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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    In this webinar, MISHC Research Fellow Philippa Dodshon analyses research into practitioners’ experiences with incident investigation to determine how they can be used to enhance organisational learning and reduce the prospect of repeat accidents.
  2. Event
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    This webinar, moderated by Dr Charlotte Tai, will discuss the lessons learnt and advances in practice in diagnosis, treatment, and prevention of Ventilator-associated Pneumonia. Speakers: The role of the oral cavity and the endotracheal tube in the aetiology of VAP Dr Matt Wise, Consultant Adult Critical Care, University Hospital of Wales Relationship between VAP and mortality Professor Saad Nseir, Professor of Critical Care at the Medical School of Lille, France Ventilator-associated pneumonia in critically ill patients with COVID-19 Dr Andrew Conway Morris, Honorary Consultant in Intensive Care Medicine, Cambridge University Hospitals NHS Foundation Trust Panellists: Dr Mark Blunt, Lead Critical Care Consultant, Queen Elizabeth Hospital, Kings Lynn Helen Hughes, Chief Executive, Patient Safety Learning Register
  3. Content Article
    The MedicAlert Foundation first launched in Turlock, California, in 1956, before coming to the UK over 55 years ago. As the pioneers of medical IDs, they remain the only charity provider of life-saving medical ID services worldwide. MedicAlert UK is based in Buckinghamshire, with a production unit creating bespoke medical ID jewellery and a member services team including in-house Registered Nurses to support our 42,000 members.
  4. News Article
    Every adult who has tested positive for COVID-19 in Scotland is to be invited to take part in a major new study into the effects of long Covid. Researchers hope to identify how many people in Scotland continue to be unwell after having the virus. The Covid in Scotland Study (CISS) will ask people what their symptoms are and how it affects their lives. Those taking part will be asked to use a phone app to answer questions about their health before and after Covid. Early estimates suggest as many as 6,000 people in Scotland were experiencing long term symptoms after the first wave of the pandemic but it is not known what that tally is now. Read full story Source: BBC News, 12 May 2021
  5. Content Article
    Substantial evidence indicates that patient outcomes are more favourable in hospitals with better nurse staffing. One policy designed to achieve better staffing is minimum nurse-to-patient ratio mandates, but such policies have rarely been implemented or evaluated. In 2016, Queensland (Australia) implemented minimum nurse-to-patient ratios in selected hospitals. In a study published in the Lancet, McHugh et al. aimed to assess the effects of this policy on staffing levels and patient outcomes and whether both were associated.
  6. News Article
    New research examining the effect of minimum nurse-to-patient ratios has found it reduces the risks of those in care dying by up to 11%. The study, published in The Lancet, also said fewer patients were readmitted and they had shorter stays in hospital. It compared 400,000 patients and 17,000 nurses working in 27 hospitals in Queensland, Australia to 28 other hospitals. The state has a policy of just one nurse to every four patients during the day and one to seven at night, in a bid to improve safety and standards of care. The research said savings made from patients having a shorter length of stay, which fell 9%, and less readmissions were double the cost of hiring the extra nurses needed to achieve the ratios. NHS England has resisted moves towards minimum nurse to patient ratios, suspended work by the National Institute for Health and Care Excellence (NICE) on safe nurse staffing in 2015. This came as the watchdog was preparing to call for minimum ratios in accident and emergency departments. It has advised that eight or more patients to one nurse is the point at which harm can start to occur. Read full story Source: The Independent, 12 May 2021
  7. News Article
    The government has confirmed its commitment to bring in new health legislation during this Parliament, but social care reform has again been ‘kicked into the long grass’. Today’s Queen’s Speech confirmed that planned, radical changes to the Health and Social Care Bill 2012 will be laid before Parliament this year. The changes, first outlined in the government’s proposals this February, will put integrated care systems on a statutory footing, dissolve clinical commissioning groups, water down the internal market within the NHS and increase the powers the health secretary has over NHS England and the service. Today’s Queen’s Speech said these changes meant “patients will receive more tailored and preventative care, closer to home [and will] empower the NHS to innovate and embrace technology”. However, it did not add any further information to the government’s already stated plans to “bring forward proposals in 2021” for social care reform. The 2019 Queen’s Speech, the first delivered during Boris Johnson’s tenure as prime minister, promised to bring in ”legislation for long-term social care reform in England”. To date, the government has failed to act on this promise. Read full story Source: HSJ, 11 May 2021
  8. News Article
    The Department of Health and Social Care (DHSC) is facing being taken to court over an inquiry it launched into the deaths of dozens of mental health patients in Essex. Last year, the government said it would commission an independent inquiry into at least 36 inpatient deaths in Essex, which had taken place over the last two decades. However, more than 70 families are calling for a full statutory public inquiry, which can compel witnesses to give evidence. They have lodged judicial review proceedings at the High Court against the government to that effect. The DHSC said it could not comment on ongoing legal proceedings. The current inquiry was launched in response to a highly critical report from the Parliamentary Health Service Ombudsman, published in June 2019, into the deaths of two patients at North Essex Partnership University Foundation Trust, which has since merged to form Essex Partnership University FT. There has also been an investigation by Essex Police into 25 of the deaths. This concluded in 2018, when the force said there had been “clear and basic” care failings, but there was not enough evidence to prosecute the trust for corporate manslaughter. Read full story (paywalled) Source: HSJ, 11 May 2021
  9. News Article
    Major change is required if Northern Ireland's emergency departments are to avoid another "exceptionally difficult" winter, a senior consultant has warned. Dr Brendan Lavery, who works for the Western Health Trust, said "standing still is not an option". He described the system as currently operating on a "knife edge". The Department of Health said it was "a very challenging time" for staff "with COVID-19 restrictions impacting on an already fragile system". Speaking to BBC News NI, Dr Lavery likened the situation to "Groundhog Day" with decade-long problems like capacity and staffing exacerbated by the lingering effect of the COVID-19 pandemic on other healthcare services. The department responded: "Well before COVID-19, there was clear evidence that our urgent and emergency care services were under increasing pressure. This is an unsustainable position that requires sustained investment and reform, including, of course, long-term investment in staffing. There is no quick or easy solution to these problems." Read full story Source: BBC News, 12 May 2021
  10. Event
    COVID-19 has been incredibly stressful—personally and professionally—and has profoundly affected everyone in healthcare, including those of us in patient safety, quality, and risk management. Join this Patient Safety Association's virtual round table to decompress and share your experiences. Some of your colleagues have offered to discuss their coping strategies, and please feel free to do the same. Resources from professionals trained to handle stress will be provided. Register
  11. Event
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    We have known for several years that nurses are at higher risk of suicide than the general population and that nurses have more job-related problems recorded prior to death by suicide. What we have now learned about those job-related problems is troublesome at best with implications for risk managers, hospital executives, and all leaders in healthcare. The panel in the Patient Safety Association webinar will describe the issues and implications for advocacy and policy change necessary to right the wrongs leading to death by suicide amongst nurses through personal testimony and review of recent research findings. This webinar is sponsored by CHPSO. By the end of the session, the participants will be able to: Identify major issues stemming from the workplace that lead to death by suicide. Identify institutional, professional, and individual actions that can be taken to reduce risk. Describe the flaws in the current system that prevent accurately tracking and action-planning to reduce risks amongst nurses. Register
  12. News Article
    There are many reasons why mental wellbeing is important. Not only is it protective against physical illnesses and linked to greater productivity, but the mental wellbeing of a population is essential for a country’s sustainability, long-term growth and development. But despite the clear benefits, governments tend to focus public spending on treating and preventing disease, and providing care for those who are ill. While this is important and should continue to be prioritised, such strategies alone won’t increase levels of mental wellbeing overall. Not only would enhancing mental wellbeing across all segments of the population lead to better health on average, it would also be beneficial from an economic perspective. In a new study, the link between mental wellbeing and government expenditure was explored. It was found that each increase in mental wellbeing in a population was associated with lower social and health care costs the following year. In other words, the greatest savings could be made by maximising everyone’s mental wellbeing. Read full story Source: The Independent, 11 May 2021
  13. News Article
    Thousands of doctors feel under pressure from their employers to work extra shifts, often unpaid, to help tackle the backlog of care caused by the covid pandemic, the BMA has warned. The warning came after results from the BMA’s latest tracker survey showed that more than half its respondents (58%, 2834 of 4876) had worked extra hours in the previous month as part of the response to the pandemic. Almost a third (29%, 1387) said they were not paid for the additional time they worked. More than two fifths (44%) of respondents (2086 of 4719) said they felt under pressure from their employer to do extra hours in the last month. And more than a third (36%, 1759) had either skipped taking full breaks altogether or taken them on rare occasions in the past fortnight. Nearly six in 10 doctors who responded (57%, 2889 of 5059) reported a higher than normal level of fatigue or exhaustion because of working or studying during the pandemic. Chaand Nagpaul, the BMA’s chair of council, said, “To learn that an already depleted and now exhausted workforce feels forced into doing more and more hours, with many reporting higher levels of fatigue than ever, is extremely worrying. It is putting them and their patients at risk. Working ‘flat out’ without a change to rest and recuperate is simply unsustainable and unsafe." Read full story Source: BMJ, 10 May 2021
  14. News Article
    Just 10% of money allocated to help treat young people with eating disorders reached the NHS frontline, a new analysis has revealed. The latest data on NHS mental health spending comes amid concern the pandemic has exacerbated eating disorders in young people, sparking a rise in demand. A report commissioned by MPs compiled by the eating disorder charity Beat, using NHS data, shows local clinical commissioning groups (CCGs), who purchase NHS services on behalf of NHS England, spent just £1.1m of the £11m they were given for community eating disorder services in 2019-20. The money was set aside by NHS England to try and tackle increasing referrals and to ensure young people could get treatment. Wera Hobhouse MP, chair of the All-Party Parliamentary Group on Eating Disorders, and which commissioned the work said: “Eating disorders are serious mental illnesses, and we know that early intervention and access to specialist treatment saves lives." “NHS England has continued to allocate extra funding to clinical commissioning groups for children and young people’s community eating disorder services, but this report shows that much more needs to be done to ensure this money reaches the frontline services, particularly now as they face unprecedented numbers of referrals.” Read full story Source: The Independent, 11 May 2021
  15. News Article
    A nurse accused of murdering eight babies in an alleged year-long killing spree at an NHS hospital has appeared in court. Lucy Letby, aged 31, appeared at Manchester Crown Court via videolink from HMP Peterborough on Monday morning. She has been charged the murder of five boys and three girls at the neonatal unit at the Countess of Chester Hospital. The babies all died between June 2015 and June 2016. Read full story Source: The Independent, 10 May 2021
  16. News Article
    A world-leading treatment that halves the risk of lung cancer patients suffering a return of the disease after undergoing treatment, is to be rolled out by NHS England. In a trial of the drug – the first of its kind – around nine out of ten patients treated, remained alive and disease-free after two years – compared to more than four in ten who hadn’t received the new therapy. Lung cancer is the most common cause of cancer death in the UK, accounting for one in five of all cancer deaths. Around 100 patients in England with a rare form of cancer will initially have access to the drug, called Osimertinib, with many more expected to benefit this year. Read full story Source: NHS England, 7 May 2021
  17. Content Article
    Moira Durbridge, Director of Quality Transformation & Efficiency Improvement for University Hospitals of Leicester NHS Trust, describes her typical day.
  18. News Article
    A perfect storm of pandemic pressures, changes to the medical curriculum and inadequate Health Education England funding threatens to leave 700 anaesthetists without a job this summer, HSJ has learned. The news comes as the NHS prepares to tackle the huge backlog of elective care work that has built up during the pandemic. Anaesthetists will play a critical role in the recovery effort. Each year around 300 higher training, or ST3, places for anaesthetists are offered by the NHS. However, this year there are over 1,000 applicants for these posts. The oversupply has been created by the inability of trainees to seek work overseas because of the pandemic and a change in the curriculum overseen by the Royal College of Anaesthetists. Royal College of Anaesthetists’ council member Helgi Johannsson told HSJ he was concerned trainees could become “so demoralised” after failing to secure a a job that they might switch to another specialty. “We need those trainees to come through,” he said. “There is a shortage of anaesthetists with around 10 per cent of consultant jobs unfilled and we need to protect our supply line and get on top of our elective backlog.” Read full story (paywalled) Source: HSJ, 7 May 2021
  19. Content Article
    The Royal College of Nursing (RCN)’s 'Nursing Workforce Standards' have been created to explicitly set out what must happen within workplaces to ensure the delivery of safe and effective patient care. The RCN's Nursing Workforce Standards are the first ever blueprint for tackling the nursing staff shortage levels across the UK. They set the standard for excellent patient care and nursing support in all settings, and all UK countries. Developed by the RCN's Professional Nursing Committee, the Nursing Workforce Standards suggest a roadmap for designing a workforce in both the NHS and the wider health and social care sector that can offer patients the quality of care they deserve. The 14 standards – the first of their kind – have been designed for use by those who fund, plan, commission, design, review and provide services which require a nursing workforce. They can also be used to help nursing staff understand what they should expect to be in place to enable them to do their jobs safely and effectively.   The standards apply across the whole of the UK and to every setting where nursing care is delivered. They’re being launched as new polling reveals seven in 10 people believe there are too few nurses to provide safe care. Of the 1,752 members of the public who were surveyed, more than a quarter said they felt themselves or their families may not get the care required when needed.
  20. News Article
    New standards for the safe working of nurses across hospital wards, care homes and in the community have been set out by the Royal College of Nursing, for the first time in its 100 year history. In a bid to underline the safety-critical nature of expert nurses in healthcare, the RCN hopes the minimum standards will be used to force improvements in safe staffing levels and the treatment of nurses across the country by NHS trusts and other employers. It comes as a new poll finds a majority of adults believe there are not enough nurses to provide safe care. There are 50,000 nursing vacancies across the NHS and research has repeatedly shown having degree-educated nurses leads to better patient safety. A major study across 500 hospitals in 12 European countries found for every extra patient a nurse was expected to look after, the chances of the patient dying increased 7%. Other studies have shown replacing degree-educated nurses with less educated staff led to an increase in mortality of 21%. Despite the research, the UK government and NHS England has consistently opposed tougher ratios of nurses to patients and has invested in new non-degree roles to fill gaps in staffing. Read full story Source: The Independent, 9 May 2021
  21. News Article
    Blood cancer patients are one of the most vulnerable groups of people at risk of COVID-19, according to research, being 57% more likely to suffer severe disease compared to other cancer patients. Despite the high risk these patients face, charities such as Anthony Nolan, which assist blood cancer patients with finding a stem cell match, were left out of the allocated government budget that was announced in March. The cancellation of face-to-face fundraising and events, despite the increase in demand for services, have led their gross income to be down by an estimated £5.5m for 2021. Henny Braund, chief executive of the charity, said people with blood cancer and blood disorders were “heavily impacted by the pandemic and everyone who needs treatment and support must be able to access it without delay”. Read full story Source: The Independent, 9 May 2021
  22. News Article
    Ten junior doctors have been removed from a struggling hospital over concerns they were being left without adequate supervision on understaffed wards. Health Education England (HEE) removed the 10 foundation year one doctors, all on a general medicine rota, from Weston General Hospital last month. The General Medical Council said the trust’s previous efforts to address the issues “have not been sufficient or sustainable”. University Hospitals Bristol and Weston Foundation Trust did not say which services HEE had removed the juniors from or what mitigations had been put in place. However, the trust told HSJ none of the positions concerned were from the hospital’s emergency department, where the GMC has already imposed conditions on juniors’ training. HEE very rarely uses its power to withdraw trusts’ trainees. HSJ reported last June the regulator had only removed two posts at trusts under enhanced monitoring since the start of 2019. William Oldfield, University Hospitals Bristol and Weston FT medical director, said in a statement to HSJ: “We recognise the seriousness of the step taken by HEE to temporarily suspend the training programme for a small number of junior doctors at Weston General Hospital. ”We are working to provide the assurance HEE require to allow this training to recommence, and in the meantime we have appropriately mitigated the impact on services at Weston.” Read full story (paywalled) Source: HSJ, 10 May 2021
  23. News Article
    More than a million children and young people will have access to mental health support at school, as the NHS rapidly expands services to help deal with the huge disruption caused by coronavirus and lockdown. From this year, teams of experts are offering support to children experiencing anxiety, depression, and other common mental health issues. Around 400 mental health support teams will be up and running covering 3,000 schools in England, offering support to almost three million pupils, by 2023. The roll-out represents a dramatic acceleration of the programme announced in the NHS Long Term Plan, funded from £79 million to boost mental health support for children and young people in England, which is part of £500 million Government pot for investment in mental health services. Experts hope that by intervening early they can prevent problems escalating into serious mental health issues, with health chiefs warning that the isolation and upheaval of the pandemic can be compounded by factors like pressure experienced on social media platforms. Read full story Source: NHS England, 8 May 2021
  24. Content Article
    The Queen Elizabeth University Hospital Review was prompted by public and political concern following reports of the deaths of three patients between December 2018 and February 2019. The deaths had been linked to rare microorganisms and concern was growing that these organisms were in turn linked to the built environment at the Queen Elizabeth University Hospital (QEUH) and Royal Hospital for Children (RHC). The Review's remit was: “To establish whether the design, build, commissioning and maintenance of the Queen Elizabeth University Hospital and Royal Hospital for Children has had an adverse impact on the risk of Healthcare Associated Infection and whether there is wider learning for NHS Scotland”.
  25. Content Article
    The Care Inspectorate’s chief executive Peter Macleod has written to providers of care home services for adults and older people. Peter’s letter outlines key findings from our inspections between April 2020 and March this year. This includes the positive practice and improvements found as well as general areas for improvement identified.
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