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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. News Article
    A nurse who admitted she was unfit to practise after dragging a patient with dementia to her room and forcefully attempting to administer a sedative has been suspended for a year by the nursing regulator. Carol Picton was working in the stroke unit at the Western General Hospital in Edinburgh in November 2017 when colleagues raised concerns about her treatment of a vulnerable older woman. Witnesses who gave evidence to an NMC fitness to practice (FtP) panel said they heard the patient screaming in distress after being roughly dragged by her arm back to her room by Ms Picton. The nurse then attempted to forcefully administer the anti-psychotic drug Haloperidol without checking the correct dosage, the hearing was told. She tried to give the drug orally using a 2ml injection syringe rather than an oral syringe. Ms Picton denied forceful mistreatment and panel found no evidence she had shown insight into her misconduct When the patient spat out the drug Ms Picton gave her more without knowing how much she had ingested, risking an overdose, the panel heard. Ms Picton, who was referred to the NMC by her employer following an internal investigation, was also said to have tilted the patient’s bed to prevent her getting out and leaving her room. The panel, which found five charges proven, concluded that Ms Picton’s actions were ‘deplorable’ and amounted to harassment and abuse. Read full story Source: Nursing Standard, 21 March 2022
  2. News Article
    Healthcare leaders have written an open message to NHS staff, drawing attention to “the dangerous level” of abuse many are confronted with, “simply for going to work”. In the message, more than 40 NHS leaders in London said that every year “tens of thousands” of NHS staff are “confronted with violence and aggression from patients”. “Now, the abuse is at a dangerous level, with many of our once hailed heroes fearing for their safety,” they said. “We, leaders of the NHS in London, are speaking with one voice to say that aggression and violence towards our staff will not be tolerated.” Signatories include Andrew Ridley, the NHS England London interm regional director, integrated care system leaders, leaders from general practice and community pharmacy, and many trust bosses from the capital, including Central and North West London FT chief executive and national director for mental health Claire Murdoch. The message thanked NHS staff for continuing to care for people and encouraged the reporting of “all forms of verbal and physical abuse from patients, their families and friends so that we may take action”. They also sent a message to patients and their families: “We will strive to do our best for you and your loved ones. People who are most unwell do need to be seen most urgently, but all our patients are important to us and will receive the care needed. While we are thankful for the support shown by so many, to those who show violence and aggression let it be known: abusing our staff is never ok.” Read full story (paywalled) Source: HSJ, 21 March 2022
  3. News Article
    Members of the House of Lords have passed an amendment to the Health and Care Bill to enshrine mandatory training for health and care staff on learning disabilities and autism in law. The Oliver McGowan Mandatory Training in Learning Disabilities and Autism programme is being developed by Health Education England in partnership with organisations such as Skills for Care and the Department of Health and Social Care, and alongside Oliver’s family. “It means that organisations have no choice but to free up their staff to attend this training” The training is named after Oliver whose death shone a light on the need for health and social care staff to have better training on learning disabilities and autism, and has been campaigned for by his parents Paula and Tom McGowan who believe his death was avoidable. The 18-year-old, who had mild hemiplegia, focal partial epilepsy, a mild learning disability and high-functioning autism, died in November 2016 after he was given antipsychotic medication even though he and his family warned it could be harmful to him. Following campaigning efforts and a consultation on training proposals for health and care staff, in November 2019, the government committed to developing a standardised training package. It draws on existing best practice, the expertise of people with autism, people with a learning disability and family carers and subject matter experts. Read full story Source: Nursing Times, 18 March 2022
  4. News Article
    The number of people who have died from Covid in Britain during the pandemic is impossible to determine because of the inconsistent definitions of what is meant by a coronavirus death, researchers have concluded. Experts from Oxford University discovered that public health and statistics organisations across the UK are operating under 14 different definitions to classify a death from Covid. Freedom of Information (FOI) requests show that many people who died in the first wave never tested positive for the virus, particularly older people who died in care homes. Instead, their deaths were registered as Covid simply based on a statement of the care home provider, and because coronavirus was rife at the time. The authors also point out that it is unlikely that a Covid infection on its own could cause death in the absence of contributing factors, such as other illness, or the infection leading to a more deadly condition such as pneumonia. The report also found that in some trusts, up to 95% of Covid deaths were in people with Do Not Resuscitate (DNR) orders. The team said the confusion meant they were unable to separate deaths caused by Covid from those triggered by the pandemic response, and called for a proportion of deaths to be verified by post-mortem in future pandemics to determine the true reason. Read full story (paywalled) Source: The Telegraph, 19 March 2022
  5. News Article
    A Derby doctor who has been the subject of eight tribunals in less than nine years has been sanctioned for a further four months. Dr Anatta Nergui was originally found guilty of misconduct in 2014 and has been found to have not fully reflected on the severity of his offending in six different hearings since. The psychiatrist was suspended by the Medical Practitioner Tribunal Service (MPTS) in 2014 for running a website and blog which offered incorrect medical advice to those who got in contact with him. In 20 of 22 cases, he was found to have failed to recommend that the patient saw a doctor or psychiatrist, and failed to recommend a counselling or psychotherapy course in 30 cases, among other complaints, which put patients at "significant risk of harm". The latest tribunal aimed at assessing his fitness to practice, held in March 2022, has imposed a further four months of conditions on him, after the MPTS found that "despite there being a low risk of repetition, the remediation had not yet been completed", according to the chair of the tribunal, Jetinder Shergill. In the MPTS determination, released on Thursday (March 17), Mr Shergill said: "While the tribunal was satisfied that there is sufficient evidence Dr Nergui is a competent and safe doctor, there remains a lingering concern that he did not appreciate the findings made against him from the patient’s perspective and/or did not express this in a clear, cogent manner. The tribunal considered that Dr Nergui might have benefitted from seeking feedback from a trusted colleague or mentor, reflecting on what went wrong and setting out his thought processes on avoiding similar risk. "In short, the self-reflection has led Dr Nergui down a restricted path of understanding, leading him to focus on the legal aspects of the process and semantics rather than the primary issue which was one of patient safety. If he had sought the input of a third party, it may have led to him developing an alternative view rather than the binary approach that he has adopted. This left the tribunal with the view that whilst there has been some insight, remediation is not yet complete." Read full story Source: Derbyshire Live, 18 March 2022
  6. Content Article
    This film from NHS England and NHS Improvement follows patients at the NHS specialist Post-Covid service at Newcastle’s Royal Victoria Infirmary, one of 90 such services that are now established across England, as part of a £200m NHS investment to support people experiencing the long term effects of Covid. Featured in the film is John, who explains how the ongoing effects of Covid have impacted on his overall health and day-to-day life. As part of his assessment, John gets a psychological and physical check-up from a multidisciplinary team of NHS professionals to help him manage his symptoms and support his recovery. Anyone who is concerned about long-lasting symptoms following Covid-19 should contact their GP, or go online to the NHS Your Covid Recovery website for further advice: https://www.yourcovidrecovery.nhs.uk/
  7. News Article
    A trust has admitted it is having to discharge patients inappropriately into care homes or community hospital beds because of a shortage of home care workers. A report to East Kent Hospitals University Foundation Trust’s board last week revealed that 160 extra beds had been commissioned to maintain flow across the local health economy “due to insufficient domiciliary/care package capacity.” It went on: “The clinical commissioning group have tried via Kent County Council to commission additional domiciliary care without success. It is acknowledged by the local health economy that it is important to withdraw from these additional beds as quickly as possible as they are not a cost-effective resource and more importantly, in many cases, they are not the ideal discharge destination for those patients who could have been discharged home with a care package. “Patients are being transferred into community hospital beds or residential home beds due to a lack of domiciliary care packages. Although this is a national issue, it will not be resolved locally until appropriate pathway capacity is commissioned.” Professor Adam Gordon, president elect of the British Geriatrics Society, said: “If people have been sent to a care home when they don’t want or need to be there that can affect their motivation and result in a form of deconditioning. One of the principles of effective rehabilitation in older people is that if you don’t use it, you lose it.” Read full story (paywalled) Source: HSJ, 17 March 2022
  8. News Article
    A vaccine has been used to free a man who was trapped at home by a Covid infection that lasted for more than seven months. It is the first time that a vaccine has been used to "treat" Covid rather than "prevent" it. Ian Lester, 37, has a weakened immune system due to Wiskott-Aldrich syndrome, and was unable to defeat the virus on its own. He says he became a prisoner in his home in Caerphilly, Wales, as he isolated for months on end. He shielded during the first wave of Covid, but coronavirus eventually found him in December 2020. He had one of the classic symptoms - a slight loss of sense of taste and smell - which cleared up within a month. For most of us that would be the end of it, but Ian's Covid journey was only just beginning. His doctors wanted him to keep on testing because his weakened immune system meant there was a risk he could be contagious for longer than normal. But month after month, test after test came back positive. Ian had to give up work. Scientists and doctors were monitoring the battle between the virus and Ian's immune system at Cardiff University and at the Immunodeficiency Centre for Wales in the University Hospital of Wales. The analysis showed Ian had a long-term infection, it was not just "dead virus" being detected, and his symptoms were not long-Covid. Prof Stephen Jolles, clinical lead at the Immunodeficiency Centre, said: "This infection was burbling along, but with his [weakened] immune system it was just not enough to kick off a response sufficient to clear it. "So the vaccine really made a huge difference, in antibodies and T-cells, and utilised and squeezed every last drop out of what his immune system could do." Read full story Source: BBC News, 21 March 2022
  9. News Article
    The former health secretary Jeremy Hunt will join doctors’ representatives today in a call to stem the “bleed” of GPs or risk endangering patients. Polling shows that almost nine in ten GPs fear that patient safety is being put at risk by shortages of family doctors and too little time for appointments. The government has admitted that it will fail to fulfil an election pledge to recruit 6,000 extra full-time GPs by 2024. Hunt is campaigning with the British Medical Association and the GPDF, which represents local medical committees, in calling for the government to put forward a GP workforce plan to “rebuild general practice”. He said: “The workforce crisis is the biggest issue facing the NHS. We can forget fixing the backlog unless we urgently come up with a plan to train enough doctors for the future and, crucially, retain the ones we’ve got. “As someone who tried hard to get more GPs into local surgeries but ultimately didn’t succeed because the numbers retiring early exceeded those joining, I’m passionate about fixing this.” The campaign wants the government to deliver on its pledge for an extra 6,000 GPs in England and action to tackle the reasons for GPs leaving the profession, such as burnout. It says that a plan is needed to reduce GP workload, which would improve patient safety.
  10. Content Article
    In July 2019, NHS England and NHS Improvement launched the NHS National Patient Safety Strategy. A key element of this is the development and implementation of a patient safety syllabus, which was created by Academy of Medical Royal Colleges (AoMRC) based on a proactive approach to the prevention of harm. UCLPartners is working in partnership with the Chartered Institute for Ergonomics and Human Factors’ (CIEHF) Lantern Group to support Trusts across London to assess their readiness to implement the syllabus through the development of an organisational self-assessment tool. This work has been commissioned by Health Education England (HEE). The organisational self-assessment tool has been developed alongside a Facilitator’s Guide. 
  11. Content Article
    Long Covid Support are keen to hear your experiences of Long Covid service(s) for adults in England. The purpose of this survey is to collect information on the patient experience of healthcare and other support services for Long Covid. Because services differ by nation, this survey is for patients in England only.  This survey has been designed and developed by people who have Long Covid. You can do the survey for yourself, or on behalf of a friend or relative who has Long Covid. The survey will take 15 - 30 minutes to complete depending on your answers. You may save the survey and finish it later as long as you use the same device to complete it. Long Covid Support is a not-for-profit organisation, advocating for those impacted by Long Covid.
  12. News Article
    A hospital in Devon has declared a second critical incident following extreme pressures, as Covid-19 admissions in the region double, The Independent has learnt. North Devon Healthcare Trust declared a critical incident on Monday, after it declared another earlier this month it has confirmed. The news comes as the number of people with Covid-19 across two hospitals in Devon has doubled in just two weeks. As of Thursday, there were 292 Covid positive patients in across hospitals in Devon, with a further 37 awaiting test results. According to a statement from healthcare leaders in Devon, Plymouth and Torbay, as of Thursday there were almost 1,200 NHS staff off work due to Covid. Meanwhile 183 care services, such as care homes and other social care providers, in the area have reported Covid outbreaks, making it harder to discharge patients, the leaders said. NHS data published on Thursday showed there were 213 patients across three hospitals in Devon, waiting to be discharged. Covid-19 infections are also continuing to rise across most of the UK, with levels in Scotland hitting another record high, new figures show. Read full story Source: The Independent, 19 March 2022
  13. News Article
    A young woman died following “gross failings” and “neglect” by a mental health hospital in Essex which is also facing a major independent inquiry into patient deaths. Bethany Lilley, 28, died on 16 January whilst she was an inpatient at Basildon Mental Health unit, run by Essex Partnership University Hospitals. The inquest examined the circumstances of her death this week and concluded that her death was contributed by neglect due to a “plethora of failings by Essex University Partnership Trust”. Following the three week inquest, heard before coroner Sean Horstead, a jury found “neglect” contributed to Ms Lilley’s death and identified “gross failures” on behalf of the trust. The jury identified a number of failings in her care including evidence that cocaine had made its way onto a ward where she was an inpatient. There was evidence of “very considerable problems in the record-keeping at EPUT psychiatric units.” It was also concluded staff failed to carry out a risk assessment of Ms Lilley in the days leading up to her death, and failed to carry out observations. Ms Lilley’s death is one of a series of patients who have died under the care of mental health services in Essex, which have been brought into the light following the campaigning of bereaved families. Read full story Source: The Independent, 19 March 2022
  14. News Article
    More than 80% of GPs believe that patients are being put at risk when they come into their surgery for an appointment, a new survey shows. A poll of 1,395 GPs found only 13% said their practice was safe for patients all the time. Meanwhile, 85% expressed concerns about patient safety, with 2% saying patients were “rarely” safe, 22% saying they were safe “some of the time” and 61% saying they were safe “most of the time”. Asked if they thought the risk to patient safety was increasing in their surgery, 70% said it was. Family doctors identified lack of time with patients, workforce shortages, relentless workloads and heavy administrative burdens as the main reasons people receiving care could be exposed to risk. The survey, which was self-selecting, also found that: 91% said more GPs would help improve the state of general practices. 84% have had anxiety, stress or depression over the past year linked to their job. 31% know a colleague who was physically abused by a patient in the last year. 24% know of a member of general practice staff who has taken their own life due to work pressures. Read full story Source: The Guardian, 21 March 2022
  15. News Article
    A paediatrician who was at the centre of one of Northern Ireland's longest running public inquiries will appear before a professional misconduct panel. Dr Heather Steen is accused of several failings following the death of Claire Roberts at the Royal Belfast Hospital for Sick Children in October 1996. The nine-year-old's death was examined by the hyponatraemia inquiry, which lasted 14 years. It examined the role of several doctors. Among his findings, the inquiry's chairman Mr Justice O'Hara said there had been a "cover-up" to "avoid scrutiny." Monday's tribunal will inquire into allegations that, between 23 October 1996 and 4 May 2006, Dr Steen "knowingly and dishonestly carried out several actions to conceal the true circumstances" of the child's death. Also that the doctor provided inappropriate, incomplete and inaccurate information to the child's parents and GP regarding the treatment, diagnosis, clinical management and cause of her death. The tribunal website adds: "It is also alleged that Dr Steen inappropriately recommended a brain-only post-mortem for Patient A (Claire Roberts) when a full post-mortem was necessary. "In addition, it is alleged that Dr Steen failed to refer Patient A's death to the coroner, inappropriately completed the medical certificate of cause of death and inaccurately completed the autopsy request form for Patient A. "Furthermore, it is alleged that during a review of Patient A's notes, Dr Steen failed to consult with the necessary colleagues and medical teams and provided a statement and gave evidence to the coroner's inquest into Patient A's death which omitted key information." Read full story Source: BBC News, 21 March 2022
  16. News Article
    Infection control rules in hospitals are ‘now disproportionate to the risks’ posed by covid and should be relaxed, some of the NHS’s most senior leaders have warned. The government rules – such as not allowing covid-positive staff to work, and separating out services for covid, non-covid and covid-contact patients – make a big dent in hospital capacity and slows down services. Glen Burley, who is chief executive of three Midlands trusts and involved in national-level discussions on elective matters, told HSJ: “Pretty much every pathway has a covid and non-covid route, which slows down flow and staff productivity. “There is a growing argument that these rules are now disproportionate to the risks. With covid cases in the community also rising now, we may have to question again the relative risks of continuing to isolate staff.” NHS Confederation director of policy Layla McCay told HSJ: “Healthcare leaders are concerned the current [IPC] measures are having a serious knock-on effect on capacity and that the measures in their current form are reducing efficiency and capacity within healthcare settings. “We need more clarity on if and how current measures can be safely adjusted so [the NHS] can further increase bed capacity and patient throughput, as well as the ability to transport patients more quickly and efficiently.” But NHS Providers, which has previously said relaxing the IPC guidance would not enable a “rapid” increase in the NHS’ capacity to tackle the elective care backlog and could pose significant “risks”, remains more cautious. Read full story (paywalled) Source: HSJ, 21 March 2022
  17. Content Article
    World Patient Safety Day (WPSD) is observed globally on 17 September every year. The objectives of WPSD are to increase public awareness and engagement, enhance global understanding, and work towards global solidarity and action by all stakeholders to improve patient safety. The theme of WPSD 2021 was “Safe Maternal and Newborn Care” and all stakeholders were urged to “act now for safe and respectful childbirth!”. Maternal and child mortality is one of the major health issues of the current times. Every day we lose 810 women due to pregnancy-related complications, 6,700 newborns lose their lives, and there are 5,400 stillbirths globally. The tragedy is that most of these deaths are avoidable through the provision of safe care. The World Patients Alliance (WPA) conducted the largest WPSD campaign globally as over 800 events were organised all over the world. This newsletter presents highlights of these events. 
  18. Content Article
    People with COVID-19 often have symptoms in the long term (ie, long COVID), including fatigue, breathlessness, and neurocognitive difficulties. The disease mechanisms causing long COVID are unknown, and there are no evidence-based treatment options. Clinical guidelines focus on symptom management, and various treatment options are being evaluated. The scarcity of advice has often left people with long COVID feeling isolated and frustrated in their search for therapies. Research is needed to understand the self-management practices that are being used to manage long COVID symptoms; factors influencing their uptake; and the benefits, harms, and costs. There is also a need to assess the potential harmful effects of polypharmacy and drug–drug interactions in these individuals. The Therapies for Long COVID (TLC) Study (ISRCTN15674970) will begin to explore self-management practices through a survey of people with long COVID. This study aims to be a first step towards understanding this important and under-researched public health issue. 
  19. Content Article
    The Guidance for Human Factors Evaluations in the Procurement of Medical Devices, Equipment and Technology document provides comprehensive recommendations on how one may integrate human factors evaluations into procurement processes. While it is a relatively new aspect to consider in healthcare supply management, and may entail robust change management to implement, incorporating human factors evaluation in purchasing will enable best value and outcomes in health care.
  20. Content Article
    “Hi, I’m the doctor. First I need to apologise for how long you’ve been waiting.” An apology is now the default way I introduce myself to patients in the busy emergency department where I work, writes an emergency medicine consultant in an article for the Independent newspaper. An apology for the shortage of beds, an apology for the shortage of staff and most importantly for the person in front of him, an apology for how long they’ve waited, in pain and distress, to be seen.
  21. Content Article
    In this article published by Economics By Design, Colin Lewry and Jacque Mallender argue that, despite recent history, treating healthcare staff as a cost and not an asset needs to be reversed when developing workforce plans and approaches in 2022.
  22. Content Article
    Last month, Boris Johnson argued that the downward trends in Covid cases and hospitalisations meant that it was time to scrap restrictions. Now both are rising. But the government is ending testing and most surveillance studies. Sajid Javid, the health secretary, said that the rise was “to be expected” – though this foresight did not extend to having a plan to deal with the increase in infections. Instead, he dismissed the concern about the new Deltacron variant. The health secretary seemed nonchalant about the threat the virus now posed. Sajid Javid may be right that the country has weathered the worst of the pandemic, but Covid is not yet in retreat. It makes no sense to withdraw funding from a series of studies that allow the spread of the virus to be mapped in detail. Without the data, experts won’t be able to effectively monitor the disease. The country will be less effective in responding and adjusting to future waves of infection. Individuals will be less able to make informed choices about the risks involved. The clinically vulnerable face being cut off from everyday life. “It is like turning off the headlights at the first sign of dawn,” Stephen Reicher, a psychologist at the University of St Andrews, told the Guardian. “You can’t see what’s coming and you don’t know when it makes sense to turn them on again.”
  23. News Article
    US health officials are monitoring an unusual situation in the UK, where COVID-19 cases and hospitalisations are simultaneously climbing due to the BA.2 subvariant, CNN reports. COVID-19 cases were up 52% in the UK last week compared with the week prior, and hospitalisations were up 18%t over the same period, according to the UK Coronavirus Dashboard. The seemingly in-tandem ascent of cases and hospitalisations is unusual, given that increases in COVID-19 cases preceded increases in hospitalisations by about 10 days to two weeks in previous waves. "So we're obviously keenly interested in what's going on with that," Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, told CNN. Dr Fauci said in conversation with his U.K. counterparts, they attribute the rising cases and hospitalisations to three things, listed in order of contribution: the BA.2 variant, which is more transmissible than the original omicron; the opening of society, with people socializing indoors without masks; and waning immunity from vaccination or prior infection. Hospitalisations in the U.K. raise questions, given that BA.2 doesn't appear to cause more severe disease. "The issue with hospitalization is a little bit more puzzling, because although the hospitalizations are going up, it is very clear their use of ICU beds has not increased," Dr. Fauci said. "So are the numbers of hospitalizations a real reflection of COVID cases, or is there a difficulty deciphering between people coming into the hospital with COVID or because of COVID?" Read full story Source: Becker Hospital Review, 16 March 2022
  24. Content Article
    Mr David O’Regan, Director of the Faculty of Surgical Trainers, offers this new video series exploring topics that are pertinent to surgical training and trainers. He looks beyond the field of surgery and interviews internationally recognised professionals in their own fields. He also features conversations with a select group of esteemed surgeons who are recognised for their impact on effective training – both giving and receiving – has had on their career and their legacies. Role modelling, situation awareness and team playing are key to reading any training scenario and David will discuss with his guests how a variety of skills required across a huge range of industries can benefit discussions and offer best practice in Surgical Training.
  25. Event
    This conference focuses on patient involvement and partnership for patient safety including implementing the New National Framework for involving patients in patient safety, and developing the role of the Patient Safety Partner (PSP) in your organisation or service. The National Framework for involving patients in patient safety was released by NHS England in June 2021. This conference will enable you to: Network with colleagues who are working to involve patients in improving patient safety. Reflect on patient perspective. Understand how to implement the June 2021 National Framework for Involving Patients in Patient Safety. Improve the way you recruit, work with and support Patient Safety Partners. Develop your skills in embedding compassion and empathy into patient partnership. Understand how you can improve patient partnership and involvement after serious incidents. Identify key strategies for support patients, their families and carers to be directly involved in their own or their loved one’s safety. Learn from case studies demonstrating patient partnership for patients safety in action. Examine methods of involving patients to improve patient safety in high risk areas. Self assess and reflect on your own practice. Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes. Register hub members receive a 20% discount. Email info@pslhub,org for discount code.
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