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Patient Safety Learning

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  1. News Article
    Patients have described the effect on their health and wellbeing of the “new normal” of drug shortages in the UK, which has led to three-month delays and 80-mile round trips to acquire medication. Simon Bell, a 43-year-old data analyst from Tyne and Wear, has cystic fibrosis and requires medication that allows him to digest food. “For people with cystic fibrosis, the part of our pancreas which releases enzymes and allows us to digest food doesn’t work, so we have to take these tablets, which does the job of what’s missing from our pancreas,” he says. Since the outbreak of the coronavirus pandemic, Bell says he has been experiencing shortages of Creon 25000, the drug he takes, and once was unable to get his medication for more than three months. Bell decided he had no choice but to stockpile the medication when he could get it, as the effects of going without the drug are much graver than taking a lower dose. “I went three months without getting any, so after that I started just to build up stock by not taking my full amount of medication every month, so now I always keep three months’ supply. Doctors would never advise this but I feel like I have no choice,” Bell says. The situation has prompted concerns for Bell that his other medications will begin experiencing shortages, which could make him seriously ill. “Kaftrio is an expensive drug that if we stop taking would make us really seriously ill,” he says. “If I couldn’t get hold of that medication that would have serious implications in terms of health, long-term health and my ability to work. It could be quite devastating.” Read full story Source: The Guardian, 18 April 2024
  2. Content Article
    This report from the BME Leadership Network comprises examples of anti-racist initiatives from BME Leadership Network members, to help advance equality within the workforce and for service users.
  3. Content Article
    The Patient safety rights charter is a key resource intended to support the implementation of the Global Patient Safety Action Plan 2021–2030: Towards eliminating avoidable harm in health care. The Charter aims to outline patients’ rights in the context of safety and promotes the upholding of these rights, as established by international human rights standards, for everyone, everywhere, at all times.
  4. News Article
    The true scale of the number of medical trials using infected blood products on children in the 1970s and 80s has been revealed by documents seen by BBC News. They reveal a secret world of unsafe clinical testing involving children in the UK, as doctors placed research goals ahead of patients' needs. They continued for more than 15 years, involved hundreds of people, and infected most with hepatitis C and HIV. The trials involved children with blood clotting disorders, when families had often not consented to them taking part. The majority of the children who enrolled are now dead. Documents also show that doctors in haemophilia centres across the country used blood products, even though they were widely known as likely to be contaminated. Luke O'Shea-Phillips, 42, has mild haemophilia - a blood clotting disorder that means he bruises and bleeds more easily than most. He caught the potentially lethal viral infection hepatitis C while being treated at the Middlesex Hospital, in central London, which was administered because of a small cut to his mouth, aged three, in 1985. Documents seen by the BBC suggest he was deliberately given the blood product - which his doctor knew might have been infected - so he could be enrolled in a clinical trial. Read full story Source: BBC News, 18 April 2024
  5. News Article
    Trusts and NHS England are failing to prioritise training for senior leaders on listening to whistleblowers — despite repeated findings of serious concerns going unheard — the National Guardian’s Office has said. The Guardian’s Office — set up by the government to ensure whistleblowers and other staff raising concerns are properly listened to — made the claim in its written evidence to an inquiry into NHS leadership, performance, and patient safety. The Commons health and social care committee is considering regulation of NHS leaders and managers, among other issues, including progress made on the 2022 report for ministers by General Sir Gordon Messenger. The NGO’s evidence, published on Wednesday, said: “In our opinion, there has been little progress on recommendations from the Messenger Review to date… “The NGO has developed, in collaboration with [NHSE], three e-learning modules (Speak Up, Listen Up, Follow Up) which are freely available for anyone who works in healthcare. We have recommended to the sector that these modules should be a minimum standard for all staff and be made mandatory. “Although accessible to all, many organisations have not adopted them, and NHS England has not prioritised these across the system.” Read full story Source: HSJ, 18 April 2024
  6. News Article
    Britain’s health cover market has grown by £385m in a year as the NHS crisis prompted more people to seek out private medical treatment and demand for dental insurance increased, according to a report. The total health cover market, including medical and dental insurance and cash plans, grew 6.1% to £6.7bn in 2022, the latest year for which figures are available, according to the health data provider LaingBuisson. About 4.2 million people were subscribed to medical cover schemes. Including dependants on the policies, 7.3 million people were covered – the highest number since 2008. The NHS waiting list in England continued to lengthen, to a peak of nearly 7.8m last September. In February, it was still 7.5m and half of the patients had been waiting for 18 weeks or longer. Private medical insurance, the largest part of the health cover market, grew by 6% year on year in 2022 to £5.3bn, more than triple the average annual growth rate of 1.8% between 2008 and 2019. After a decade of decline until 2018, more people signed up, particularly in the aftermath of the Covid-19 pandemic which led to a backlog of major procedures such as hip and knee replacements. Tim Read, author of the report, said: “Demand began to increase in 2018, as the NHS waiting list began to rise out of control. A new Labour government is likely to aim to tackle it but will have limited fiscal headroom to make substantial progress. “With people still struggling to access NHS services and the waiting list remaining stubbornly high, there is little likelihood that demand for health insurance is going to fall any time soon.” Read full story Source: The Guardian, 18 April 2024
  7. News Article
    Predatory staff who target vulnerable adults in care homes are free to move jobs unchallenged, The Independent can reveal, as almost 10,000 incidents of sexual abuse have been recorded in the last three years. The fact that abusers can move from home to home emerged in an independent review sparked by complaints made three decades ago by the family of a man with learning disabilities. Clive Treacey was allegedly groomed and sexually abused at the age of 23 in a private care home in Cheshire and then moved to Staffordshire where his abuser was able to access him again, it was claimed. Both Mr Treacey and his alleged abuser have since died. His story was first reported by The Independent in 2021 and the review into his care – carried out by the most senior safeguarding expert in England Professor Michael Preston-Shoot and seen exclusively by this publication – showed huge failures in dealing with concerns raised by his family. It warned that vulnerable adults across the country could still be at risk of harm with no national guidance for officials on how to respond to allegations of abuse of adults by care home staff in positions of trust. Read full story Source: The Independent, 18 April 2024
  8. Content Article
    Diagnostic errors cause substantial preventable harms worldwide, but rigorous estimates for total burden are lacking. Newman-Toker and colleague previously estimated diagnostic error and serious harm rates for key dangerous diseases in major disease categories and validated plausible ranges using clinical experts. In this study they estimated the annual US burden of serious misdiagnosis-related harms (permanent morbidity, mortality) by combining prior results with rigorous estimates of disease incidence. They found that  an estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.
  9. Content Article
    A study published in the BMJ has investigated the risks of multiple adverse outcomes associated with use of antipsychotics in people with dementia. The authors of the study found that antipsychotic use compared with non-use in adults with dementia was associated with increased risks of stroke, venous thromboembolism, myocardial infarction, heart failure, fracture, pneumonia, and acute kidney injury, but not ventricular arrhythmia. The range of adverse outcomes was wider than previously highlighted in regulatory alerts, with the highest risks soon after initiation of treatment.
  10. News Article
    The Met Police has launched an investigation over concerns about stem-cell injections being offered to children as a cure for autism. The Royal Borough of Greenwich told BBC London it was aware of concerns surrounding "experimental procedures" on autistic children. The Met said it was investigating "a reported fraud relating to the provision of medical services". The National Autistic Society said there was no "cure" for autism. Greenwich Council said it issued a warning to schools and nurseries in the borough after it became aware of concerns. A spokesperson said the authority had recently been made aware of concerns that "an individual claiming to be a doctor plans to visit the UK to offer dangerous, experimental procedures on children with autism". "We understand that this person is proposing the transfer of bone marrow and spinal fluid to the brain by injection," the spokesperson said. "This unlicensed procedure poses a significant threat to life and there is no evidence of any benefits. "The safety and welfare of our children and young people is of the utmost importance." Read full story Source: BBC News, 17 April 2024
  11. News Article
    Doctors are being urged to reduce prescribing of antipsychotic drugs to dementia patients after the largest study of its kind found they were linked to more harmful side-effects than previously thought. The powerful medications are widely prescribed for behavioural and psychological symptoms of dementia such as apathy, depression, aggression, anxiety, irritability, delirium and psychosis. Tens of thousands of dementia patients in England are prescribed them every year. Safety concerns have previously been raised about the drugs, with warnings to medics based on increased risks for stroke and death, but evidence of other dangers was less conclusive. New research suggests there are a considerably wider range of harms associated with their use than previously acknowledged in regulatory alerts, underscoring the need for increased caution in the early stages of treatment. Antipsychotic use in dementia patients was associated with elevated risks of a wide range of serious adverse outcomes, including stroke, blood clots, heart attack, heart failure, fracture, pneumonia and acute kidney injury, the study’s authors reported. Read full story Source: The Guardian, 18 April 2024
  12. News Article
    Nearly a dozen junior doctors have been relocated from a London hospital’s general surgery department by NHS England, after concerns about a culture of fear, poor support, and reports of bullying. NHSE has withdrawn 11 surgical foundation year trainees from Barnet Hospital, in north London, after a review uncovered concerns regarding staff behaviour and safety. The General Medical Council has opened a case into the hospital’s department, which is run by the Royal Free London Foundation Trust, and the trainees have been placed elsewhere in the trust. Colin Melville, the GMC’s medical director and director of education and standards, told HSJ: “Doctors in training in the department reported a culture of fear, worry, and feeling unsupported and unable to raise concerns in the appropriate manner. “There are also concerns over their supervision, bullying, and undermining behaviours in the department, as well as doctors’ physical and mental wellbeing. “Because of the [trust’s] failure to meet the high standards we require, we stand firmly with NHSE workforce, training, and education London’s decision to relocate the 11 trainees, [to] where they can work and learn in a supportive environment. “This action is necessary not only to ensure their safety, but to protect the public as well.” Read full story (paywalled) Source: HSJ, 18 April 2024
  13. News Article
    Preventable deaths of seven people from sepsis – including four children – have prompted coroners to flag major concerns about NHS services’ management of the condition. Since the start of March, six English coroners have sent formal warnings to trusts, NHS England and the government warning of systemic failures to spot sepsis and delays in administering antibiotic treatments. It comes after an HSJ investigation in February uncovered more than 30 avoidable deaths from sepsis, and undertook analysis of internal figures revealing repeated failures by NHS trusts to provide prompt treatment. Coroner warnings since March include: Two notices were sent this week by Nottingham assistant coroner Elizabeth Didcock to Sherwood Forest Hospitals Foundation Trust, raising concerns over its ability to provide safe paediatric care following the deaths of 10-week-old Tommy Gillman and five-year-old Meha Carneiro from sepsis; A warning from earlier in April criticising University Hospitals Birmingham FT for its failure to treat 56-year-old Tracey Farndon’s sepsis and low blood pressure. Read full story (paywalled) Source: HSJ, 17 April 2024
  14. Content Article
    There have been two turning points in trends in life expectancy in England this century. From 2011, increases in life expectancy slowed after decades of steady improvement, prompting much debate about the causes. Then, in 2020, the Covid-19 pandemic was a more significant turning point, causing a sharp fall in life expectancy, the magnitude of which has not been seen since World War II.  This article from the King's Fund examines trends in life expectancy at birth up to 2022, the impact of Covid-19 on life expectancy, gender differences and inequalities in life expectancy, causes of the changing trends since 2011, and how life expectancy in the UK compares with other countries.
  15. Event
    until
    NHS England is currently seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement. Never Events are defined as patient safety incidents that are ‘wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’. This webinar, hosted by the National NatSSIPs Network and supported by Patient Safety Learning, will feature a panel discussion on the Never Events framework and the proposals set out in this consultation. The National NatSSIPs Network is a group of healthcare professionals aiming to reduce the number of patient safety incidents related to invasive procedures. Speakers: Helen Hughes Dr Annie Hunningher Dr Sam Machen Claire Cox Guest Speaker Guest Speaker Register
  16. News Article
    Global supply problems have caused a “shock rise” in shortages of life-saving drugs like antibiotics and epilepsy medication, new research reveals. These shortages come at a cost to the patient and the taxpayer, and are happening despite the NHS spending hundreds of extra millions trying to mitigate the problem. The UK risks being left in the cold when it comes to co-ordinated EU attempts to tackle them. That’s according to a new report by the Nuffield Trust think tank and a group of academics, funded by the Health Foundation, which examined key indicators on drug shortages in the UK in the context of global problems with supply chains and the availability of key ingredients. It finds that the past two years have seen constantly elevated medicines shortages, in a "new normal" of frequent disruption to crucial products. Key findings on drugs shortages include: Price concessions (where the government gives extra funding because there are no drugs left at the NHS price) have risen sharply in recent months: prior to 2016 there were rarely more than 20 per month but in late 2022 they peaked at 199 and have remained high ever since. The excess cost for medicines in months when they were subject to price concessions was £220m across the year to September 2023. There are now over double the number of notifications by drugs companies warning of impending shortages than there were three years ago: in 2023 there were 1,634 such alerts issued, compared to 648 in 2020 (a spike in 2021 was caused by concerns over supply fears in Northern Ireland following Brexit). The UK has been slower to approve drugs than the EU for new drugs that are authorised centrally. Of drugs authorised in the year to December 2023, 56 drugs authorised in Europe were approved later in the UK and eight have not been approved. Four were approved faster. The report shows that the EU Exit has not caused the recent spike in medicine shortages, but it is likely to significantly weaken the UK’s ability to respond to them by splitting it from European supply chains, authorisations and collective efforts to respond to shortages. In particular, the research highlights the risks posed to the UK from being left out of key initiatives like the Critical Medicines Alliance and Voluntary Solidarity Mechanism, led by EU member states to work together to insulate themselves from the impact of medicines shortages. Read full story Source: The Nuffield Trust, 18 April 2024
  17. News Article
    Hospitals which rely heavily on locum doctors are 'undoubtedly' risking patient safety, a study of NHS practice found. While temporary staff are a 'vital resource' to plug workforce gaps, issues such as unfamiliarity with protocols and procedures mean they 'pose significant patient safety challenges' for the NHS, experts say. The report warned many were left feeling isolated and stigmatised by resident staff, creating a 'hostile environment'. This has led to a 'defensive' culture over mistakes, hindering improvements to care, according to researchers. Calling for greater monitoring by inspectors, NHS leaders must rethink how these professionals are supported and used, the authors said. Writing in a linked editorial, Professor Richard Lilford, of the Institute of Applied Health Research at the University of Birmingham, said the findings suggested 'the life of the locum is a difficult and lonely one, opening up many pathways to unsafe practice.' Likening it to airline pilots, he suggested staff would benefit from standardised practices – such as how the medicine cabinet is stocked – to minimise mistakes. Agencies providing staff should be given routine feedback by employers and locum staff, to enhance patient safety, he said. Read full story Source: MailOnline, 16 April 2024
  18. News Article
    This is a sick country, getting sicker. NHS waits will take years to clear, if at all. While people wait, they get sicker. When more and more people slip into absolute poverty – a fifth of people now – they get even sicker. More sicken as they age, and that peak has not yet been reached. Every part of the NHS feels at the sharp end, coping mostly because, amazingly, they just do, even with no end in sight to the stress. NHS data released last week on people waiting more than 18 weeks with serious heart problems suggests some will probably die before they get treatment. When waiting patients have heart attacks and strokes they call an ambulance – so there’s been an astonishing 7% rise in those category 1 calls. At an ambulance dispatch centre in Kent, Polly Toynbee listens in to calls like this at the South East Coast Ambulance Service dispatch centre in Gillingham, north Kent, covering Surrey, Sussex and Kent. She sat with D, a seasoned and sympathetic emergency medical adviser, call handler and life-and-death decider. Read full story Source: The Guardian, 17 April 2024
  19. News Article
    The Government is inviting views on how well GP practices and other NHS organisations are complying with their legal duty of candour when things go wrong. Patients and health professionals are being asked whether the statutory duty is well understood and adequately regulated by the CQC. Under the statutory duty of candour, introduced for all CQC-registered providers in 2015, GP practices must be open and honest with their patients when something goes wrong and has caused harm. In December, the Department of Health and Social Care (DHSC) announced a review into whether healthcare providers are following the duty of candour rules. This was in response to concerns that the duty is not always being met and that there is variation in how the rules are being applied. The DHSC has published its ‘call for evidence’ to gather views on how well the duty of candour obligation is working for both patients and health professionals. Patients have been asked whether GP practices and other providers ‘demonstrate meaningful and compassionate engagement’ with patients who have been affected by an incident. The call for evidence also asks for views on whether the criteria for triggering the duty are appropriate and well understood by staff. Read full story Source: Pulse, 16 April 2024
  20. Content Article
    The Nursing & Midwifery Council (NMC) is commissioning independent research into nursing and midwifery students’ practice learning to ensure members of the public can shape this work from the start and throughout. One way people can get involved is by being part of a new Public Advisory Group on practice learning.
  21. Event
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    Riphah Institute of Healthcare Improvement & Safety (RIHIS) has been organizing the region’s largest International Conference on Patient Safety (ICPS) annually for the last 5 years which draws key opinion leaders, domain experts, regulators, academia, and other stakeholders working in this space from all over the world. ICPS provides a platform to allow experts in Patient Safety to come together to create a momentum in the advancement of Healthcare Quality and Patient safety. Objectives of the Conference are: To create awareness about patient safety, medical errors and healthcare quality in Pakistan and the region. To help in developing a patient-centric mindset. To build a capacity of professionals, involved in the process of delivering quality healthcare and managing patient safety in their institutions. To bring together the stakeholders in Pakistan on this important subject objectives. Register
  22. Event
    Decades of research has shown that the health of the population in England is unequal, with people who live in more deprived areas experiencing illness earlier in life and dying younger. Previous Health Foundation analysis has projected that 9.3 million people could be living with major illness by 2040, which is 2.6 million, or 39%, more people than in 2019. In April, the Health Foundation’s REAL Centre published its second report in their ‘Health in 2040’ series, this time exploring how current patterns of ill health vary with deprivation across England, and to what extent this is projected to change by 2040. The findings have important implications for health inequality among the working age population and how it poses a challenge to labour supply and economic growth. This webinar will convene experts to explore what the findings mean for how we might need to change as a society, and what can we do to better prepare for the future. Register
  23. Content Article
    The use of temporary doctors, known as locums, has been common practice for managing staffing shortages and maintaining service delivery internationally. However, there has been little empirical research on the implications of locum working for quality and safety. This study aimed to investigate the implications of locum working for quality and safety. The participants of the study described the implications of locum working for quality and safety across five themes: (1) ‘familiarity’ with an organisation and its patients and staff was essential to delivering safe care; (2) ‘balance and stability’ of services reliant on locums were seen as at risk of destabilisation and lacking leadership for quality improvement; (3) ‘discrimination and exclusion’ experienced by locums had negative implications for morale, retention and patient outcomes; (4) ‘defensive practice’ by locums as a result of perceptions of increased vulnerability and decreased support; (5) clinical governance arrangements, which often did not adequately cover locum doctors. The study concluded that locum working and how locums were integrated into organisations posed some significant challenges and opportunities for patient safety and quality of care. Organisations should take stock of how they work with the locum workforce to improve not only quality and safety but also locum experience and retention.
  24. News Article
    The parents of a baby who died from sepsis said their son deserved a "fighting chance" after concerns were raised over his care in hospital. Ten-week-old Tommy Gillman was admitted to King's Mill hospital on 7 December 2022 but died the next day. Tommy Gillman, from Coddington, Nottinghamshire, was "extremely unwell" with what proved to be Salmonella Brandenburg meningitis when admitted to the Sutton-in-Ashfield hospital at 12:35 GMT. His assessment was delayed, and then the severity of his condition missed, meaning correct treatment with antibiotics and fluids did not start until 17:00. A coroner's report identified a lack of experienced paediatric nurses and confusion in handovers between staff. "I am not reassured that necessary actions to address these serious issues identified are in place," the coroner said. Sherwood Forest Hospitals NHS Foundation Trust said it welcomed the review and a "rapid" programme of improvements was being worked on. Tamzin Myers and Charlie Gillman said their son deserved "a fighting chance" by getting prompt treatment Read full story Source: BBC News, 17 April 2024
  25. Content Article
    The US Leapfrog Group has released Recognizing excellence in diagnosis: Leapfrog’s national pilot survey report, which analyses responses from 95 hospitals on their implementation of recommended practices to address diagnostic errors, defined as delayed, wrong or missed diagnoses or diagnoses not effectively communicated to the patient or family. The National Academy of Medicine has warned that virtually every American will suffer the consequences of a diagnostic error at least once in their lifetime and noted that 250,000 hospital inpatients will experience a diagnostic error every year.   While progress varies considerably, more than 60% of hospitals responded that they were either already implementing or preparing to implement each of 29 evidence-based practices known to prevent harm from diagnostic error. The practices were identified in an earlier Leapfrog report, Recognizing excellence in diagnosis: Recommended practices for hospitals. The hospitals reported barriers to putting the practices in place that include staffing shortages and budgetary pressure.  
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