insurers and companies utilising technology to drive efficiency and customer satisfaction. Don't miss this opportunity to network with peers, gain new perspectives and stay ahead of the curve in the ever-changing world of health insurance. Register hub members receive 10% using discount code: HCC23SPKR10
  9. Event
    This webinar shares the findings of a co-production project in Nottingham and Nottinghamshire Integrated Care Board (ICB) to remove barriers to shared decision making. The partners in the project were the ICB’s Personalised Care Team, the My Life Choices lived experience panel, the Patient Information Forum (PIF), and us, the Patients Association. The project was one we highlighted during Patient Partnership Week last year; you can learn more about it before attending this webinar by watching the recording of the Partnering with patients and communities - what's happening in ICSs session. Over the course of six co-production meetings, we developed simple resources to support patients and professionals to have better shared decision making conversations. This webinar shares the findings of the project. Speakers will discuss practical solutions to help patients and professionals get the most from limited appointment times which can be applied nationally. Register
  10. Event
    Attend Europe’s Largest Infection Prevention and Control 2-Day Conference in Birmingham at The National Conference Centre. There are 40 free spaces available for AfPP Members. Bookings can be made by contacting t.shuttleworth@knowlex.co.uk quoting code AfPP1.
  11. Event
    DECON UK is back for 2023, providing valuable insights into decontamination and infection prevention it is a free event for healthcare professionals. The Royal Wolverhampton NHS Trust, Wallsall Healthcare NHS Trust and University Hospitals Birmingham NHS Foundation Trust jointly brings you DECON UK 2023. This event is expected to host over 150 healthcare professionals from various fields within the decontamination sector. We aim to provide a high quality of educational content to our delegates with a comprehensive programme covering water, air and sustainability. Register
  12. Event
    Energy-based devices, lasers and diathermy are some of the most commonly used pieces of equipment in operating theatres today. Dangerous emissions can be produced that affect the respiratory systems of everyone in the operating theatre. This study day will look at the occupational hazards of exposure to surgical plume in the operating theatre, as well as the associated risks to the surgical team, patients and visitors. It will also highlight how to assess risk and mitigate against the dangers of surgical plume and how to implement changes. Topics Include: Electrosurgery/diathermy/laser. Anaesthetic airway fires. Laparoscopic surgery aerosolisation. Health and Safety and risk assessment. Surgical plume. Register
  13. Event
    Free online congress, in Santiago de Chile. Welcome to all of you. Please find attached the programme. FINAL FLYER OFICIAL 2 (1).pdf
  14. Content Article
    Findings The investigation found there are currently no long-term haemodialysis catheters on the UK market, or being developed, that have integrated ‘safety-valves’. Manual clamps on haemodialysis catheters rely on people ensuring that the clamp is on before accessing the haemodialysis catheter ports and do not mitigate against design-induced error. A review of patient safety risks associated with other haemodialysis devices (for example, fistulas) showed several mitigations which are not consistently used for haemodialysis catheters. These include a coloured patient wristband, line labelling, alert cards being carried by the patient and educating patients/family members. The training and education of all grades of medical staff has not been consistent in relation to the risks of catheter-related air embolism. There is currently no recognised national training or national training guidelines regarding the safe access of haemodialysis catheters. Incidents appear to be under-reported to the Medicines and Healthcare products Regulatory Agency, due to misconceptions about ‘human error’ being the cause, rather than the design of the equipment. The Medicines and Healthcare products Regulatory Agency, in partnership with NHS England, have explored integrated incident reporting system possibilities. While a recent funding bid to support full development for an in-service solution was unsuccessful, the organisations are committed to drive this project forward. There is a general lack of literature on, and knowledge of, catheter-related air embolism in relation to access when the catheter is in situ (in position), rather than during insertion or removal of the catheter. Safety recommendations HSIB recommends that the General Medical Council engages with relevant stakeholders to amend the procedure for taking blood cultures in its ‘Practical skills and procedures’ guidance, making clear that the procedure relates to taking blood from a peripheral site, so mitigating the risks to patient safety associated with central lines. HSIB recommends that the General Medical Council, supported by the Medical Schools Council, revises ‘Achieving good medical practice’ to include guidance for medical students on how to handle uncertainty in clinical settings, including challenging a culture, or an expectation, that a learner undertake unfamiliar tasks to gain competencies without appropriate supervision or support. HSIB recommends that the Medicines and Healthcare products Regulatory Agency amends its 2022 ‘Dialysis guidance’ to include the safety risk of air emboli associated with unclamped haemodialysis catheters. Safety observations It may be beneficial for manufacturers of haemodialysis catheters to develop an engineering solution to maintain a sealed system upon disconnection, thereby reducing the risk of an air embolism. It may be beneficial to consider how junior doctors can be supported to work safely within their level of competence and feel empowered to decline tasks they are not competent to undertake, with specific reference to the safety risks associated with accessing haemodialysis catheters if not trained and competent. It may be beneficial to explore the design of a visual alert which prompts healthcare professionals to the increased safety risks associated with in situ haemodialysis catheters and the access to this medical device by staff specifically trained in their use. It may be beneficial if the approach outlined in the White Paper published by the National Infusion and Vascular Access Society in 2022 was adopted for wider bore lines such as haemodialysis catheters. This is in relation to a standardised structure and approach for the NHS to deliver vascular access services in every hospital.
  15. News Article
    NHS Highland has been reprimanded for a data breach which revealed the personal email addresses of people invited to use HIV services. The health board used CC (carbon copy) instead of BCC (blind carbon copy) to send an email to 37 people. The Information Commissioner's Office (ICO) said the error amounted to a "serious breach of trust". It called for improvements to be made to data protection safeguards for HIV service providers. The mistake meant all recipients of the email could see the personal addresses of the others receiving it. One person said they recognised four other individuals, one of whom was a previous sexual partner. Read full story Source: BBC News, 30 March 2023
  16. News Article
    New restrictions are being introduced for autism assessments, with some areas now only accepting referrals for patients in crisis, HSJ has learned. Commissioners in North Yorkshire and York have become the latest to introduce new criteria for autism and attention deficit hyperactivity disorder referrals. Getting a diagnosis is key to unlocking care packages such as speech and language therapy, counselling, or special educational needs. They said the changes are due to “unprecedented demand that has exceeded supply, resulting in unacceptable wait times and the need to prioritise resources towards children and most at-risk adults”. Read full story (paywalled) Source: HSJ, 30 March 2023
  17. News Article
    A review of the whistleblowing framework – the laws that support workers who blow the whistle on wrongdoing in the workplace – has been launched by the Government. The review will seek views and evidence from whistleblowers, key charities, employers and regulators. Whistleblowing refers to when a worker makes a disclosure of information which they reasonably believe shows wrongdoing or someone covering up wrongdoing. Workers who blow the whistle are entitled to protections, which were introduced through the Public Interest Disclosure Act 1998 (PIDA). Successive governments have taken steps to strengthen whistleblowing policy and practice. It provides a route for employees to report unsafe working conditions and wrongdoing across all sectors. This was keenly felt during the height of the Covid-19 Pandemic, when the Care Quality Commission and Health and Safety Executive recorded sharp increases in the number of whistleblowing disclosures they received. The review will gather evidence on the effectiveness of the current regime in enabling workers to speak up about wrongdoing and protect those who do so. The evidence gathering stage of the review will conclude in Autumn 2023. Read full press release Source: Gov.UK, 27 March 2023
  18. News Article
    A rise in the use of slimming jabs could lead to an increase in unsafe treatment for tummy tucks and surgery to remove excess skin, UK surgeons have warned. Drugs such as semaglutide and liraglutide are approved for use on the NHS for certain groups of people with obesity, and could help people reduce their weight by more than 10%. Surgeons have warned that people using the jabs may not realise they could be left with excess skin. “Whilst the newly introduced weight-loss drugs are not likely to produce comparable weight loss to bariatric surgery there is always the possibility that accompanying weight loss, a patient might be left with a degree of deflation and redundant skin,” said Marc Pacifico, the president of the British Association of Aesthetic Plastic Surgeons. However, access to surgery on the NHS to remove excess skin is limited because the NHS do not fund post-weight loss plastic surgery any more, so it has to be undertaken in the private sector. That costs about £4,500 to £6,000 in the UK, so Mr Pacifico warned patients might seek cheaper procedures abroad.. “I would strongly warn against this as there might not be the safeguards and assurances that the drugs being used are of the same quality and provenance as those being prescribed in the UK,” he said. He also warned that there are risks associated with having weight-loss plastic surgery abroad, such as the inability to undertake proper research on a surgeon, as well as the risks associated with flying straight after significant surgery – such as blood clots, as well as a lack of accessible follow-up with the surgeon and clinic to treat post-operative wound infections. Read full story Source: The Independent, 29 March 2023
  19. News Article
    The Care Quality Commission’s follow-up of whistleblowing concerns from health and care staff has been poor and inconsistent, and there is a “widespread lack of competence and confidence” on dealing with race and racism at the organisation, two reviews have found. A “Listening, learning, responding to concerns” review was published by the Care Quality Commission, alongside a linked independent review into how the regulator failed Shyam Kumar, a consultant orthopaedic surgeon in the North West, who was also a CQC specialist professional adviser. The wider review looked at a range of issues including how the CQC deals with racism; how well it listens to whistleblowers in providers; and how it deals with its own staff, including as part of a recent restructure, and its internal “Freedom to Speak Up” process. It followed concerns bring raised, in addition to Mr Kumar’s case, about these issues. Scott Durairaj, a CQC director who joined it last year and led the review work along with a panel of advisers, reported there was “clear evidence, during the scoping, design phase and throughout the review, of a widespread lack of competence and confidence within CQC in understanding, identifying and writing about race and racism”. Read full story (paywalled) Source: HSJ, 29 March 2023
  20. Content Article
    These documents make up the report from phase 1 of our review into how well CQC listen and respond when people share concerns with them. Phase 1 was an independent review which Zoë Leventhal KC was appointed to lead. This looks into the handling of protected disclosures shared by Mr Kumar, alongside a sample of other information of concern shared with us by health and care staff. See also Listening, learning, responding to concerns (phase 2).
  21. Content Article
    Back to Our Purpose: The Reboot of Safety Partnering with Patients to Improve Diagnostic Safety Incorporating CPPS™ Certification into Academic Curriculum