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Patient Safety Learning

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Everything posted by Patient Safety Learning

  1. Content Article
    The Patient Experience Library provides the latest and best evidence on patient experience and patient/public involvement. This quarterly Patient Experience magazine offers thought-provoking comment alongside the best and latest research. Download the latest issue below.
  2. Content Article
    The Canadian Academy of Health Sciences (CAHS) released its report on health human resources (HHR) in Canada. The report provides key findings designed to inform stakeholders (including governments). The report provides evidence-informed approaches to addressing the current challenges facing the Canadian health workforce.   The three overarching themes were identified: support and retention deployment and service delivery planning and development.
  3. Content Article
    The eagerly anticipated Hewitt Review into integrated care systems (ICSs), led by former Health Secretary Patricia Hewitt set prevention decentralisation and cross government co-production as key priorities. What have we learned so far? David Duffy discusses the key takeaways.
  4. Content Article
    In this 1202 Human Factors Podcast, Rob Hutton gives us an insight into naturalistic decision making and how it takes methods out of the Lab.
  5. News Article
    Junior doctors have been accused of putting “politics above patient safety” as figures showed excess deaths almost tripled after their strikes. Office of National Statistics (ONS) figures showed the number of deaths above average increased significantly in the two weeks during and after the first round of industrial action by the British Medical Association (BMA). Junior doctors walked out for 72 hours between March 13 and 15, with more than 175,000 appointments and operations cancelled. Health experts said the walkout around that time could be linked to the rise. A government source said: “The militant leaders of the BMA junior doctors committee seem willing to put politics above patient safety. They have adopted increasingly hardline tactics whilst demanding a completely unrealistic 35 per cent pay rise. Read full story (paywalled) Source: The Telegraph, 13 April 2023
  6. News Article
    “You’re just unlucky,” the doctor told me. Whichever GP I saw, wherever I was, male or female, I would be asked the same questions. Do you drink alcohol? Are you sexually active? Is your underwear too tight? If I heard another woman being relentlessly quizzed like that today, I’d probably call it victim blaming." "... when you’re told, over and over, that it’s just bad luck and that some women suffer more than others, you believe it. You put your trust in the professionals. You don’t advocate for yourself because you don’t understand that there’s anything that needs fighting for." Claire Cohen, 39, had spent much of her life since her mid-teens in acute pain, begging for help. Now she’s finally been diagnosed with endometriosis, she looks at how medicine is still failing to treat a condition that can have a devastating effect on one in ten women Read full story (paywalled) Source: The Times, 13 April 2023
  7. News Article
    Thousands of children with severe developmental disorders have finally been given a diagnosis, in a study that found 60 new diseases. Children, and their parents, had their genetic code - or DNA - analysed in the search for answers to their condition. There are thousands of different genetic disorders. Having a diagnosis can lead to better care, help parents to decide whether to have more children, or simply provide an explanation for what is happening. The Deciphering Developmental Disorders study, conducted over 10 years in the UK and Ireland, was a collaboration between the NHS, universities and the Sanger Institute, which specialises in analysing DNA. Among the findings, researchers discovered Turnpenny-Fry syndrome. Jessica Fisher's son, Mungo - who took part in the study - was diagnosed with the syndrome. Jessica subsequently started an online support group for the syndrome, which is now made up of 36 families from around the world, including America, Brazil, Croatia and Indonesia. "It's devastating to learn that your child has a rare genetic disorder, but getting the diagnosis has been key to bringing us together," said Jessica. Read full story Source: BBC News, 13 April 2023
  8. Content Article
    Outpatient and daycase hysteroscopy and polypectomy (OPHP) are widely recognised methods for the treatment of endometrial polyps. There have been concerns regarding pain affecting satisfaction and tolerability of the outpatient procedure. Dr Bhawana Purwar and colleagues from the Royal Wolverhampton Hospitals NHS Trust conducted a service evaluation of their outpatient hysteroscopy and polypectomy (OPHP) and compared it with their daycase procedures. They concluded that the OPHP is cost-effective and efficient method with reasonable acceptability. It is well tolerated with remarkable success rates and excellent patient satisfaction. As compared to daycase group, it requires less time for recovery and sooner returns to work.
  9. Content Article
    Dawn Stott has worked in healthcare for many years. Her passion is customer care and service improvement. She has designed courses to support healthcare providers improve practice through capturing enthusiasm and sharing best practice.  For the last thirteen plus years she has worked as CEO of the Association for Perioperative Practice (AfPP), a healthcare charity that supports theatre personnel who work in hospitals. When faced with lock down, Dawn shared her thoughts and feelings, via regular emails with her work team. The result is a culmination of her musing, along with some impressions, observations and learning that formed the basis for her book. 
  10. Content Article
    Technologies abstract intelligence and provide predictor and precision insight in workflows that manage disorders, similar to cardiology and hematological disease. Positive perceptions of Artificial Intelligence (AI) that support Machine Learning (ML) and Deep Learning (DL) manage transformations with a safe system that improves wellbeing. In sections, workflow introduces an eXamination (X = AI) as an end-to-end structure to culture workstreams in a step-by-step design to manage populace health in a governed system. The author undertook structure and practice reviews and appraised perspectives that impact the management of AI in public health and medicine.
  11. Content Article
    "One family told me their mum had only been waiting six hours on the floor for an ambulance. Only six hours. For a moment I thought this was a positive outcome. A patient in their 80s, lying on a cold hard floor for the equivalent of three quarters of my shift and I felt this was good patient care. Sadly, this genuinely was better than earlier in the year with patients waiting over 12 hours on the floor and an additional 16 plus hours in an ambulance. I cried when I got home about how far we’ve fallen." An anonymous junior doctor shares his experience on the NHS frontline.
  12. News Article
    Around 10 per cent of the 1.2 million accident and emergency attendees in February waited 12 hours or more, newly published NHS England data has revealed, laying bare the true extent of the NHS’s emergency care crisis. The data – which NHSE has collected for years but has only now started to publish – shows 125,505 patients waited 12 hours or more from their arrival at A&E to be admitted, transferred or discharged. This is more than double the highest figure under the existing metric of around 55,000, which only starts the clock from when the patient has received a decision to admit. NHSE’s decision to publish the data for 12-hour breaches from time of arrival follows a concerted campaign by the Royal College of Emergency Medicine, which has long raised concerns the measure from decision to admit has significantly masked the true extent of long waits in A&E. Read full story (paywalled) Source: HSJ, 13 April 2023
  13. News Article
    The UK is experiencing a “rapidly escalating” diabetes crisis, with cases topping five million for the first time and under-40s increasingly affected, a report has revealed. About 90% of diabetes patients have type 2, a condition much more likely to develop if people are overweight. About two-thirds of adults in the UK are overweight or obese. Statistics published by Diabetes UK reveals an all-time high for type 2 and type 1 combined of 4.3m officially diagnosed cases and another 850,000 people living with one or other of the conditions but still to be diagnosed. Another 2.4 million people are at high risk of developing the type 2 form in the UK. “These latest figures show we’re in the grip of a rapidly escalating diabetes crisis, with spiralling numbers of people now living with type 2 diabetes and millions at high risk of developing the condition,” said Chris Askew, the chief executive of Diabetes UK. “These latest figures show we’re in the grip of a rapidly escalating diabetes crisis, with spiralling numbers of people now living with type 2 diabetes and millions at high risk of developing the condition,” said Chris Askew, the chief executive of Diabetes UK. The stark figures mean millions of Britons are at increased risk of complications including heart attacks, kidney failure, stroke, amputation and blindness. As a result, the UK faces a public health emergency unless action is taken, Askew said. “Diabetes is serious, and every diagnosis is life-changing. It’s a relentless condition, and the fear of serious complications is a lifelong reality for millions of people across the UK. “But it doesn’t have to be this way. With the right care and support, cases of type 2 diabetes can be prevented or put into remission. What we need to see is the will, grit and determination from government and local health leaders to halt this crisis in its tracks and improve the future health of our nation for generations to come.” Read full story Source: The Guardian, 13 April 2023
  14. News Article
    Ghana is the first country to approve a new malaria vaccine that has been described as a "world-changer" by the scientists who developed it. The vaccine - called R21 - appears to be hugely effective, in stark contrast to previous ventures in the same field. Ghana's drug regulators have assessed the final trial data on the vaccine's safety and effectiveness, which is not yet public, and have decided to use it. The World Health Organization is also considering approving the vaccine. Malaria kills about 620,000 people each year, most of them young children. It has been a massive, century-long, scientific undertaking to develop a vaccine that protects the body from the malaria parasite. But widespread use of the vaccine hinges on the results of a larger trial involving nearly 5,000 children. These had been expected to take place at the end of last year, but have still not been formally published. However, they have been shared with some government bodies in Africa, and scientists. Read full story Source: BBC News, 13 April 2023
  15. News Article
    England’s pharmacies are on the brink of collapse – struggling with a shortage of staff and medical supplies – combined with increased patient demand and soaring costs, according to an industry survey shared exclusively with this programme. Staff say that some patients are so frustrated by the supply problems, they’re getting aggressive. The Pharmaceutical Services Negotiating Committee, the industry body which carried out the survey, says the Government and NHS need to step in now, before it’s too late. View video Source: Channel 4 News, 12 April 2023
  16. News Article
    A top doctor has blamed a "dysfunctional" culture at NHS Highland for a crisis in medical recruitment and retention engulfing its rural hospitals. Dr Gordon Caldwell, a consultant physician who was the clinical lead at Lorn and Islands hospital in Oban until he resigned last summer, said there "still seems to be a lot of fear" among staff more than four years on from a bullying scandal that cost the health board nearly £3 million in settlements. Dr Caldwell - who joined NHS Highland in 2018 - said an exodus of senior consultants from Oban and Fort William over the past 18 months is down to management "undermining us, bullying us, and blaming us for problems that were due to a lack of leadership". The 66-year-old, who is internationally regarded for his expertise in medical education, became so concerned about the impact on junior doctor training in Oban that he whistleblew to NHS Education for Scotland (NES) while on sick leave for stress after finding his own internal complaints rebuffed. A resulting inspection report, published in May last year, said NES had "serious concerns about the training environment" at Lorn and Islands hospital, including around the "safety of care". Read full story Source: The Herald, 1 April 2023
  17. News Article
    Staff in hospital emergency departments in England are struggling to spot when infants are being physically abused by their parents, raising the risk of further harm, an investigation has found. Clinicians often do not know what to do if they are concerned that a child’s injuries are not accidental because there is no guidance, according to a report from the Healthcare Safety Investigation Branch (HSIB) that identifies several barriers to child safeguarding in emergency departments. Matt Mansbridge, a national investigator, said the report drew on case studies of three children who were abused by their parents, which he said were a “hard read” and a “stark reminder” of the importance of diagnosing non-accidental injuries quickly, since these are the warning sign in nearly a third of child protection cases for infants under the age of one. “For staff, these situations are fraught with complexity and exacerbated by the extreme pressure currently felt in emergency departments across the country,” Mansbridge said. He said the clinicians interviewed wanted to “see improvement and feel empowered” to ask difficult questions. “The evidence from our investigation echoes what staff and national leads told us – that emergency department staff should have access to all the relevant information about the child, their history and their level of risk, and that safeguarding support needs to be consistent and timely/ Gaps in information and long waits for advice will only create further barriers to care,” he said. Read full story Source: The Guardian, 13 April 2023
  18. Content Article
    Clinicians in emergency departments (EDs) will see babies and young children with injuries that may be non-accidental. If the cause of such injuries is missed, there is a risk of further harm to the child. However, making a judgement about whether an injury might be accidental or not is complex and difficult. This Healthcare Safety Investigation Branch (HSIB) investigation explores the issues that influence the diagnosis of non-accidental injuries in infants (children under 1 year of age) who visit an ED. Specifically, it explores the information and support available to ED clinicians to help them to make such a diagnosis. Due to the nature of the subject matter no specific incident was used to explore this area of care. Instead, the investigation analysed 10 serious incident reports (reports written by NHS trusts when a serious patient safety incident occurs) to identify the factors that contribute to non-accidental injuries not being diagnosed. These factors were grouped into themes, which informed the terms of reference for the investigation.
  19. News Article
    Many care home staff worked extra hours without extra pay to prop up the system during the pandemic, a study suggests. Public money helped stabilise UK care homes during the first wave of Covid-19 but it was withdrawn too soon and not focused on staff, says the research, led by Warwick Business School. The researchers studied the accounts of more than 4,000 UK care home companies, from just before the pandemic and during the first year of the health crisis. They found nearly two thirds (60%) of care homes were already financially fragile as the pandemic took hold. The report concludes: "The decision by government to end financial support for care home companies after the peak of the pandemic had passed has likely contributed to the current financial and operational difficulties experienced by the sector." It states the financial plight of many staff and the immense pressure they were under "means it is not surprising the care home sector has struggled to both recruit and retain staff once lockdown restrictions were removed and the wider economy re-opened". Read full story Source: BBC News, 12 April 2023
  20. Content Article
     In the wake of the Covid-19 pandemic, we are all too aware of the urgent health inequalities that plague our world. But these inequalities have always been urgent: modern medicine has a colonial and racist history. Here, in an essential and searingly truthful account, Annabel Sowemimo unravels the colonial roots of modern medicine. Tackling systemic racism, hidden histories and healthcare myths, Sowemimo recounts her own experiences as a doctor, patient and activist. Divided exposes the racial biases of medicine that affect our everyday lives and provides an illuminating - and incredibly necessary - insight into how our world works, and who it works for.
  21. Event
    Dr Leslie Hamilton, assistant coroner and retired cardiac surgeon, will speak about the importance of creating and maintaining a no-blame culture within NHS and independent healthcare organisations. This should help to ensure that people feel able to share and reflect honestly whenever things go wrong in care, so that lessons can be learnt and changes made to improve patient safety. Register
  22. Event
    Rhys Hadden, a barrister from Serjeants’ Inn Chambers, will consider: Key case law and important updates from the past 12 months; Any updates on the revisions to the Code of Practice to the Mental Capacity Act 2005; and What is the latest with the Liberty Protection Safeguards? Register
  23. Event
    This session will build on the concepts discussed within HSIB’s Level 2 in Safety Investigation programme and will provide an opportunity to ‘have a go’ and discuss some of the challenges and practical aspects of using thematic analysis for the purpose of learning from patient safety issues. Enrol
  24. Event
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    This virtual workshop will provide health care professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
  25. Event
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    This virtual workshop will provide health care professionals with background theory and hands-on practice in incident analysis using Root Cause Analysis (RCA) and in proactive risk assessment using Failure Mode and Effects Analysis (FMEA). Register
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